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OMEGA, Vol. 59(3) 221-238, 2009
HOW DO THE YOUNG SUICIDE SURVIVORS
WISH TO BE MET BY PSYCHOLOGISTS?
A USER STUDY*
KARI DYREGROV
Center for Crisis Psychology, Bergen/
Norwegian Institute of Public Health, Oslo
ABSTRACT
Little user-knowledge has been documented on the experiences of young
suicide bereaved with psychosocial assistance and therapy. Thirty-two
adolescents who had lost a close family member or friend by suicide
participated in a research project by filling in questionnaires and participating
in focus group interviews. The article explores the young people’s
experiences with and wishes for help from psychologists, and shows that the
young bereaved do not receive the psychological assistance they wish for and
need. The shortcomings are discussed in relation to the organization, form,
and contents of the help. In order to reach youth with adequate assistance in an
extreme life situation, it is worth listening to their opinions about how they
want to be approached in the wake of a suicide.
INTRODUCTION
Norway is a small, wealthy, Western country with a population of only 4.7 million
people, but as most Western countries, Norway has a large number of suicides per
*This article was originally published in the Journal of the Norwegian Psychological
Association (Tidsskrift for norsk psykologforening), 2006; 43, 787-794, and has been trans-
lated to English with their kind permission. Also, the author acknowledges The Norwegian
Foundation for Health and Rehabilitation, The Norwegian Organization for Suicide Survivors,
and the Norwegian Sudden Infant Death Society for their support.
221
Ó2009, Baywood Publishing Co., Inc.
doi: 10.2190/OM.59.3.c
http://baywood.com
year. In 2003 when the study was carried out, 502 people took their own lives,
of these 374 men and 128 women. The suicide rate (number of suicides per
100,000 residents) was 16.5 for men and 5.6 for women and the total suicide
rate was 11. The most recent records do not deviate much from this.
Each and every suicide will affect the close bereaved for a long period
of time. Shneidman (1972) expressed this metaphorically: “The person who
commits suicide puts his psychological skeleton in the survivor’s emotional
closet.” The large number of annual suicides around the world implies that very
many bereaved persons, among these many young people, are left in a state of
shock and grief. In addition, their family, friends, schoolmates, and colleagues
are also deeply affected.
Young People Struggle After a Suicide
The Support and Care project, carried out at the Center for Crisis Psychology
(SfK) in Norway from 1996 to 2003 (Dyregrov & Dyregrov, 2005a, 2005b), and
other studies have documented that children and young people struggle to a
significant degree in the aftermath of the suicide of a close friend or family
member (Brent, Moritz, Bridge, Perper, & Canobbio, 1996; Cerel, Fristad, Weller,
& Weller, 1999; Rakic, 1992; Sethi & Bhargava, 2003). Pfeffer, Martins, Mann,
Sunkenberg, Ice, Damore, et al. (1997) came to the conclusion that child suicide
survivors were at greater risk for specific forms of psychosocial dysfunction
than children who had experienced other types of deaths. The most important
difference, in comparison with other studies, was that posttraumatic symptoms
were only observed in children who had experienced suicide and not in connection
with non-dramatic deaths. Brent et al. (1993) found that young siblings bereaved
by suicide more frequently suffered from depression, anxiety, and posttraumatic
stress disorder (PTSD) than did a control sample. The young suicide survivors
experienced a lack of energy, sleep disturbances, appetite and body weight
disorders, an increase in emotional and physical agitation, guilt, social withdrawal,
concentration problems, and suicidal thoughts. Rakic’s study (1992) and the
Support and Care project (Dyregrov & Dyregrov, 2005a, 2005b) confirm these
findings. In a related study, Nelson and Frantz (1996) point out that suicide can
lead to prolonged/complicated processing of grief due to the fact that many
of the young survivors are incapable of sharing their experiences and thoughts,
particularly any feelings of guilt with which they may be struggling. Sethi and
Bhargava (2003) found that 50% of the young bereaved fulfilled the criteria
for serious depression on the average nine and a half months after the suicide of a
close friend or family member, while only 6.6% in the control sample fulfilled
these criteria. Both Rakic’s study (1992) and the Support and Care project showed
that many young people experienced great difficulties in expressing their grief
openly within the family. In Demi and Howell’s study (1991), adult survivors
expressed extreme frustration 15 years after the suicide of a sibling, in connection
222 / DYREGROV
with what they had experienced as the keeping of secrets, silence, and blocked
family communication after the death. A serious consequence of the difficult
overall situation of the young suicide survivor is widespread learning and con-
centration difficulties in the context of schooling (Dyregrov, 2006; Dyregrov
& Dyregrov, 2008).
In 1988 McIntosh and Wrobleski (1988) referred to the young suicide sur-
vivors as “the forgotten bereaved,” and much indicates that this remains the
case today. The Support and Care project showed that parents bereaved by
suicide were extremely worried about their living children and wanted far
more and better help for them than that which had been offered. In particular,
they wanted help from psychologists for young people (Dyregrov, 2002). They
emphasized that it was difficult to acquire help from a psychologist, and in
cases where they had received such help the contact was too brief in its duration,
allegedly because the young people found the benefits to be of limited value.
Also, clinical practitioners working with young crisis-stricken individuals have
argued that helpers within the psychological health care sector must meet young
people in another manner than that which was the current practice (A. Dyregrov,
2004). Research projects have shown that many young people criticize “the
silent therapists—those who do not say very much and put pressure on young
people to take responsibility for the counseling session” (A. Dyregrov, 2004,
p. 723; Dyregrov, 2008).
Despite documentation of the serious ramifications of current conditions, little
research has been carried out on the type of follow-up that the young bereaved
by suicide find they need, the type of help offered and how any help that is offered
is received by young people. In order to acquire such knowledge, it is necessary
to listen to the users of such services so these may be performed to a larger extent
on the terms of the user. The survivor should have a right to influence the help
offered to them, being of therapeutic value as well as a means of improving and
quality-assuring the services. The client’s experience of the therapeutic relation
and the client’s experience of change early in the course of treatment appear to
be the factors that best determine the outcome of the treatment. With an objective
of contributing to critical discussion and proposals for improvement, a social
science research approach has been applied in different areas of psychological
health care to connect the users’ experiences to features of the health care service
scheme and professional practitioners’ processes of reflection and interpretation.
The above-mentioned perspective and research approach comprise the framework
for the study presented in this article.
A Norwegian Study
In order to give young suicide survivors the requisite voice, in relation to
society and the public assistance scheme, the Norwegian Organization for Suicide
Survivors (LEVE) carried out the project “An improved care scheme for the young
YOUNG SUICIDE SURVIVORS AND THE PSYCHOLOGISTS / 223
bereaved by suicide.” The project consisted of three phases. The first phase
involved weekend gatherings of young suicide bereaved. The second phase was
a research segment to outline and analyze the young people’s personally felt
situation, whereas the third phase involved dissemination, in order to inform
potential support communities of how they can support young people during the
period following a suicide. Only the research part, carried out by the author, is
addressed in this article. The objective of this was, among other things, to outline
the young people’s wishes and needs for help, how they experienced being met
by the social network and assistance scheme, and whether offers of help were
successful. Self-help strategies and personal growth were also registered. This
article discusses the type of help that the young people wanted from a psychol-
ogist, in terms of content, scope and quality.
METHOD
Sample
The sample consisted of young people who participated in LEVE’s youth
gatherings. These participants had been recruited through notices in the daily
newspaper, schools, and nursing service, and through LEVE’s membership publi-
cation. The youth survivors are therefore presumed to be representative of the
type of young people who would consent to this kind of participation. A total of
32 young people, out of a total population of 33 that were asked to participate,
filled out questionnaires and took part in qualitative focus group interviews.
Ten (31%) of the participants were boys/men and 22 (69%) were girls/women.
Their ages varied from between 13 and 24 years, with an average age of almost
18 years (M= 17.8; SD = 3.20). The young people were in elementary school
(25%), high school (50%), college/university (16%), or working (9%). They
represented all of the health regions of Norway; 69% were from urban areas
while 31% lived in rural areas. Only five (16%) of the young people were present
when the individual who had committed suicide was found. Six (20%) had lost
a mother or father, 22 (69%) had lost a brother or sister, while the others had
lost other close relatives or friends (11%). The ages of the deceased varied from
12 to 56 years of age, with an average of almost 27 years of age (M= 26.69;
SD = 12.49). The amount of time that had passed since the deaths varied from
1 month to 7 years (84 months), with an average of around 3 years (M= 35.5 mos;
SD = 23.58).
Data Collection
Data collection took place following the youth gatherings, whereupon young
people filled out questionnaires and took part in focus group interviews. A total
of 11 group interviews, with two (one group) to four participants per group were
224 / DYREGROV
carried out either in connection with a gathering, at the researcher’s office, or in
the young person’s home. Approvals were acquired from the Privacy Ombudsman
for the Norwegian universities (NSD) and the Regional Committee for Medical
Research Ethics (University of Bergen).
Perspective and Procedure
The study was based on a user perspective, where the informant is considered
to be an expert on own experiences and knowledge. Moreover, mixed methods
were used (questionnaires and in-depth interviews; Coyle & Williams, 2000) to
outline the young people’s needs for help and support from the public assistance
scheme, the school, and the social network. A four-page “help form” produced by
SfK outlined the scope of the help received and wanted, and consisted of 172
standardized questions and five open questions. In order to ensure the validity and
reliability of the form, the form was reviewed critically by two young bereaved
and an adult version of the form has been translated into English, discussed with
researchers, and used on comparable groups in several other countries.
While the help form outlined the scope of the help received, the focus group
interview was chosen as a method for the exploration of individual experiences.
The interviews were based on a phenomenological approach where the objective
was to acquire descriptions of the interviewee’s life-world, with an eye toward
interpretation of the described phenomena (Giorgi, 1975; Kvale, 1996). By dis-
closing the scope and variation of the young people’s subjective experiences of
their encounter with the public assistance scheme, the method provided an oppor-
tunity to illuminate experiences of importance for the young people, of which
assistance professionals could be unaware. The use of a theme guide ensured that
certain subjects were addressed systematically. The qualitative data was analyzed
according to Kvale’s (1996) five-step analysis for qualitative data. The method is
designed to condense expressed opinions in order to find basic units of meaning
and processes in relation to the issues under investigation. The researcher specifies
the main theme for the units of meaning before the analyzed material is interpreted
in relation to the issues under investigation, relevant theory, and former research.
Descriptive analyses (frequency distributions, average, and standard deviation) of
the questionnaire data were carried out using STATISTICA 7. In a social science
perspective, the results of the analyses are connected with the informants’ subjec-
tive experiences in order to say something about the assistance scheme and the
psychologist’s approach.
RESULTS
The majority of the young people were of the opinion that young suicide
survivors will need support and help from outside the family:
YOUNG SUICIDE SURVIVORS AND THE PSYCHOLOGISTS / 225
There are very few who can go through such things without receiving help.
I believe that most need to have help. I believe so. I believe regardless
that it is important to speak with someone from outside of the family.
(17 year-old girl)
All of 69% (22) of the young informants indicated that they experienced a need
for help from professionals to an extremely large/quite large/certain extent, while
a respective 19% and 12% to a small extent or not at all had experienced a need
for such help (Dyregrov, 2008; Dyregrov & Dyregrov, 2005a, 2005b).
In the interviews, the young people gave the impression that there was a large
variation in the type of help that they had received. According to them, it appeared
to be quite random who happened to receive help and why they received it. But a
few informants, who previously had been in touch with the public health care
scheme for problems, experienced receiving better follow-up than others. The
helpers whom the informants most frequently had spoken with/had some contact
with after the suicide were psychologists (52%), teachers (35%), public health
nurses (35%), and clergymen (29%). The psychologist was also the one who
gave the greatest number in the study information (23%) and help of a practical
nature (16%), and the one who was considered to be the most important helper,
along with public health nurses, clergymen, and doctors.
In spite of the key role that the young bereaved wished the psychologist
to play, there was a great deal of frustration in connection with help from
psychologists. The majority had broken off contact with their psychologist after
a relatively short period of time or was dissatisfied with the relation, while
others had wished for this type of help without having received an offer. A few
reported having received good and important help from a psychologist. In order
to be able to learn from the young people’s frustrations, the subsequent findings
will present some of their reflections regarding why many young bereaved by
suicide do not receive adequate psychological help.
Barriers to Establishment of Contact
with Psychologist
Both the young people who had succeeded in getting an appointment with a
psychologist and those who had not, indicated a number of different reasons for an
inadequate “establishment of contact.” They mentioned factors that were not only
due to the helpers, but also to themselves, to the way the help was organized or the
result of a combination of different factors. Because they did not have the strength
or did not manage to take contact personally, the lack of an automatic assistance
program was a barrier to help. Also, they did not know who or what could help.
Moreover, lack of offers when the young people were “ready” prevented them
from adequate professional help. Finally, the young people pointed out that they
did not make further attempts after disappointing encounters, or they might also
refuse offers of help due to lack of motivation and support.
226 / DYREGROV
The Need for Help is Not Recognized
The most important barrier to psychological help that the young people men-
tioned was the lack of any system to identify their need for help. They emphasized
that after a suicide one is in complete shock, and one “can’t tell up from down
in the situation” and as such, one does not have the energy to take contact and
ask for help. In addition, the young people were uncertain of the type of help
they needed, or of the type of help available, but they nonetheless believed that
psychologists were the professional group most appropriate to offer assistance
with all of their exhausting thoughts. Many parents neither managed to encourage
the young bereaved to accept help or to find them adequate help because they
had problems enough in coping with their own grief, particularly immediately
following the death. In addition, there were young people who had had poor
or disappointing meetings with helpers that resulted in their not taking further
initiative, in spite of the fact that they experienced a need for help. Others
mentioned that they had wanted contact with another professional group than
that from which the offer of help had come (e.g., with a psychologist rather than
a clergyman).
Two of the young people who had not received early offers of help spoke of
having such great difficulties in acquiring help quickly from a psychologist when
they suddenly needed it that this had resulted in involuntary hospitalization in a
psychological health care institution. Some of the oldest informants pointed out
that it is also difficult to ask for help when in adolescence. One is concerned about
what other people think and experiences having to receive help as a personal
failure, and the young suicide survivors are therefore reluctant to accept the help
that is offered:
I think it was worse (seeing a psychologist) when I was 17 years old than
now. Yes, obviously. I think that I was more worried about what others
would think of me. It was that kind of high school set-up and you were not
supposed to be different. (23-year-old boy)
Insufficient Offers of Help When the Young
People are “Ready”
The young people had also experienced that it was difficult to find counseling
at a later point in time if they had turned this down the first time it was offered.
A lack of available capacity on the part of the psychologist made it impossible
to get an appointment when the young people were “ready” to accept help,
either because adults had worked with them or they had personally gradually
acknowledged that they needed help:
When I called the office at Vinderen (to make an appointment) after having
received a referral, I got the answer: “No, we receive from 20-30 phone
calls on this here every day, so I really don’t know. You can send in the
YOUNG SUICIDE SURVIVORS AND THE PSYCHOLOGISTS / 227
referral and we’ll see what we can do.” My referral went into a pile . . .
I don’t know. The referral has probably expired now. (19-year-old girl)
Some young survivors had spent a long time motivating themselves to seek
help from a psychologist and said that they needed to be asked several times,
so that the idea could mature in conjunction with a gradually experienced need
for help. But then it was also important that the helpers understood this and
subsequently did not stop making offers of help too soon.
Discontinuation of Contact
Due to the stressful situation stemming from having concentration difficulties,
there were some young people who had failed to turn up for scheduled counseling
sessions because they had not had the strength to show up or had forgotten
appointments. This had embarrassed them to the extent that they had not dared
to take further contact and if the psychologist neither took contact that was the end
of their psychological assistance. Some young people had discontinued group
counseling sessions with their families because they had not felt sufficiently
taken care of, in that the main focus had been on the parents. Others who had
been offered counseling together with other close family members had declined,
because they wanted a more private type of counseling or to protect their parents
from learning how much pain they were in. Most of the young people who had
broken off contact with a psychologist did so because they were disappointed and
dissatisfied with the offer of help they had received. The criticism predominantly
addressed the contents of the help and the style of the helper.
Why were These Young Suicide Survivors
Not Satisfied with the Psychologist?
The young people who were dissatisfied with the help from a psychologist
indicated different reasons for this. Moreover, they experienced that the psychol-
ogists did not sufficiently address their problems, and signaled professional and
emotional uncertainty. Finally, the young persons claimed that too many lacked
empathy and true compassion, which did not inspire trust.
Did Not Address the Problems
Through the interviews many of the young people stated that they did not
receive the type of help that they had needed qualitatively speaking. One quickly
noticed if the psychologist used an approach that helped or not, and many stated
that they “did not see the point of” speaking with the psychologist. A number
stated that they would have liked the psychologist to have been more active, and
perhaps ask individual questions that they could have answered but without
pressuring them too much, too quickly. They had often felt pressured to tell
the story of what had happened while they in fact were not able to put their pain
228 / DYREGROV
into words. They neither saw the point in telling “their entire life story.” Here is a
sample of what the young people reported in the interviews:
I was at BUP (the National Psychiatric Polyclinic for Children and Adoles-
cents) in . . . and I stopped going there after only a short while because I felt
like I was not getting anything out of it. When I went there I had to start
explaining and then I did not know what to say, so there was a lot of silence,
like. And maybe it was just the wrong day, that I didn’t want to talk about it
and then felt pressured to do so because I had gotten an appointment there.
(14-year-old boy)
The one (the psychologist) I went to, I had to explain like everything I
could remember from the beginning of my life, no point to it whatsoever.
(17-year-old girl)
She (the psychologist) said very, very little, I would have preferred that
she told me a bit about the normal reactions after having lost someone by
suicide. She didn’t do that at all. During the first session she sat and answered
a couple of question, a lot of awkward silences and cookie eating and such
and the next time was not any better. (18-year-old girl)
So I received an offer of some kind of psychologist thing, but it was just
foolishness. I went in there and I did not think there was any point in sitting
there and listening to those two strangers talking all kinds of nonsense
about my brother, and it was like . . . it was much easier for me to talk with
those who knew him, than with two tricky strangers. (17-year-old boy)
I went to see the psychologist just a couple of times and then I couldn’t
be bothered to go any more. So I just talked to my friends, which was a lot
better. (16-year-old boy)
I went to the counselor at school and the health nurse at school, who contacted
PPT (the National School Psychology Service) for me. So when I went to
see that psychologist at PPT, it was like she wanted to get it all out, what I
thought and bla, bla, bla, it’s like totally . . . like presenting my whole life
story to a complete stranger, it doesn’t work. (17-year-old girl)
A number of informants were critical about the fact that the psychologist did
not address what really bothered them: thoughts of guilt, questions about why,
anger toward the deceased, anxiety about further losses, frightening dreams
and nightmares about suicide, or problems handling daily life because so much
time and energy went toward keeping the pain at bay. They emphasized that
psychologists dwelled too much on the past, either the young person’s or the
deceased person’s, while they would have preferred for the psychologists to have
instead been more focused on the things that were bothering them and that had
turned their lives upside down. Some therefore had some thoughts regarding the
kind of help a psychologist should give young people:
It is very important that they think about the individual sitting in front of
them and not the individual who is dead. Even though you perhaps can give
YOUNG SUICIDE SURVIVORS AND THE PSYCHOLOGISTS / 229
a description and talk about the deceased person, what they were like, I
believe it is important that they in a way make real contact with you and
find out how you are doing. And then they need knowledge to straighten
that out, which is very important. Because if you just sit there and talk about
the weather, as I have heard that they do, and about the deceased, it wouldn’t
help me particularly at any rate. It would not. (17 year-old girl)
Other young people were disappointed over having been met with a lack
of understanding for their problems being serious enough to merit psycho-
logical help:
It was a strain going to the psychologist because he made me feel that my
problems were trivial. (22 year-old girl)
Lack of Empathy and Sincere Compassion—
Does Not Inspire Trust
The young people who had taken the step and made an appointment with a
psychologist, imposed strict requirements with regard to the importance of there
being a ”chemistry” based on trust, empathy, and sincere compassion between
themselves and the psychologist if they were to continue attending. If their trust in
the psychologist was violated, because they did not sense that he/she had a true
interest and empathy for them in their extremely vulnerable situation, then they
quickly stopped going:
I had a psychologist and when I came in, he did not pay attention when I
started talking. And I had not told very many people then, so it was like
baring your soul and then he did not fully pay attention and did not catch
really what I said and so on. I think he had another opinion regarding what
I was there for, and otherwise his body language expressed that he was not
really there, not really listening. It really irritated me, and I got even angrier.
I did not go back anymore. (18-year-old girl)
The young people were also very sensitive about whether the deceased was
spoken about with respect and had strong reactions if the psychologist became too
“buddy-like,” such as by speaking as if they knew the deceased very well when
they did not:
They (the psychologists) must be careful not to talk as if they knew the person
they are speaking about for the past 30 years. Because it is like ...itistrust
that is needed and that they focus on the right things. (16-year-old boy)
Signaled Lack of Experience and
Authority in the Field
The young people’s stories could also indicate that a number of psychologists
did not have much experience with the young bereaved by suicide and did
not inspire sufficient trust because they were personally uncertain about how to
230 / DYREGROV
meet young people in grief and crisis. A young person who had been struggling
a great deal and personally sought out the help of a psychologist, stated:
So I went to see the psychologist and she had just graduated and she could
not help me at all. She did not understand why I was there and the only thing
that she asked me about was why I did not want to use the name of the
deceased. That was the only thing that she asked about and why I had
suddenly decided that I needed to see a psychologist. She did not ask about
anything else whatsoever. And then she said that no, I don’t think it’s
necessary for you to come here. She could not help me with grief; I would
have to get over it myself. She did not ask me how I was feeling. . . .
(18-year-old girl)
Other therapists had lectured young people on the basis of theoretical
knowledge and disclosed that they “did not know really what the point was in
practice”:
It is no help for me whatsoever to sit and tell a person what is happening
when the other person does not know what in fact occurs but has only read
about it. (17-year-old girl)
Some young people emphasized the importance of professionals daring to be
direct in their communication about the suicide and not sugar coating things:
Why can’t they say instead: When your mother hung herself . . . because when
they say the words, time after time, that helps to take the sting out of it. It
hurts like anything to hear it, but there’s something about facing what actually
happened, that one speaks frankly. (18-year-old girl)
Push Us a Bit More!
Many young people admitted that they personally had certainly contributed
to their not receiving the help that they later would have liked to have received.
They were not always so adept at expressing themselves and informing helpers
that they were not doing well and some had rejected offers of help. Because the
young people for various reasons tried to hide their problems, they understood
that it was not easy for others around them to help. Most of them stated in this
regard: “push us a bit more” and repeat the offers of help. They emphasized that
helpers must dare to be a bit more on the offense and not just accept the first refusal
at face value. Other young persons who had not received help believed it would
have been difficult to accept an offer, particularly from adult strangers, but stated
that they would have accepted had the right person encouraged them to do so.
At the same time, several stated that they were skeptical about being pressured
too quickly to open up (too much) and then it is a matter of, as one young person
put it, “finding the traction point”:
The psychologist I had was all about getting me to say absolutely everything.
I really did not want to say so very much, but he actually got me to say a lot.
YOUNG SUICIDE SURVIVORS AND THE PSYCHOLOGISTS / 231
So that is surely what destroyed it, that I did not receive the kind of help that
I needed. Maybe not pressure, but in a way, a little push . . . like find the
traction point. But we must have a say in deciding. (17-year-old girl)
The young people understood that it was not always easy for professionals or
family members to “find the traction point” or to know how much they should
push the individual young person in order to provide the help they might need or
manage to accept at any given time. Many of the informants stated that they in the
beginning had suppressed their reactions in order to be able to keep functioning.
Just after the suicide, they were obliged to absorb the reality little by little and then
they were not able to deal with well-meaning helpers or family members who so
desperately wanted to help them. Proximity and repeated, tactful offers of help and
support would therefore be the solution. It would also be a great help if family
members or others could give the psychologist some insight into what had
happened, so young people could be spared having to tell the whole story again at
the first session. They also wanted psychologists who, on the basis of previous
experience with and insight to the young bereaved by suicide, could offer concrete
advice on expected reactions, about what they could do to alleviate the difficulties
particular to the situation and how they could best give support to parents and
siblings. In particular, they emphasized that their experiences had taught them the
importance of follow-up and involvement over time. The young people therefore
sought a routine, professional offer of help, adapted to the individual young
person’s particular help-needs, which is offered repeatedly at different points in
time. They emphasized that the helpers must not ask whether one needs help—that
it must simply be offered because one does not manage to ask for help personally
(Dyregrov, 2008; Dyregrov & Dyregrov, 2005a, 2005b).
DISCUSSION
The significance of listening to users of health care services is an important
principle in the study. It is in particular of importance to illuminate the young,
vulnerable groups’ experiences of meetings with helpers because the accounts of
such experiences for various reasons are often not heard. Hopefully, young
people’s subjective experiences and researchers’ interpretations of these will
comprise a contribution to critical reflection upon clinical practice. The discussion
of the young people’s meeting with the psychologist/counselor and other helpers
must therefore be viewed in the light of the user perspective and methodological
considerations.
Methodological Discussion
Although it is a nationwide selection, the sample is small in order to generalize
from the quantitative analyses. Still, I think that the following discussions may
apply for many, especially Westernized, cultures.
232 / DYREGROV
The selection can be distorted, because the study followed youth gatherings
where the young bereaved by suicide met others in the same situation. Accord-
ingly, one may have recruited persons to the study who are more interested in
the problems addressed there, because they are struggling or who have a greater
awareness of their own reactions. The young people in the study can be more
resourceful or more confrontational than other young bereaved. Although it
is difficult to conceive of the possibility of the informants constructing new
experiences in connection with their unique situation after having heard the
accounts of others, it is likely that the group interviews, gatherings, and the
preliminary questionnaire may have influenced the interviews, in the sense of
causing the young people to develop further reflections and associations to own
thoughts and experiences (Bloom, Frankland, Thomas, & Robson, 2001). The
qualitative material’s validity and generalizability, both theoretically and analyt-
ically speaking, will be connected with degree of its plausibility and to which it
is confirmed through recognition on the part of the young bereaved, in theory
and by clinicians (Kvale, 1996). It is a strength that the qualitative material is
comprehensive in relation to the focus of the article. Two young bereaved read
through and “validated” the final report without objections to the presentations;
psychologists at the Center for Crisis Psychology recognized the young people’s
problems, while there is little literature to support the findings. Despite group
differences on available basic background variables for this and a previous study
(Dyregrov & Dyregrov, 2005a, 2005b) with young suicide survivors, great simi-
larities in wishes for help were seen. This may reduce the likelihood for biased
findings due to recruitment method. Also, as earlier studies have shown that
the non-participants might even be worse off than those who do participate in
such studies (Paykel, 1983), it is possible that those who do not seek or are
receptive to help (the group gatherings) may want even more, rather than less,
support from psychologists.
The Help Desired had Difficulties
Getting Through
The young suicide survivors’ wishes for an automatic, proactive, and qualified
offer of help with an orientation toward the individual’s unique situation over
time corresponds with the wishes of an adult bereaved with regard to help after
a suicide (de Groot, de Keijser, & Neeleman, 2006; Dyregrov & Dyregrov, 2005a,
2005b; McMenamy, Jordan, & Mitchell, 2008; Wilson & Clark, 2005). Like
the adults, the young people also view the psychologist as one of their most
important potential helpers in the period after the suicide. It is therefore par-
ticularly problematic that so many young people experience that this type of help
does not get through. The main problem in the meeting between the young
bereaved by suicide and the psychologist appears to be twofold. Either the young
people for different reasons do not manage to establish a therapeutic relation to the
YOUNG SUICIDE SURVIVORS AND THE PSYCHOLOGISTS / 233
psychologist or the contact is experienced as not being particularly meaningful
and many stop going. The failure on the part of the assistance scheme, as
experienced by the young people, is interpreted as having explanatory variables
connected with organization, form, and content.
Psychological Services Lacking in Organization?
The young people’s descriptions indicating that the desired help from a
psychologist had not gotten through to them to the degree required and
desired, can have a connection with the assistance scheme’s organization and
ideology not being adapted to the unique situation of the young bereaved.
Despite the experience that they need therapeutic help, the young people state
that they cannot bear to contact the assistance scheme, lack knowledge about
who or what can help, are not “ready” when psychologist help is there, or
refuse offers of help because they lack motivation and support. The young
people, however, emphasize the need for being contacted with an offer of
help for their situation. A lack of the necessary organized measures to
accommodate the young people can be connected with large parts of the
assistance scheme functioning according to a traditional patient-therapist
model, where it is up to the patient to define his/her problem and
subsequently seek help. The variation between municipalities, as indicated by
the young people, can thus be connected with the existence of different ideologies
with regard to the follow-up of the crisis-stricken—shall one think prevention,
treatment or let it be exclusively up to the social network to help the bereaved
by suicide (K. Dyregrov, 2004)?
When one evaluates the young people’s descriptions of the help they
received, it is only right to take into consideration that most of the suicides
discussed here took place a few years ago. There are tendencies in the
material indicating that following more recent suicides young people are more
frequently offered help. It can in such a case reflect that many municipalities
are now working more actively with psychosocial follow-up after suicide than
was the case previously, both in Norway and other countries. When the
municipalities’ psychosocial follow-up of the bereaved by suicide was
mapped out in 1998 in the Norwegian nationwide Support and Care study, a
mere one-third of the municipalities had established crisis teams, 43% had
written routines for follow-up, while only 16% had such a formal system
between primary and secondary services (Dyregrov, 2002). The municipalities
themselves indicated that such organizational measures, in particular written
routines and crisis teams, were crucial to ensuring good follow-up of the bereaved
by sudden death. This was also confirmed in the study, in that the bereaved who
received follow-up in the municipalities through organized measures were more
satisfied with the help and received better offers of help (Nordanger, Dyregrov, &
Dyregrov, 2003).
234 / DYREGROV
Inadequate Knowledge About Crises
Leads to an Uncertain Form?
It can also appear as if a lack of knowledge about suicide, trauma, and crises can
contribute to uncertainty in the therapeutic relation with young people. The young
people’s stories indicate that a number of psychologists were inexperienced with
regard to the young suicide survivors and did not adequately inspire trust because
they were personally uncertain about how to receive young people in this type of
grief and crisis. The uncertainty is compounded by the fact that most psychologists
are seldom in contact with the young suicide bereaved and that such contact
involves an emotional strain. The young people confirm a number of previous
reflections in a former journal article (A. Dyregrov, 2004), where the significance
of active and sensitive relation-building in the first encounter with crisis-stricken
young people is indicated. As a number of the young bereaved emphasized: the
therapist must not expect the young person to “tell all” in the first session and to
take responsibility for keeping the conversation going. If the therapist is expectant
and passive, they push the young person away. The young people’s frustration
over the therapeutic alliance can accordingly be connected with a therapeutic
tradition that is inexpedient with regard to the particular issues with which the
young people are struggling.
Adequate Therapeutic Tradition?
Some features of traditional therapeutic practice can seem meaningless to the
young bereaved in relation to the issues with which they are struggling and want
help. There can be a contradiction between their need for information about and
an active relation to what has happened, own reactions and possibilities for
mastery, and the psychologist’s more passive, expectant, and retrospective attitude
in their meeting with the young people. When the psychologist expects the young
person to take control of the conversation and speak, this can be connected with
a lack of professional knowledge about young suicide survivors. In accordance
with crisis psychology, being active and helping the young people to create
structure and order in a chaotic life situation is central (Dyregrov, 2001). Psycho-
education will be an important tool (Pfeffer, Jiang, Kakuma, Hwang, & Metsch,
2002). By taking as a point of departure information about common reactions
following a suicide, the psychologist will also contribute to creating the necessary
confidence and belief that he or she can help the young person. Crisis psychology
emphasizes the importance of the therapy taking as a point of departure from the
experiences which the young people find most disturbing, and early on provide
self-help advice (Dyregrov & Dyregrov, 2005a, 2005b; Murray, Terry, Vance,
Battistutta, & Connolly, 2000). Subsequent to this, one can implement more
trauma-therapeutic methods such as exposure therapy, cognitive therapy and
EMDR, to address the problems they are struggling with (Bryant, Harvey, Dang,
& Sackville, 1998; Cohen, Mannarino, & Knudsen, 2004).
YOUNG SUICIDE SURVIVORS AND THE PSYCHOLOGISTS / 235
When the therapist serves as an active and advisory teammate, young people’s
belief in their own resources and mastery is strengthened. Many young suicide
survivors need and wish for help from a psychologist and hereby contribute
with their advice.
The young people claimed that good care giving on the part of a psychologist
would entail:
I. automatic offer of help so that they would not need to seek out and ask for
help;
II. early offer of help, which is repeated according to changing needs/
resistance over time; and
III. stand-by help if and when one needs it.
Moreover, they asked for the following connected to the form of the help:
1. flexibility a rule of thumb, nothing should be “shoved down one’s throat”;
2. an empathetic and interested helper—the chemistry must be right; and
3. a personal focus or individual sessions so they can speak freely.
Finally, considering the content of the help, the suicide survivors asked for
counseling from therapists with knowledge about suicide/crisis psychology. They
needed help with specific problems in the aftermath of a suicide, as well as
information about reactions, how to support others, and advice about self-help.
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Direct reprint requests to:
Kari Dyregrov
Center for Crisis Psychology
Fortunen 7. 5013 Bergen
e-mail: kari@krisepsyk.no
238 / DYREGROV
