“That feeling of solidarity and not being alone is incredibly, incredibly healing”: A qualitative study of participating in suicide bereavement peer support groups

Abstract

Suicide can have a significant impact on the bereaved. Peer support groups for suicide bereavement have been shown to enhance the wellbeing of those attending. However, research is lacking on the mechanisms that underlie these benefits. Semi-structured interviews were conducted with 12 adults attending peer-facilitated support groups in Ireland and thematic analysis was used. The findings highlighted the enduring emotional impact including guilt and questioning, loss of identity, as well as wider impacts. Mechanisms of the groups included the opportunity to share experiences and feel validated, connection and belongingness and collective processing of grief. Groups were found to have a unique role alongside other informal and formal supports. This study highlights the important role of peer support groups in lessening this burden and adds to the literature through identifying potential mechanisms by which peer support groups contribute to improved wellbeing for the suicide-bereaved and practical steps to facilitate these mechanisms.

Introduction

Each year, more than 700,000 people die by suicide (World Health Organization, 2021). The personal, societal, and economic costs of suicide are significant, underlying the need to work toward the prevention of suicide using a multi-level approach (Hegerl et al., 2008, 2021). For each suicide that occurs, it is estimated that 135 individuals may be impacted (Cerel et al., 2019) and the estimated lifetime prevalence of suicide bereavement is 21% (Andriessen et al., 2017).

It is well documented that bereavement due to suicide is different to other forms of loss, including other forms of traumatic death. People bereaved by suicide often report experiencing more intense and prolonged feelings of guilt, shame, and stigma, along with extensive rumination concerning the person’s motivation for dying and the circumstances surrounding the death (Pitman et al., 2018; Shields et al., 2017; Tal Young et al., 2012). Furthermore, bereavement by suicide has shown to be associated with poor mental health, including depression, anxiety, and suicide risk (Pitman et al., 2014, 2022). There are also some indications of poor physical health outcomes (Spillane et al., 2017).

Consequently, the support needs for those bereaved by suicide may be different and best practice indicates that supports tailored to the specific type of bereavement are most beneficial (Andriessen, Krysinska, Kõlves, et al., 2019). However, there is limited evidence for the effectiveness of supports in improving outcomes and reducing symptoms of grief (e.g., Andriessen, Krysinska, Hill, et al., 2019; Bartone et al., 2019; Linde et al., 2017). Peer support groups are commonly sought by those bereaved by suicide. While there is limited evidence regarding their effectiveness, groups facilitated by peers with lived experience are generally seen as being highly acceptable and beneficial to those who attend (Higgins et al., 2022).

The features of groups that may facilitate effective support have been highlighted in a recent scoping review (Higgins et al., 2022). That review identified important features including training and experience of facilitators, flexibility regarding the format and delivery of groups, and the mix of kinship and experiences among members. The processes underlying peer support have been hypothesized including social support, normalization of thoughts and feelings, modeling, and learning from others (Harrington-LaMorie et al., 2018). However, research is limited and often of low-quality in this area, particularly in relation to exploring the specific features and mechanisms of peer groups. Furthermore, little is known about how peer support is situated in relation to other forms of support, including therapeutic counseling.

The current study builds on a longitudinal survey study of adults participating in suicide bereavement peer support groups in Ireland, demonstrating that participation in the groups was associated with a reduction in symptoms of grief and an improvement in overall wellbeing at follow-up (Griffin et al., 2022), with those improvements varying according to the time since bereavement. The study also identified specific benefits of the group from survey comments, including shared understanding, safety, belonging and connection, which are in line with previous research (Harrington-LaMorie et al., 2018; Higgins et al., 2022). Further in-depth exploration of the experiences and mechanisms of benefit among these peer support groups is needed to understand the factors leading to improvements in grief experiences and wellbeing. The aim of this study was to explore individuals’ experiences of participating in peer-facilitated support groups for suicide bereavement.

Materials and methods

Study design

A qualitative descriptive design (Bradshaw et al., 2017; Sandelowski, 2010) was used to explore and describe experiences of participating in peer support groups for individuals bereaved by suicide.

The peer support groups

The peer support groups in this study are run in Ireland by the charity organization Healing Untold Grief Groups (HUGG), described in detail elsewhere (Griffin et al., 2022; HUGG, 2022). These evidence-informed groups are facilitated by trained facilitators who each have been directly impacted by suicide bereavement. The groups follow a common meeting structure informed by guidelines in the United Kingdom and Australia (Lifeline Australia, 2009; Support after Suicide Partnership & National Bereavement Alliance, 2011). Group guidelines are reinforced at the beginning of each meeting including confidentiality and non-judgement. Within each meeting, time is set aside to discuss a particular topic around grief, bereavement, or suicide. Anyone interested in joining the groups must complete an intake form and will be subsequently contacted by a facilitator to discuss their experiences and readiness to join a group. There exist protocols for the processes of contacting new members, signposting to other services, and running the groups, including handling distress of a group member. The groups are held fortnightly, have a maximum duration of two hours and up 12 adults can attend any meeting. HUGG was set up in 2018 and the groups originally met in-person but moved online in April 2020 due to the COVID-19 pandemic. At the time of data collection, the organization ran 14 groups across Ireland. Each support group has a corresponding messaging application, into which members can opt. It is moderated by the groups’ facilitators.

Participants and recruitment

Participants were recruited from active peer support groups that had been running for more than three months in different parts of Ireland. Participants were required to be over 18 years of age and have had at least three months’ experience of participating in the groups to be included in the study. Researchers described the study and provided the study information sheet to group facilitators who subsequently passed on the information to members of their group. Those interested in participating in an interview were invited to contact the research team directly via telephone or email. All those participating in the interviews provided written informed consent electronically. The researcher spoke with each participant prior to interview to explain the study and address any questions, to ensure they met the inclusion criteria and that they felt in a position to participate in the interview, given the sensitive nature of the topic.

A safety protocol was developed to respond to any situation in which a participant became distressed and was coordinated by senior researchers with clinical expertise (EA and EG). The interviewer (SOC) was experienced in conducting individual interviews and providing emotional support. Within the interview, the protocol included the options of skipping a question, taking a break, holding the interview in two parts, or stopping the interview. Following the interviews, the interviewer debriefed with participants about their experience and emotional state and reminded them of available supports. If the participant was distressed or indicated a need for further support, guidance was sought from the senior researchers and appropriate signposting/referral was provided to the participant as well as a follow-up telephone call.

Data collection

Semi-structured interviews were conducted online via Zoom. A semi-structured approach enabled flexibility in identifying issues of importance to the participant and probing of ideas emerging during the interviews. At the beginning of the call, the interviewer (SOC) provided a description of the research and described their research role. Participants had the opportunity to ask any further questions. The interviewer had no prior relationship with the participants and sought to establish rapport with participants prior to and throughout the interview.

The topic guide was informed by previous literature and survey research with the members of the peer support groups (Griffin et al., 2022). The initial questions focused on the participants’ experience of suicide bereavement and the support they received following their loss (See Topic Guide in Supplementary File 1). Then participants were asked in detail about their experience of participating in the peer support groups and any helpful/unhelpful aspects of the groups. Participants were also asked about the experience of online or in-person groups and any other improvements needed in terms of suicide bereavement support. Efforts were made to mirror the language used by participants. The interviewer took some brief notes regarding language or follow-up questions during the interview. Any further field notes were made following interview. The interviewer (SOC) engaged in reflection after each interview by debriefing with a senior researcher (EG) and journaling to aid reflexivity, that is paying attention to how personal experiences and assumptions might impact data collection and analysis (Mays & Pope, 2020).

Interviews with twelve participants were conducted between December 2021 and February 2022. The interviews ranged in length from 50 to 94 minutes (Mean = 77). All interviews were audio-recorded with the participants’ consent and were fully transcribed. Identifying details were removed from transcripts and participants were given a pseudonym. The sample size was informed by several considerations: overall numbers attending peer-support groups (Griffin et al., 2022), previous experience of reaching data saturation concerning experience of suicide bereavement, and the specific focus on experiences of peer support groups (Braun & Clarke, 2021). In addition, the lead researcher did not identify new codes pertinent to experiences of peer support from coding of the ninth interview onwards.

Data analysis

The interviews were analyzed using thematic analysis (Braun & Clarke, 2006). The researcher (SOC) familiarized themselves with the transcripts, including listening to audio-recordings alongside the transcript. NVivo 12 was used to assist with data management and coding. The interviews were coded inductively, and potential themes were identified. All interviews were coded by the lead researcher (SOC) and 33% (n = 4) were coded independently by a second researcher (MIT). Coding and initial themes were compared, and any discrepancies were discussed and resolved with the assistance of a third researcher (EG). The themes were then reviewed internally and against all interview transcripts. Negative cases, or those with experiences that seemed contrary to the majority of participants were examined in the development of themes. The final themes were reviewed and discussed by three authors (SOC, MIT, EG). An audit trail was kept of the data collection and analysis processes.

Ethical approval

This study was approved by the Clinical Research Ethics Committee of the Cork Teaching Hospitals (ECM 4 (h) 07/07/2020 & ECM 3 (hh) 01/06/2021).

Results

In total, twelve adults participated in semi-structured interviews (10 women and 2 men). Most participants (n = 11, 92%) had lost one person to suicide. Participants had varying relationships with the deceased, with representation from people who had lost a parent, sibling, child, (ex-) partner/spouse and friend. The median time since bereavement was 36 months (IQR = 25) while the median length of time attending the groups was 10 months (IQR = 5). Participants represented different peer support groups across the country. At the time the interviews were conducted, most participants had primarily attended online groups, and only a very small number of in-person sessions.

Three themes were identified in the analysis that describe the contribution of peer support groups in the context of experiencing suicide bereavement and other supports: Experiences of suicide bereavement; Features of peer support groups; and Accessing peer alongside other supports (See Coding Tree in Supplementary File 2).

Experiences of suicide bereavement

Emotional impact of suicide bereavement

The significant emotional impact of suicide was to the fore of all participants’ accounts. In the immediate aftermath of the death, they often described being in a fog, a sense of shock, disbelief, and numbness. The emotional impact was experienced as challenging for all.

And just waking up in the morning, it was like the first thought and it was just that sense of this kind of like waking up into a nightmare. Yes. Just, you are kind of trundling along and this thing comes along and it’s just a total body blow and it makes you really question everything about yourself and everything about the world. (Caroline)

The impact continued into the long-term and many described that the grief felt worse after the initial shock and “fog” had lifted, which was typically after the first six months to a year following the loss. The COVID-19 pandemic was also felt to influence the trajectory for many, with some participants feeling this kept them stuck in certain aspects of grief for longer than they might have been in non-pandemic times.

So like the first few months was hard and then COVID hit in March, so we hadn’t even got our head around what was after going on and then that happened. Um so I think even up to last year was quite numbing. The reality is just after hitting this year. (Sinead)

Guilt and questioning regarding suicide were common. Most reported that they questioned why the person had died and if they could have done more to prevent the death.

So it’s hard then to know what you could have done, what you didn’t do, what you should have done. So it’s all questions all the time isn’t it. You’re just backtracking and doubting yourself and thinking “What if?” or “what shoulds?” (Sinead)

Other issues identified were feelings of loss of identity. Participants grieved the loss of a person with whom they would normally share their experiences with and they questioned how to exist in the world following the death.

It was just kind of “oh my goodness, who am I now?” The person I spent every day with, I talked to all the time, you’d get the phone and you’d be like, “oh I can’t talk to that person.” Just complete absence. (Laura)

Additional challenges of suicide bereavement

Physical impacts of bereavement were highlighted and were perceived as being related to emotional stress. Many experienced exhaustion and tension in their bodies while others described somatic symptoms such as developing rashes and other sicknesses/infections readily.

I was in that awful place of pain and emotional pain, physical pain. Yes, [the] physical pain of grief is horrendous. I never knew that. Nobody told me my neck is going to be hurting, my shoulders are going to be hurting, my belly is going to be hurting. No. Where the hell does that come from? (Margaret)

Some participants reported a negative impact on their relationships with others. This was primarily related to differing views on the death or blame regarding the death and often occurred in the context of family relationships.

I think after suicide the whole family changes, so the dynamics shift, and nothing is the same again. It takes a while to build up, not even the trust but, to know who’s right and who’s wrong. Like your parents think one way or your mother might think one way. (Sinead)

There were also practical challenges resulting from the bereavement such as dealing with legal proceedings following the death and supporting bereaved children and young people.

Features of peer support groups

Group fundamentals

Shared understanding

Participants consistently identified shared lived experience as the underpinning feature of peer support – that all members of the group, including facilitators, have a shared experience of suicide bereavement. This contributes to a common understanding and empathy with other members such that there is an automatic understanding of other members’ experiences that does not need to be fully articulated. This sets the foundation for many other aspects of the group that people find beneficial.

Having others in there who know exactly, you are not on edge, you are not afraid you are going to upset someone else, because we all know exactly what we are all talking about, you know? (Bridget)

Participants spoke of how they had considered or tried other bereavement support groups (e.g., for spouses or parents) but mostly did not feel they belonged there given the unique experience of being bereaved by suicide and the emotions associated with it, including guilt and anger. Within their experience, participants acknowledged they may find even greater similarities with those who lost a person with the same relationship as well as other commonalities such as the unexpectedness of the death or children affected by the loss.

Yes, so that’s a big part of what ties us all together, is the guilt that we have around the person who passed away. And what we perceive that we should have done. “Ifs, buts and maybes,” we constantly talk about them. And sometimes after talking about it, it can ease a little bit and you kind of see a bit more rational and that, but it never really goes away. (Martin)

The groups were seen as a safe and confidential space, primarily owing to this shared experience. This was also strengthened by a routine meeting structure where the beginning of the group involves a reminder of the guidelines, including the equality of each members’ grief experience and the confidentiality of the group.

Flexibility in participation

A second underpinning feature of the groups was their flexibility with regards to participation. This involved both flexibility in the extent to which people participate in the meetings but also in communicating with the group members outside of the regular session. Participants valued that they could contact members of the group outside of the scheduled meeting times. Mostly participants recounted experiences of their shared group messaging platform. On this platform, someone could reach out if having a bad day, at the time of an anniversary, or people also shared quotes or ideas that they believe are helpful to others. This provided reassurance that support was available when they needed it.

I love the group chat as well; if someone’s having a really bad day people will post in there and we’ll support each other, we’ll put quotes or things about bereavement or just uplifting quotes and things like that to look out for each other, I guess. And so, I feel like they’re there all the time. (Sarah)

Some participants had missed sessions due to other commitments or not feeling up to it but valued that this was not problematic in the group setting and that they could return at the subsequent session or link in with the messaging platform. Within the groups, they valued that there was no pressure to contribute to the meetings and that listening to others was also sufficient. Most felt that there was a natural flow of conversation. A small number acknowledged that sometimes it might be difficult for everyone to get an opportunity to talk, particularly if all group members are present, but did not see this as being overly problematic.

And, look, there’s no pressure to talk, if people don’t want to talk, they don’t have to, and there are meetings where the way the conversation ebbs and flows, you mightn’t contribute a lot, but you’re still taking in stuff from what people are saying. (Noreen).

Group mechanisms

A number of group processes or mechanisms were identified by participants as helping them to cope with their bereavement.

Sharing and validating experiences

One of the basic benefits of the peer support meetings was the opportunity to speak freely about emotions and experiences that could not easily be discussed with family and friends and to feel those emotions and experiences were validated by their peers.

And then to have that outlet for… I suppose I was able to just take the safety valve off a little bit and talk about how hard I was finding things, how difficult life was. (Noreen)

Obviously, people are different and it affects us all differently, but there are…the amount of times that people will mention something on Zoom and you’d see people nodding. Or we’d speak up and say “yes, I felt exactly the very same.” (Martin)

Increased connection and belonging

Feeling connected with others and reduced isolation were key aspects of the groups such that participants now felt less alone in their grief. The connection was particularly emphasized by some who felt they had limited support from their own family and friends.

I think the thing I felt the most was I felt really alone in my grief, like I felt no-one else understood, I felt I’d never find anyone else who understood or who’d actually hear me and understand. That’s what I get in HUGG and that’s the only place I have had that and have since, so it’s really important to me and I feel really strongly about it. (Sarah)

While participants were amazed at the level of connection that could be established in online groups, many reported that connection was enhanced in the in-person groups compared to those online. This was related to the atmosphere in the room, the opportunity for physical embrace as well as the opportunity for smaller group conversations at the beginning or end.

Comparisons with peers

Participants recalled benefitting from comparisons they made between themselves and others in the groups. Mainly, they described upward comparisons or modeling where they were re-assured to see people further along in their grief journey and where people re-assured them things would improve.

It’s really helpful for people early on to see someone sitting there breathing, alive, after four or five years of this and saying “It does get better, it’s not always this.” But yes, that’s really helpful to people, especially early on when you really feel despairing. (Sarah)

Others recounted comparing themselves to others more recently bereaved or in a more challenging phase and found solace in seeing the progress they had made in their grief and coping.

I felt “god, haven’t you come a long way, you were there.” And it was a real moment for me, that. I suppose it was a moment of strength because I have, I’ve lived through hell and that woman was in hell. [Pause] That I suppose was probably the most amazing moment I’ve had with HUGG was right that evening. (Margaret)

A small number of participants spoke of developing self-compassion through comparing themselves with peers. If for example, another participant was speaking about guilt, they would empathize with the person and subsequently identify that they should offer similar compassion to themselves.

Collective processing of grief

Participants identified how the groups were helping them to process their grief and spoke of a type of collective processing in the group context. This included humanizing the experience of grief and then dealing with questioning and guilt to move more toward a place of self-compassion and acceptance. Hearing about someone else’s grief experience would trigger their own thoughts and feelings about this. For many this created opportunity for reflection and growth.

From week to week you’re reflecting on what is discussed and what is said and how people view things and maybe somebody might say something that might make you look at something a little bit differently, will help you then move on and through that, so it’s that kind of collective, almost unsolving of things and unpacking of things. (Clare)

However, exposure to other peoples’ experiences could also make participating in the groups challenging. Some participants recounted finding some experiences particularly triggering. However, this did not diminish the value of the group meetings, as articulated by participants in this study. They managed their own participation in the groups depending on how they were feeling.

And seeing her so upset and I got really upset as well. And yes, yes, it just hit home and it hit me hard. […] So when I got home, I was wrecked. […] You’d be so tired but it’s almost like a release when you come home that you feel you’ve gotten stuff off your chest, and you feel really heard and validated in your experience and stuff as well. (Sarah)

To a lesser extent, participants spoke of both benefits of sharing practical information within the groups and activities to commemorate the deceased. Participants valued opportunities to commemorate the deceased and discussions within the group that helped them to prepare for anniversaries or occasions.

Accessing peer alongside other supports

Accessing peer support

Participants highlighted the need for greater awareness of peer support and availability of groups. Most came across the organization via their own online research, through word-of-mouth or media advertisement. They felt there needed to be greater awareness of the organization, particularly via gatekeepers and other professionals who encounter people bereaved by suicide.

I don’t think a lot of people know about it you know. A lot of people I spoke to afterwards who had been bereaved by suicide were saying “god I never heard of that” and “oh that’s nice but haven’t heard of it.” So it’s pure luck that I saw it. (Sinead)

Many participants spoke of the importance of having a standardized approach to early outreach that would provide people with a list of support services, including peer support, in the early stages following bereavement so that the person could access these when ready. Participants had varied perspectives on what is an appropriate time to join a peer support group and the overarching sentiment was that may vary depending on the person.

I suppose I think that people have access to the information, which you think all of the information that you need is in that HSE booklet. It’s having somebody to give it to you, to know that it’s there and having a solid enough head space to be able to read it. I don’t know. I suppose in the early days you’re hardly able to hear anything or anyone, but I suppose somebody telling you that there is help out there, there are people who care, there is support out there. (Margaret)

Holding group sessions online was seen as a way of increasing access to the groups. While face-to-face groups were perceived by some to be superior in terms of connection and atmosphere in the room, others felt that they may have been more hesitant to start attending a group in person and therefore the online platform enabled them to join. Participants highlighted that the online groups allowed people from other geographical areas to access peer support where they would not otherwise have been able to.

The upside of it is that it’s great because you can reach people that don’t have HUGG in the county and that’s very important. It has a place for the likes of that and that’s very important. (James)

Peer and informal support

Many participants recounted support from other family/friends who were also affected by the same loss, and this was valued in terms of being able to talk about the person and details specific to them. While many received positive support from friends and family, there were some challenges with this support such as fear of upsetting others. Friends and family who were not directly linked to the deceased often provided useful support, particularly if they had also experienced bereavement or could empathize in some way.

So we talk about it but we talk about it in quite a factual way and I’m always very conscious not to cause [sister] concern, not to say anything that may make her overthink and get overly concerned about something, whereas with somebody like my friend, one of my friends, I might be a little bit less… he would have known [deceased] really well as well but I suppose he would be a slight bit more distanced from me and from [deceased] than my sister would. (Clare)

Some participants found that people close to them took varying roles of providing emotional support or practical support. They noted how some people felt an awkwardness in speaking about suicide that was related to stigma and thus some people, like friends and colleagues, were unsure how to offer emotional support:

It’s the most open secret that people have such huge discomfort talking about. […] There was a colleague of mine, [who’s friend had been bereaved by suicide] and she came to me and she said, “What do I say to her?” (Margaret)

Peer and other formal supports

Most participants had experiences with other formal support such as counseling/therapy and many attended peer support during the same time periods as counseling. Many of these experiences were positive but there were a small number of accounts where people had felt their experiences were not validated by the counselor or therapist and this situation contrasted with the shared understanding of the peer support group members.

Even when I said to the counselor that I had recently, about feeling guilty, and I think he just said, “Why?” and I was like… I know it was his job and he needs to get me to talk but I was like “why the fuck do you think,” whereas I said one day, in the HUGG, I was like, “Do you know what, the guilt is tough,” and they just kind of nodded and they were like, “Yes, it is.” That was just what I needed more, do you know? (Karen)

Participants also highlighted the idea that counseling and peer support differ somewhat in that the former deals with the rational aspect of managing grief while the latter supports people in “living life” following suicide bereavement or moving from “your head to your heart.”

It has been a different order to the help that I received in one-on-one counseling, which feels like more about your rational take on your bereavement, but there’s just a beautiful empathy with being in the same space as people who have suffered the same grievous loss and somehow it just lightens the load. (Caroline)

Peer group support and individual counseling were also seen as offering unique benefits. In comparison with the peer support groups, counseling was felt to be beneficial for focusing on other aspects of a person’s wellbeing whereas the groups mainly focused on bereavement.

I don’t know if you necessarily have to have a grief counselor, it depends. He has helped me and continues to help me through the grief, but I’m glad he’s seeing it, he’s seeing beyond the grief itself. (Clare)

Discussion

This research builds upon a previous study finding positive impacts of peer-facilitated support groups for those bereaved by suicide in Ireland (Griffin et al., 2022). Using a qualitative approach via semi-structured interviews, the current findings provide insight into the specific features and processes of peer support groups that may underlie improvements in wellbeing and grief experiences. The study highlights that people bereaved by suicide highly value support from others who have experience of suicide bereavement. Participants described their own experiences, including guilt and stigma due to the suicide death, and the impact this had on their overall physical and mental wellbeing. Peer support groups for those bereaved by suicide had benefits such as the opportunity to share experiences, increased connection and belongingness, perspective on their own situation via comparison with peers, and collective processing of grief. Participants also highlighted how peer support groups provided unique benefits compared to other formal and informal supports and how these supports fulfilled complementary roles.

This study adds to the knowledge of potential mechanisms or psychological processes that contribute to the positive impact of peer support groups for those bereaved by suicide. The shared experience of suicide bereavement helped members to feel connected to a group and normalized their experiences, thoughts, and feelings, as has been noted in previous studies of peer support (Harrington-LaMorie et al., 2018). For some participants, connection was enhanced in in-person/face-to-face meetings with peers, however, the online groups offered advantages in terms of increased accessibility. Positive impacts of online peer support groups have been found, as in our previous study (Griffin et al., 2022). While further comparison of the effectives of online versus in-person support is recommended (Higgins et al., 2022), the current study highlights that having the option of in-person and online groups may provide the greatest opportunities for engagement in peer support based on individual preferences.

Processes of social comparison and modeling were evident in the study such that group members benefited from comparing their current situation with those who may be either at earlier or later stages of the grief journey (Salzer & Shear, 2002). The latter was reported to inspire hope for the future. This finding supports having a diverse group membership according to time since bereavement to facilitate these comparisons and related discussion. A small number of participants also highlighted that they began to extend the compassion they felt for other group members to themselves. The process of fostering self-compassion in peer support groups has not been extensively documented in the literature and may warrant explicit focus in the peer support given the intense guilt, blame and stigma that can be experienced by this group, as evidenced in this study and others (Pitman et al., 2016). Furthermore, self-compassion interventions have been found to reduce rumination and self-criticism (Ferrari et al., 2019). Memorialization and having opportunities to commemorate the deceased were also valued in this study, though this was not as prominent as other studies of online support that focused primarily on memorialization (Lestienne et al., 2021). This study identified potential mechanisms of peer support that may be important in ensuring peer support benefit, though further research is needed to confirm the role of these mechanisms.

Our study highlighted a lack of awareness of peer and other supports among those bereaved by suicide. Ensuring early outreach of support was one of the central messages in our study, an emerging area of suicide postvention models (Andriessen, Krysinska, Kõlves, et al., 2019). Participants felt that contact from support in the early days after bereavement could provide early validation of experiences and highlight the available supports that may be of benefit over time. Early outreach was one of the most common needs reported in a study of people bereaved by suicide in Canada (Ligier et al., 2020). Specifically, the study recommended contacting the suicide-bereaved immediately following the death to answer questions and provide information on available resources, and to follow-up within six-months to refer them to supports based on their psychosocial or practical/financial needs. A preliminary evaluation of an active postvention model in the United States (Cerel & Campbell, 2008) found that people who received active outreach were more likely to present to services sooner than those receiving passive postvention and on average attended more group sessions. More recently, an evaluation of the Standby service model in Australia—which includes an outreach component and crisis support from 1 to 5 days and up to 12 months following the death—found that people who received the intervention had improved outcomes in terms of suicidality, social support and loneliness compared with a control group (Gehrmann et al., 2020). Our findings support the importance of early outreach and the need for a standardized approach to ensure that all people bereaved by suicide are reached. Furthermore, it is important to assess individual needs and preferences so that individuals can be linked with appropriate support. Our study offers additional information on the unique perceived benefits of peer-facilitated peer support and individual counseling or therapy. In addition, these can be complimentary in helping a person process their grief and improve wellbeing, with most participants in the study having experienced individual counseling either before or alongside peer support.

The literature points to a range of potential challenges in providing peer support for people bereaved by suicide, though these were not prominent in this study. One issue is the potential for causing emotional distress or what Harrington-LaMorie et al. (2018) describe as the potential to “retraumatize” participants (Higgins et al., 2022). Participants in this study described an emotional challenge of participating in groups but this was not seen as outweighing the positive impacts of the group. The emotional experience was seen by some as part of the journey of processing grief, the group being a safe space to share and express their feelings. However, it is important to consider the potential for group participation to retraumatize or cause excessive distress to participants. Protocols for assessing suitability for group participation and identifying and managing participant distress within groups are key to minimizing these risks. Another crucial aspect is the practices for referring or signposting people to other supports where necessary (Harrington-LaMorie et al., 2018). For example, psychotherapeutic approaches incorporating cognitive behavioral and emotion-based therapies are showing benefit for those experiencing post-traumatic stress or prolonged grief (Eddinger et al., 2021; Szuhany et al., 2021). The organization providing peer support in the current study ensures a thorough intake process including an assessment of readiness to join, a process for checking-in with new members, and signposting to other services at intake and later in group participation. Furthermore, facilitators receive training and ongoing support in their role. These features may help explain how participants in this study did not perceive the groups as emotionally overwhelming.

Previous research has highlighted challenges in setting appropriate boundaries and fostering dependency of group members of peer support groups (Harrington-LaMorie et al., 2018). In this study, challenges in boundaries were not to the fore of participants accounts. Participants really appreciated an adjunct messaging application where they messaged at various times outside the meeting and described how other group members responded with comforting messages or ideas. In the current study, the messaging app was set up when the meetings moved online in response to the pandemic. However, messaging groups were perceived as providing an additional benefit to participants under broad guidance to use them for messaging purposes in reasonable hours. Appropriate management of messaging groups may warrant ongoing consideration to ensure that group members are not overburdened by this communication.

Strengths and limitations

This research is a unique addition to the suicide bereavement literature, furthering our understanding on the impact of suicide bereavement peer support groups. Our study employed qualitative methods and lived experience accounts to explore the narratives of people bereaved by suicide, and their experience navigating this bereavement through peer support groups. The demographics of participants in this study were reflective of the overall group membership, representing a range of ages, relationships to the deceased, time since bereavement and lower participation of men than women (Griffin et al., 2022). Interviews were conducted on a platform that participants used to participate in online support groups. A further strength of this study was that it was designed in consultation with people with lived experience of suicide bereavement, further adding to the relevance of the research conducted. The findings of our study must be considered with the following limitations. Given that we recruited participants from an active peer support group, we may have only reached those with positive support experiences and may have missed out on an important group who may have had negative experiences of peer support that may lead to disengagement. Furthermore, our study took place in a specific group context, and whilst we described this group specific context and structures, findings need to be considered with this limitation.

Conclusion

People bereaved by suicide value support from others with experience of suicide bereavement, a finding reinforced by this research. Our study adds to the literature in identifying potential mechanisms by which peer support groups contribute to improved wellbeing for the suicide-bereaved and practical steps to facilitate these mechanisms. People bereaved by suicide have reported limited awareness of supports available and feel that early outreach is needed to provide validation of initial experiences as well as information on supports available. In addition, peer support offers unique benefits compared to other supports and can be complimentary to other informal and formal supports.

Relevance to clinical practice

This study provides important contributions and lived-experience insights to clinical practice relevant to those supporting individuals bereaved by suicide. While mental health services continue to be under great demand, especially following the COVID-19 pandemic, the role of peer support, which is primarily provided through the community and voluntary sector, offers an important resource to this at-risk group. Protocols for joining and running the group were positively evaluated by participants in this study and can have direct implications for potential mechanisms of benefit. These study findings endorse the need for support groups to adopt appropriate guidelines and protocols in line with up-to-date evidence (Andriessen, Krysinska, Kõlves, et al., 2019; Console, HSE National Office for Suicide Prevention, Turas le Chéile 2012). Specifically, our study reinforces the importance of protocols for assessing suitability for group participation; identifying and managing participant distress; as well as referral or signposting people to other supports. Furthermore, the findings support the need for a standardized approach to early outreach to people bereaved by suicide so they are aware of the various options of support available to them.

The findings support a number of practical considerations when developing groups. For example, having diversity in peer support groups in terms of length of time since bereavement may enhance benefit to participants. Being in a group with people longer bereaved can provide learnings and hope to participants while participants longer bereaved also realize the progress they have made when comparing themselves to those more recently bereaved. In addition, having the option of face-to-face as well as remote groups would allow people with a range of preferences to participate in the groups balancing individuals’ concerns for accessibility and increased sense of connection in face-to-face settings.

Acknowledgments 

The authors would like to thank those who generously participated in the interviews, along with Fiona Tuomey, Chief Executive Officer HUGG, and Adam Grennan, Chairperson HUGG, for facilitating this research study. 

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Requests for data should be directed to the corresponding author.

Additional information

Funding

This work was supported by the Irish Research Council’s New Foundations Scheme [NF/2020/20965640].