Evaluation of a New Online Program for Children Bereaved by Suicide: The Views of Children, Parents, and Facilitators
Evaluation of a New Online Program for Children Bereaved by Suicide: The Views of Children,...
Krysinska, Karolina; Currier, Dianne; Andriessen, Karl
2023-04-22 00:00:00
ARCHIVES OF SUICIDE RESEARCH https://doi.org/10.1080/13811118.2023.2185559 Evaluation of a New Online Program for Children Bereaved by Suicide: The Views of Children, Parents, and Facilitators Karolina Krysinska , Dianne Currier , and Karl Andriessen KEYWORDS ABSTRACT Bereavement; children; Objective: Experiencing the suicide of a parent or a sibling is one of evaluation; intervention; the most disruptive and stressful events in the life of a child or ado- suicide; support lescent. Yet, little is known about the effectiveness of support offered to children and adolescents bereaved by suicide. This study aimed to evaluate participant and facilitator’s perceived helpfulness of the new online Let’s Talk Suicide program, piloted in 2021. Method: Thematic Analysis of qualitative interviews with 4 children, 7 parents, and 3 facilitators (N ¼ 14). Results: The analysis identified four themes focused on suicide bereavement specific support, the online environment experiences, expectations and perceived outcomes of the program, and parents’ involvement in the program. Conclusions: The young participants, parents, and facilitators were very positive about the program. They felt that it supported the chil- dren in their grief after suicide, helped to normalize their experien- ces, offered social support from peers and professionals, and enhanced their language and skills to express themselves and to deal with their emotions. Though longitudinal research is needed, the new program seems to address an existing gap in postvention services for children and adolescents bereaved by suicide. HIGHLIGHTS The children felt supported in their grief as it enhanced their skills and language to express themselves. The program also acknowledged the parents and supported them in their parenting role. Future longitudinal studies may enhance the evidence of effect- iveness of the program. INTRODUCTION Experiencing the death of a parent or a sibling is one of the most disruptive and stressful events in the life of a child or adolescent. Grief in this population can manifest itself in various ways, and may include crying and feelings of sadness, guilt and longing (Balk, 2014). Moreover, there is evidence that those experiencing bereavement by suicide may experience more feelings of shock, anxiety, anger, and self-blame than those bereaved by natural causes (Andriessen, Hadzi-Pavlovic, Draper, Dudley, & Mitchell, 2018;Bartik, 2023 The Author(s). Published with license by Taylor & Francis Group, LLC. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. 2 K. KRYSINSKA ET AL. Maple, & McKay, 2020), strugglemorewith “why” questions, and experience less social support (Andriessen, Mowll, et al., 2018; Hoffmann, Myburgh, & Poggenpoel, 2010;Silven Hagstrom € , 2013). They may also develop more mental health problems (e.g., depression, anxiety, posttraumatic stress disorder), and suicidal ideation after the bereavement (Del Carpio, Paul, Paterson, & Rasmussen, 2021;Pham et al., 2018). In response to the high burden of bereavement, several child and adolescent support programs, including support groups, family interventions, and grief camps have been developed (Bergman, Axberg, & Hanson, 2017; Currier, Holland, & Neimeyer, 2007; Rosner, Kruse, & Hagl, 2010). Grief camps are short-term interventions where trained professionals, volunteers, and/or bereaved peers provide support to young participants (i.e., campers) (Clute & Kobayashi, 2013). There are differences between camps regard- ing participation requirements as some camps are tailored to support children/adoles- cents who experienced a particular type of bereavement, e.g., lost a sibling to cancer (Creed, Ruffin, & Ward, 2001), a parent to any cause of death (McClatchey & Raven, 2017), or a parent to suicide (Silven Hagstrom, 2021). Although different frameworks inform design of individual camp programs, such as family therapy or trauma-focused cognitive behavior therapy (McClatchey, 2020), over- all they aim to teach campers about grief and healthy coping, provide a psychoeduca- tional and therapeutic space to talk about the loss, and to socialize with other bereaved children, including various informal and physical activities, such as play and sports (Clute & Kobayashi, 2013). As parents are the most important facilitators of help- seeking in bereaved children and adolescents (Andriessen, Lobb, et al., 2019; Rickwood, Mazzer, & Telford, 2015), some grief camps offer a parental activity to facilitate sharing amongst parents (Clute & Kobayashi, 2013). The studies examining the effectiveness of grief camps have reported promising results such as grief camps helping children deal with their loss, develop resilience, and supporting their mental well-being (Clute & Kobayashi, 2013). Studies indicate improve- ments in self-reported grief (Griffiths, Mazzucchelli, Skinner, Kane, & Breen, 2022), reduced anxiety (Hartwig & Marlow, 2022), greater posttraumatic growth (McClatchey & Raven, 2017), and improved self-concept (Hartwig & Marlow, 2022). Young suicide bereaved campers reported a decrease in shame and self-blame related to the normaliza- tion of their grief experience (Silven Hagstrom, € 2021). Grief camps can also contribute to less coercive and more consistent parenting (Griffiths et al., 2022), and improve fam- ily communication and parents’ ability to support their bereaved children (Silven Hagstrom, 2021). Still, it is unknown whether these positive outcomes and experiences are also found in online “camps” (group support) for this population. Let’s Talk Suicide Program Since 2015, Feel the Magic, an Australian not-for-profit organization has been facilitat- ing “Camp Magic” for children and adolescents (aged 7–17) who have lost a parent, sib- ling or legal guardian, by any cause of death. Camp Magic follows a structured psychoeducational program, includes physical activities and resilience building chal- lenges, and connects campers with peers in a supportive and safe environment. ARCHIVES OF SUICIDE RESEARCH 3 In the context of the COVID-19 pandemic, in October 2020 Feel the Magic received funding from the New South Wales Department of Health to develop an online pro- gram for those aged 7–17 years and their families to minimize ongoing impacts of sui- cide in young people. Feel the Magic developed the Let’s Talk Suicide program by the end of 2020 in collaboration with the Illawarra Shoalhaven Suicide Prevention Collaborative and through a co-design process with Roses in the Ocean, a suicide- related lived experience organization. The program has been piloted in 2021 and has been offered free of charges to participants. The Let’s Talk Suicide program aimed to: (a) deliver a two-week online program for 6 to 8 children per group, and their families, providing tools and psychoeducational strat- egies for managing child grief after the suicide of a parent or sibling, (b) create a space for parents/guardians to connect with other parents/guardians, and (c) create avenues for people bereaved by suicide to use their experience to support others bereaved by suicide. The program was informed by Cognitive Behavioral Therapy approaches for identify- ing and managing thoughts and emotions, Acceptance and Commitment Therapy approaches for dealing with emotional and challenging experiences to build resilience, Narrative Therapy approaches for comprehending various layers of experience, and Somatic Therapy approaches for dealing with somatic grief manifestations. Methods across the three sessions included psychoeducational lectures, facilitated discussions of personal grief experiences, creative activities (e.g., drawing), and guided imagery/mind- fulness meditation and emotional regulation exercises. The program was offered to three age groups: 7–9, 10–13, and 14–17 years old and comprised three 1.5 hour live, online group sessions over two weekends, with one prere- corded parent orientation session and one live, online mid-week check-in for parents. Each group was facilitated by two facilitators, including one psychologist and one with lived experience of suicide bereavement. Aims Due to a paucity of intervention studies, little is known about the effectiveness of support offered to children and adolescents bereaved by suicide, including online group interven- tions (Hung & Rabin, 2009; Journot-Reverbel, Raynaud, Bui, & Revet, 2017; Lestienne, Leaune, Haesebaert, Poulet, & Andriessen, 2021). Nonetheless, evidence suggests that pro- fessionally led interventions based on supportive and psychoeducational approaches, which also involve a parental component, hold promise in terms of providing adequate help (Andriessen et al., 2019; Pfeffer, Jiang, Kakuma, Hwang, & Metsch, 2002; Ross, Krysinska, Rickwood, Pirkis, & Andriessen, 2021). This study aimed to evaluate participant and facili- tator’s experiences and the perceived helpfulness of the Let’s Talk Suicide program using qualitative interviews with participants (children/adolescents, parents) and facilitators. MATERIALS AND METHOD Evaluation Design and Recruitment We conducted the study according to the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007). Children/adolescents and their parents could 4 K. KRYSINSKA ET AL. participate in the Let’s Talk Suicide program and the evaluation if: (a) the child/adoles- cent was aged 7–17, (b) the child/adolescent had lost a parent or sibling by suicide, and (c) the death occurred at least six months before taking part in the program. The 6- months exclusion criteria to avoid including participants who might still be in a crisis after the death is in line with established good practice (Andriessen, Mowll, et al., 2018, Andriessen, Krysinska, Rickwood, & Pirkis, 2020). When enrolling in the program, Feel the Magic asked the parents (without any obli- gation) whether they and their child/adolescent were interested to take part in an inter- view for evaluation of the program. If so, they were asked to consent for their contact details to be shared with the research team. Next, the researchers emailed the parents the plain language statement with details about the study and consent. If the parent and/or their child/adolescent agreed to take part, an interview via zoom or telephone was scheduled at a time convenient for them. Participants aged 7–9 and 10–13 years were interviewed together with a parent/guardian. Parents of adolescents aged 14–17 were offered the option for an individual interview for themselves and/or their adoles- cent. Both parent and adolescents aged 14–17 could take part whether or not their own adolescent or parent participated. Feel the Magic forwarded the plain language statement and consent information to the facilitators. Those interested in the study were required to contact the researchers. Interviews (by telephone or Zoom) were scheduled at a time convenient for the participant. Participants We contacted seventeen parents and three facilitators who had expressed interest in the study. Seven parents, four children, and all three facilitators, agreed to be interviewed (Table 1). The death by suicide, where reported (n ¼ 5), was between five and ten years (M ¼ 6.8, SD ¼ 1.72) prior to participating in the program, indicating the long-term impact of a suicide in this population. The deceased person was a father (n ¼ 3), a brother (n ¼ 1), a mother (n ¼ 1), and not reported (n ¼ 2). Data Collection In line with then valid COVID-19 restrictions, we conducted the semi-structured inter- views remotely using an interview guide developed for this study (Appendix, Table A1). The lead questions were adapted to the target group (children/adolescents, parents and facilitators). Children were accompanied by a parent. Interviews were conducted by an TABLE 1. Study participants. Children/adolescents (n ¼ 4) Parents (n ¼ 7) Facilitators (n ¼ 3) Age in years: M (SD) 12.22 (0.47) 45.17 (11.65) 50.33 (1.25) Gender: % female 75% 100% 67% Age group: N (%) 7–9 years (Program 1) 3 (100%) 1 (11%) 2 (28%) 10–13 years (Program 2) 5 (56%) 3 (44%) 14–17 years (Program 3) 3 (33%) 2 (28%) % do not add up to 100% as some parents participated in more than one program; % do not add up to 100% as facilitators facilitated more than one program. ARCHIVES OF SUICIDE RESEARCH 5 experienced research psychologist (K.K.) or a social worker with extensive experience in bereavement research (K.A.). The interviews took on average 29 minutes (range 15–49). Data Analysis Interviews were transcribed professionally, and transcripts subjected to a deductive the- matic analysis, based on the interview questions, according to the principles described by Braun, Clarke, Hayfield, and Terry (2019). This approach considered the experiences of the participants in the program and its perceived helpfulness. Thematic analysis involved an iterative process of systematically identifying and organizing patterns of meaning (i.e., themes) in the data set, starting with reading and rereading the data to produce initial codes. Next, initial codes were grouped in potential themes, which were revised against the data before we decided about the themes. These recursive steps of familiarization and coding of the data is necessary to answer the research question. We used NVivo12 (QSR, 2020) for coding and data management. Researchers K.K. and K.A. conducted the analysis and discussed progress with researcher D.C. Ethics Approval The Human Research Ethics Committee of The University of Melbourne approved the study (ID 2021-20779-17259-4, May 10, 2021). We obtained written consent from all participants, including assent from those below age 16, prior to the interviews. RESULTS The analysis yielded four major themes: (1) the importance of suicide-bereavement spe- cific support; (2) appraising the online environment; (3) expectations and outcomes of the program for participants and parents, and (4) parents’ experience of involvement in the program. In what follows, participant names have been replaced with numbers; C refers to child/adolescent participant, P refers to parent, and F refers to facilitator. Theme 1: The Importance of Suicide-Bereavement Specific Support Almost all parents, young people, and facilitators perceived suicide bereavement and its aftermath was “different”. Parents and facilitators indicated the need for suicide- bereavement specific activity and welcomed the Let’s Talk Suicide program. Given the perceived stigma around suicide bereavement, the parents and young people stressed that feeling connected with others in the similar situation and mutual understanding was crucial. It’s also nice when I go to camps in the Let’s Talk Suicide programs because it shows that there’s other people who are going through the exact thing. ( … ) because there’s lot of people who had—whose parents had also committed suicide and it was—that made them understand of how to bring it up and how to cope. (C06) Some parents reported that their children, who had participated in a regular Feel the Magic camp could have felt “different” from children bereaved by other causes. 6 K. KRYSINSKA ET AL. Nonetheless, other parents appreciated the general and open grief focus of the Feel the Magic camps and perceived the new program as a valuable addition rather than a replacement. In this context, one parent cautioned against creating “silos of grief”. Parents stressed the importance of the right timing of participating in the program. One parent reported apprehension that suicide-specific focus may be “very intense” for the children, especially in an online context, where a break, such as engaging in physical activities or connecting with friends in person, is not possible. It was quite intense. ( … ) like a bit of a double-edged sword in a way because it was good for them to know that all the kids in the program had a significant other that committed suicide. But it was also difficult in a way because you can’t get away from it. (P06) The program is tailored to three age groups and most parents and young people found the program material, including the language used, appropriate and well-tailored to the three age groups, though a few children found it challenging. Parents and young people flagged that the content of the program for the youngest (7–9 years) age group could be simplified. Sometimes they did say things that were a little unclear but I did understand it after a while and so I mostly participated. (C07) The language was probably a bit too much for her, a bit too complex. ( … ) It needs to be a bit more tailored to younger kids. (P06) Most parents of participants in the oldest age group (14–17 years old) observed hesi- tation and ambivalence in their children around participation. They attributed this to various factors, such as not knowing what to expect from the program, and anger regarding the loss by suicide. Some parents reported how they negotiated participation with their children, for example, by stressing the importance of the program or suggest- ing a “let’s try it” attitude. One parent thought that a bigger group size and more spe- cific profile of participants (gender, type of relationship to deceased person) may encourage teenagers to participate. Facilitators reported that participants in the oldest age group were the most difficult to engage and the most likely to drop out. One of the suggested strategies to encourage them was to build a connection before the program starts. The older age groups, they’re a lot more resistant to being there. They don’t want to be there, they’ve been sort of coerced and dragged because they just want to have a normal life, they don’t want to be unpacking this stuff. (F3) Theme 2: Appraising the Online Environment All participants were aware of the Covid-19 pandemic and related restrictions, which made it necessary to deliver the program online, even though they would have preferred an in-person camp. Still, participants reported several advantages of an online program, including easier access for those who would be unable to attend an in-person camp due to geographic distance or economic factors. Further, participation from home lowered some parents’ apprehension around letting their children go away to a camp. Most young people and parents were familiar with the Internet and the zoom soft- ware used to run the program and had a satisfying experience. They reported that the ARCHIVES OF SUICIDE RESEARCH 7 facilitators were very skillful and committed to engaging the participants and their parents online and delivering the program. Despite the inherent limitations of an online program, the facilitators reported they felt well prepared for the sessions. In my Zoom we drew a lot of stuff on the Zoom whiteboard. ( … ) we did the activity book that we got. ( … ) It was good, and my group was really nice and everyone got a chance to speak on what we were doing and stuff. (C05) They [co-facilitators] organised the meetings and we did some serious stuff and then we did some fun stuff in some ways. It was much less stressful and less I guess triggering than I thought it would be. They did a really good job. (C06) Reported problems with the online setting included technical issues, such as connec- tion dropping off, feeling uncomfortable when some participants turned their cameras off, and ensuring privacy when joining online from home on a weekend. One child needed her parent’s help for logging in. One parent cautioned that the online setting may be inappropriate for recently bereaved children, who may need a “more human touch which you don’t get with Zoom” (P07). Parents and young participants, who had previously participated in an in-person camp commented on the differences between the online and the in-person setting. They indi- cated the lack of physical activities in the online program, which allow to take a break from the more intense psychoeducational and counseling activities. In-person participa- tion could also support engagement and commitment to participating, and allows for 24/7 availability of staff and volunteers, which contributes to a “safe space” for the children. I think I would do it again if it was in real life, not over Zoom because I think I would get to learn a lot more. Because all of Camp Magic I did—it was group participation, you did it with other people but this one you kind of had to do it by yourself. (C05) The young participants and their parents noted that sharing physical space with other children during a camp allowed to create friendship and connections, which contributed to the overall positive camp experience, which could be a challenge in the online setting. When you go to a camp you meet other people and you get to have friendships, with other people. Where on Zoom you don’t really talk to other people other than the entire group. (C05) One parent pointed out that preparation to leave for the camp allows the children to get ready to immerse themselves in the camp and the topic of grief, while joining the online program could be experienced as quite sudden. The facilitators further commented that in person camps, for example provided “opportunities to add in physical activity in-between and for campers to do things like sharing meals and sharing the memorial ceremony”. (F3). The physical activities also cre- ated opportunities to “model regulation” in interactions with peers and facilitators in a more informal setting. Theme 3: Expectations and Outcomes of the Program for Participants and Parents Most parents expected that the program would allow their children to connect with peers bereaved by suicide, learn coping skills, gain confidence and learn a language to 8 K. KRYSINSKA ET AL. talk about their emotions, in particular, their grief. A few parents did not know what to expect. Parents, whose children already had participated in an in-person Feel the Magic camp (57%), were familiar with the organization’s model and activities. We pretty much knew how that was going to go and what it was going to look like. We were going in knowing that it will give tools and a language and education to the kids that is as useful as what they got out of the Feel the Magic camps. (P05) All young participants reported perceived benefits of their participation. This included meeting and connecting with peers bereaved by suicide, learning strategies how to live with grief, and how to talk about grief and loss. Children emphasized the helpfulness of the tools, psychoeducational materials, and skills learned to better express themselves. Well, I got to talk to a lot of other people about what happened with their lives and stuff. So, it was better in a way because you just—I knew barely anyone else who had gone through the same stuff as us, so you get to know more people that have gone through the same stuff. ( … ) We learned about new ways on how to cope with grief and coping mechanisms. We also got taught how to say—who you can trust to tell people about what happened and the best ways to tell people. (C04) Similarly, all parents reported that the program had met their expectations, and they saw the benefits of participation for both their children and themselves. Parents observed that their children were more confident to talk about the loss, their emotions, and had acquired a language to express themselves. All parents stressed the importance of learning strategies to deal with grief and being emotionally overwhelmed, and commented on the significance of connecting with other bereaved children. One parent reported successfully using some of the techniques the child had learned during the program. Another parent observed that the program may be “just a starting point”: it may help the child see that they are not alone and make them feel more at ease sharing their experience, which will open them up to considering receiving further support. Another parent reported that although one of her children did not participate, the conversations around the program had a positive impact on the child. All facilitators had observed changes in the young participants. They noticed how participants connected with their peers, opened up and shared their grief and emotions, as well as modeled strategies to cope with grief for others. Through grief, by bereavement, death, suicide, this challenging subject, we’re creating a safe environment where they can connect. It’s a tough topic, but we can connect through our pain, as well as through joyous things we have in our lives. (F2) Theme 4: Parents’ Experience of Involvement in The Program All parents were involved in the program along with their children. Both parents and facilitators acknowledged that the program focuses on supporting and providing the young people an opportunity to connect with peers. One parent pointed out that wid- ows and widowers, as “solo parents,” have limited time and their involvement should be minimal. Still, most parents found their level of engagement in the program appropriate ARCHIVES OF SUICIDE RESEARCH 9 and doable, and found the content of the parent sessions helpful and informative. They reported learning skills which can help them support their children. The lived experi- ence of the co-facilitators also made it easier to open up and connect during the parent evening. We did a mid-week session catch-up with the facilitators, to check in on how the kids were doing post their first virtual camp, and to see how they were faring. ( … ) With the help of a psychologist or something, to talk through some strategies to help the parents to negotiate those rocky times. (P03) Parents valued the ease of finding connection based on the shared experience of being a parent of a child bereaved by suicide, and were pleased to have an opportunity to talk about the challenges and strategies of supporting grieving children. Some parents were able to provide support and information to others, whose bereavement was more recent. One parent mentioned the conversation triggered an emotional response in her; however, she experienced that as a “positive thing”,a “proactive grief work” (P05). The facilitators reported noticing that the sessions allowed the parents to meet others in a similar situation, break through a feeling of isolation, and normalize their feelings. They observed that the program allowed some parents and their children to reconnect and find common language. Particularly, the sessions gave parents an opportunity to focus on their own needs, which can model self-care for their children. The parents, definitely the parents around this age [10–13-years old], they’re very self- forgetting and not caring for themselves, putting their kids first, working really hard, and they forget to care for themselves, and I really strongly remind them of that. (F2) DISCUSSION We investigated the experiences of parents, young people, and facilitators regarding their involvement in a new online suicide bereavement support program for children and adolescents. The analysis identified four themes focused on suicide bereavement specific support, the online environment experiences, expectations and perceived out- comes, and parents’ involvement in the program. Almost all study participants perceived suicide bereavement as “different” from bereavement by other causes and believed that support provided to children bereaved by suicide should be tailored to their needs. This aligns with the literature indicating that people bereaved by suicide, and clinicians working with this population, may strongly focus on grief features that are more pronounced in suicide grief (Andriessen, Krysinska, & Grad, 2017; Jordan, 2020). Consensus recommendations on how best to help bereaved adolescents include a few recommendations regarding adolescents bereaved by suicide in addition to recommendations regarding all bereaved adolescents (Ross et al., 2021). Of interest, some parents in our study appreciated the general grief focus of the Feel the Magic camps and for them the new program was an important addition to the suite of generalized grief camps, rather than a replacement. The study participants valued connecting with others with a similar bereavement, and the shared understanding, especially in the context of the perceived stigma around sui- cide bereavement, has been reported as a supportive and normalizing experience in other studies as well (Silven Hagstrom, € 2021). Study participants reported that the 10 K. KRYSINSKA ET AL. program reflected well their bereavement experience and in general met their needs, including the various support and psychoeducation needs across the three age groups. Nonetheless, the older adolescents (aged 14–17 years) were the most difficult to engage in the program. Study participants spoke about advantages and disadvantages of running the program online. Those who had previously participated in an in-person camp pointed out a lack of shared physical space which facilitates peer connection, and of physical activities which provide a respite from the grief-focused psychoeducational and counseling activ- ities. According to the literature (Clute & Kobayashi, 2013; Creed et al., 2001), outdoor play and recreation are inherently included in the grief camp framework. They contrib- ute to the participants’ experience of a “safe environment” (Andriessen, Krysinska, Rickwood, & Pirkis, 2022), and meet their “developmental need to ‘go in and out of grief’ to avoid suffering overly intense emotions” (Silven Hagstrom, € 2021, p. 11). The literature has indicated that, contrary to popular belief, young people generally prefer in-person contact with bereavement or mental health professionals over online support (Andriessen et al., 2022; Cus, Edbrooke-Childs, Ohmann, Plener, & Akkaya-Kalayci, 2021; Gibson, Cartwright, Kerrisk, Campbell, & Seymour, 2016), and the literature has reported mixed findings regarding the helpfulness of online suicide bereavement support (Lestienne et al., 2021). For example, a survey of a young people accessing an online mental health service during COVID-19 pandemic revealed that 94% of those who received services via telehealth reported this as a positive experience (Headspace, 2020). Other studies revealed strong preferences for receiving support in- person (Andriessen et al., 2022; Bradford & Rickwood, 2014). The diverging findings may confirm the notion that there is no “one size fits all,” and different support formats must be developed and evaluated to cater for the various needs of children bereaved by suicide. Reflecting results of previous grief camp studies (Clute & Kobayashi, 2013; Farber & Sabatino, 2007; Griffiths et al., 2022), both children/adolescents and parents were satis- fied with the program and the majority reported that their expectations were met. The young participants appreciated the opportunity to meet and connect with peers bereaved by suicide, a finding reflected by the parents. The importance of meeting other bereaved children is stressed in previous studies as the peer connection may reduce the feeling of isolation and normalize the grief experiences (Clute & Kobayashi, 2013; Creed et al., 2001; Metel & Barnes, 2011). Young participants reported that they had acquired new coping strategies and how to talk about their grief, which reflects outcomes of other grief camp studies (Bachman, 2013; Farber & Sabatino, 2007), including camps for young people bereaved by suicide (Silven Hagstrom, € 2021). This finding was also reported by parents and facilitators, who further observed an increased confidence in young participants to talk about the bereavement and their emotions. Parents and facilitators acknowledged that the program focuses on children and ado- lescents bereaved by suicide, and other programs are available for adults (Gehrmann, Dixon, Visser, & Griffin, 2020). Nonetheless, parents were involved in the program and in general were satisfied with their level of engagement and the skills they have learned. Evaluating a grief camp for families coping with suicide, Silven Hagstrom € (2021) also found that parents appreciated the educational elements of the program, were able to ARCHIVES OF SUICIDE RESEARCH 11 implement the new skills in daily practice, and felt more confident in supporting their bereaved children. Similarly, Creed et al. (2001) reported improved communication about the death between children who participated in a grief camp and their parents. Pfeffer et al. (2002) indicated that supporting parents enhances the beneficial effect of a group intervention for children and adolescents bereaved by suicide. The study findings should be considered within a few limitations. The sample size, in particular children and adolescents, was fairly small, and participants had experienced the suicide loss a few years before participation. Nonetheless, the interviews yielded a rich data set, which allowed for a deductive thematic analysis. Obviously, a larger sam- ple, including more males and fathers, might have allowed conducting an inductive ana- lysis (focusing more on implicit meaning of the data rather than on explicit content), and presenting findings for each group separately. Although the findings are promising, further studies with larger samples and longitudinal design are needed to confirm the findings of this study and to examine participants’ long-term experiences regarding the helpfulness of the program. The study did not apply recruitment quota by gender, and it is not unusual that sam- ples in studies on suicide bereavement support consist predominantly of female partici- pants (Andriessen, Krysinska, et al., 2019). Tentatively, we conceive three main reasons. Firstly, suicide is more frequent in men than in women. Also in this study, it was mostly the men/fathers who had died by suicide. Secondly, in general, women more often seek help than men. Thirdly, in a context of bereavement, mothers, more often than fathers, are likely to take up the caring role and responsibility for daily routine for their bereaved children (Silverman & Worden, 1993), and mothers, more often than fathers, worry about externalizing problems in bereaved siblings (Howard Sharp et al., 2020). Thus, it is conceivable that mothers are more inclined to reach out to a support service or engage in a study, indicating a clear need for further research specifically tar- geted at fathers/men. CONCLUSIONS The study examined the experiences of children/adolescents, parents, and facilitators regarding a new online suicide bereavement support program for children, and how they perceived its helpfulness. Overall, study participants were very positive about the program. They felt that it supported the bereaved children in their grief after suicide, helped to normalize their experiences, offered support from peers and professionals, and enhanced their language and skills to express themselves and deal with their emo- tions. Parents felt supported in their own grief and appreciated in their role of support- ing their bereaved children. Though longitudinal research is needed, the Let’s Talk Suicide program seems to address an existing gap in postvention services for children and adolescents bereaved by suicide. ACKNOWLEDGMENTS We are very grateful to the management and staff members of Feel the Magic, and to all partici- pants for sharing their experiences. 12 K. KRYSINSKA ET AL. AUTHOR CONTRIBUTIONS KK contributed to study design, recruitment, data collection, analysis, and writing and revising the manuscript. DC contributed to study design, analysis, and writing and revising the manuscript. KA contributed to study design, data collection, analysis, and writing and revising the manuscript. All authors approved the final version of the manuscript. DISCLOSURE STATEMENT No potential conflict of interest was reported by the author(s). FUNDING K.A. is supported by a National Health and Medical Research Council Early Career Fellowship [1157796]. AUTHOR NOTES Karolina Krysinska, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia. Dianne Currier, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia Karl Andriessen Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia. Correspondence concerning this article should be addressed to Dr Karl Andriessen, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton VIC 3053, Australia. Email: karl.andriessen@unimelb. edu.au ORCID Karolina Krysinska http://orcid.org/0000-0002-7033-6904 Dianne Currier http://orcid.org/0000-0002-6614-271X Karl Andriessen http://orcid.org/0000-0002-3107-1114 REFERENCES Andriessen, K., Hadzi-Pavlovic, D., Draper, B., Dudley, M., & Mitchell, P. B. (2018). The adoles- cent grief inventory: Development of a novel grief measurement. Journal of Affective Disorders, 240, 203–211. doi:10.1016/j.jad.2018.07.012 Andriessen, K., Krysinska, K., Hill, N. T., Reifels, L., Robinson, J., Reavley, N., & Pirkis, J. (2019). Effectiveness of interventions for people bereaved through suicide: A systematic review of con- trolled studies of grief, psychosocial and suicide-related outcomes. 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OMEGA-Journal of Death and Dying, 82(2), 196–213. doi:10.1177/ Metel, M., & Barnes, J. (2011). Peer-group support for bereaved children: A qualitative interview study. Child and Adolescent Mental Health, 16(4), 201–207. doi:10.1111/j.1475-3588.2011. 00601.x Pfeffer, C. R., Jiang, H., Kakuma, T., Hwang, J., & Metsch, M. (2002). Group intervention for children bereaved by the suicide of a relative. Journal of the American Academy of Child and Adolescent Psychiatry, 41(5), 505–513. doi:10.1097/00004583-200205000-00007 Pham, S., Porta, G., Biernesser, C., Walker Payne, M., Iyengar, S., Melhem, N., & Brent, D. A. (2018). The burden of bereavement: Early-onset depression and impairment in youths bereaved by sudden parental death in a 7-year prospective study. American Journal of Psychiatry, 175(9), 887–896. doi:10.1176/appi.ajp.2018.17070792 QSR. (2020). NVivo 12 for Windows. Doncaster, Australia: QSR International Pty Ltd. Rickwood, D. J., Mazzer, K. R., & Telford, N. R. (2015). Social influences on seeking help from mental health services, in-person and online, during adolescence and young adulthood. BMC Psychiatry, 15(1), 40. doi:10.1186/s12888-015-0429-6 Rosner, R., Kruse, J., & Hagl, M. (2010). A meta-analysis of interventions for bereaved children and adolescents. Death Studies, 34(2), 99–136. doi:10.1080/07481180903492422 Ross, A. M., Krysinska, K., Rickwood, D., Pirkis, J., & Andriessen, K. (2021). How best to provide help to bereaved adolescents: A Delphi consensus study. BMC Psychiatry, 21(1), 591. doi:10. 1186/s12888-021-03591-7 Silven Hagstr€om, A. (2013). ‘ The stranger inside’: Suicide-related grief and ‘othering’ among teenage daughters following the loss of a father to suicide. Nordic Social Work Research, 3(2), 185–193. doi:10.1080/2156857X.2013.801877 Silven Hagstrom, € A. (2021). A narrative evaluation of a grief support camp for families affected by a parent’s suicide. Frontiers in Psychiatry, 12, 783066. doi:10.3389/fpsyt.2021.783066 ARCHIVES OF SUICIDE RESEARCH 15 Silverman, P. R., & Worden, J. W. (1993). Children’s reactions to the death of a parent. In M. S. Stroebe, W. Stroebe, R. O. Hansson (Eds.), Handbook of bereavement: Theory, research, and intervention (pp. 300–316). Cambridge, UK: Cambridge University Press. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. doi:10.1093/intqhc/mzm042 Appendix TABLE A1. Interview questions. You have participated in the Let’s Talk Suicide program. What did you expect from taking part in this program? Were your expectations met? What did you actually do in this program? What happened in the sessions? There were different sessions with different types of activities. Which activities did you like most? Why were these activities good for you? Were there any activities or things in the program that you did not like? All participants in the group have lost a parent or sibling by suicide. What was it like for you to be in a group like that? The program was offered online with sessions by Zoom. How did you go with that? There were two facilitators in the program. How did you relate with them? You participated in the program about two months ago. Do you feel that it helped you in any way? What have you learned from this program? Would you recommend this program to other bereaved children/adolescents?
http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.pngArchives of Suicide ResearchTaylor & Francishttp://www.deepdyve.com/lp/taylor-francis/evaluation-of-a-new-online-program-for-children-bereaved-by-suicide-jaDYM8FiFu
Evaluation of a New Online Program for Children Bereaved by Suicide: The Views of Children, Parents, and Facilitators
Evaluation of a New Online Program for Children Bereaved by Suicide: The Views of Children, Parents, and Facilitators
Abstract
Abstract Objective: Experiencing the suicide of a parent or a sibling is one of the most disruptive and stressful events in the life of a child or adolescent. Yet, little is known about the effectiveness of support offered to children and adolescents bereaved by suicide. This study aimed to evaluate participant and facilitator’s perceived helpfulness of the new online Let’s Talk Suicide program, piloted in 2021. Method: Thematic Analysis of qualitative interviews with 4 children,...
ARCHIVES OF SUICIDE RESEARCH https://doi.org/10.1080/13811118.2023.2185559 Evaluation of a New Online Program for Children Bereaved by Suicide: The Views of Children, Parents, and Facilitators Karolina Krysinska , Dianne Currier , and Karl Andriessen KEYWORDS ABSTRACT Bereavement; children; Objective: Experiencing the suicide of a parent or a sibling is one of evaluation; intervention; the most disruptive and stressful events in the life of a child or ado- suicide; support lescent. Yet, little is known about the effectiveness of support offered to children and adolescents bereaved by suicide. This study aimed to evaluate participant and facilitator’s perceived helpfulness of the new online Let’s Talk Suicide program, piloted in 2021. Method: Thematic Analysis of qualitative interviews with 4 children, 7 parents, and 3 facilitators (N ¼ 14). Results: The analysis identified four themes focused on suicide bereavement specific support, the online environment experiences, expectations and perceived outcomes of the program, and parents’ involvement in the program. Conclusions: The young participants, parents, and facilitators were very positive about the program. They felt that it supported the chil- dren in their grief after suicide, helped to normalize their experien- ces, offered social support from peers and professionals, and enhanced their language and skills to express themselves and to deal with their emotions. Though longitudinal research is needed, the new program seems to address an existing gap in postvention services for children and adolescents bereaved by suicide. HIGHLIGHTS The children felt supported in their grief as it enhanced their skills and language to express themselves. The program also acknowledged the parents and supported them in their parenting role. Future longitudinal studies may enhance the evidence of effect- iveness of the program. INTRODUCTION Experiencing the death of a parent or a sibling is one of the most disruptive and stressful events in the life of a child or adolescent. Grief in this population can manifest itself in various ways, and may include crying and feelings of sadness, guilt and longing (Balk, 2014). Moreover, there is evidence that those experiencing bereavement by suicide may experience more feelings of shock, anxiety, anger, and self-blame than those bereaved by natural causes (Andriessen, Hadzi-Pavlovic, Draper, Dudley, & Mitchell, 2018;Bartik, 2023 The Author(s). Published with license by Taylor & Francis Group, LLC. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. 2 K. KRYSINSKA ET AL. Maple, & McKay, 2020), strugglemorewith “why” questions, and experience less social support (Andriessen, Mowll, et al., 2018; Hoffmann, Myburgh, & Poggenpoel, 2010;Silven Hagstrom € , 2013). They may also develop more mental health problems (e.g., depression, anxiety, posttraumatic stress disorder), and suicidal ideation after the bereavement (Del Carpio, Paul, Paterson, & Rasmussen, 2021;Pham et al., 2018). In response to the high burden of bereavement, several child and adolescent support programs, including support groups, family interventions, and grief camps have been developed (Bergman, Axberg, & Hanson, 2017; Currier, Holland, & Neimeyer, 2007; Rosner, Kruse, & Hagl, 2010). Grief camps are short-term interventions where trained professionals, volunteers, and/or bereaved peers provide support to young participants (i.e., campers) (Clute & Kobayashi, 2013). There are differences between camps regard- ing participation requirements as some camps are tailored to support children/adoles- cents who experienced a particular type of bereavement, e.g., lost a sibling to cancer (Creed, Ruffin, & Ward, 2001), a parent to any cause of death (McClatchey & Raven, 2017), or a parent to suicide (Silven Hagstrom, 2021). Although different frameworks inform design of individual camp programs, such as family therapy or trauma-focused cognitive behavior therapy (McClatchey, 2020), over- all they aim to teach campers about grief and healthy coping, provide a psychoeduca- tional and therapeutic space to talk about the loss, and to socialize with other bereaved children, including various informal and physical activities, such as play and sports (Clute & Kobayashi, 2013). As parents are the most important facilitators of help- seeking in bereaved children and adolescents (Andriessen, Lobb, et al., 2019; Rickwood, Mazzer, & Telford, 2015), some grief camps offer a parental activity to facilitate sharing amongst parents (Clute & Kobayashi, 2013). The studies examining the effectiveness of grief camps have reported promising results such as grief camps helping children deal with their loss, develop resilience, and supporting their mental well-being (Clute & Kobayashi, 2013). Studies indicate improve- ments in self-reported grief (Griffiths, Mazzucchelli, Skinner, Kane, & Breen, 2022), reduced anxiety (Hartwig & Marlow, 2022), greater posttraumatic growth (McClatchey & Raven, 2017), and improved self-concept (Hartwig & Marlow, 2022). Young suicide bereaved campers reported a decrease in shame and self-blame related to the normaliza- tion of their grief experience (Silven Hagstrom, € 2021). Grief camps can also contribute to less coercive and more consistent parenting (Griffiths et al., 2022), and improve fam- ily communication and parents’ ability to support their bereaved children (Silven Hagstrom, 2021). Still, it is unknown whether these positive outcomes and experiences are also found in online “camps” (group support) for this population. Let’s Talk Suicide Program Since 2015, Feel the Magic, an Australian not-for-profit organization has been facilitat- ing “Camp Magic” for children and adolescents (aged 7–17) who have lost a parent, sib- ling or legal guardian, by any cause of death. Camp Magic follows a structured psychoeducational program, includes physical activities and resilience building chal- lenges, and connects campers with peers in a supportive and safe environment. ARCHIVES OF SUICIDE RESEARCH 3 In the context of the COVID-19 pandemic, in October 2020 Feel the Magic received funding from the New South Wales Department of Health to develop an online pro- gram for those aged 7–17 years and their families to minimize ongoing impacts of sui- cide in young people. Feel the Magic developed the Let’s Talk Suicide program by the end of 2020 in collaboration with the Illawarra Shoalhaven Suicide Prevention Collaborative and through a co-design process with Roses in the Ocean, a suicide- related lived experience organization. The program has been piloted in 2021 and has been offered free of charges to participants. The Let’s Talk Suicide program aimed to: (a) deliver a two-week online program for 6 to 8 children per group, and their families, providing tools and psychoeducational strat- egies for managing child grief after the suicide of a parent or sibling, (b) create a space for parents/guardians to connect with other parents/guardians, and (c) create avenues for people bereaved by suicide to use their experience to support others bereaved by suicide. The program was informed by Cognitive Behavioral Therapy approaches for identify- ing and managing thoughts and emotions, Acceptance and Commitment Therapy approaches for dealing with emotional and challenging experiences to build resilience, Narrative Therapy approaches for comprehending various layers of experience, and Somatic Therapy approaches for dealing with somatic grief manifestations. Methods across the three sessions included psychoeducational lectures, facilitated discussions of personal grief experiences, creative activities (e.g., drawing), and guided imagery/mind- fulness meditation and emotional regulation exercises. The program was offered to three age groups: 7–9, 10–13, and 14–17 years old and comprised three 1.5 hour live, online group sessions over two weekends, with one prere- corded parent orientation session and one live, online mid-week check-in for parents. Each group was facilitated by two facilitators, including one psychologist and one with lived experience of suicide bereavement. Aims Due to a paucity of intervention studies, little is known about the effectiveness of support offered to children and adolescents bereaved by suicide, including online group interven- tions (Hung & Rabin, 2009; Journot-Reverbel, Raynaud, Bui, & Revet, 2017; Lestienne, Leaune, Haesebaert, Poulet, & Andriessen, 2021). Nonetheless, evidence suggests that pro- fessionally led interventions based on supportive and psychoeducational approaches, which also involve a parental component, hold promise in terms of providing adequate help (Andriessen et al., 2019; Pfeffer, Jiang, Kakuma, Hwang, & Metsch, 2002; Ross, Krysinska, Rickwood, Pirkis, & Andriessen, 2021). This study aimed to evaluate participant and facili- tator’s experiences and the perceived helpfulness of the Let’s Talk Suicide program using qualitative interviews with participants (children/adolescents, parents) and facilitators. MATERIALS AND METHOD Evaluation Design and Recruitment We conducted the study according to the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007). Children/adolescents and their parents could 4 K. KRYSINSKA ET AL. participate in the Let’s Talk Suicide program and the evaluation if: (a) the child/adoles- cent was aged 7–17, (b) the child/adolescent had lost a parent or sibling by suicide, and (c) the death occurred at least six months before taking part in the program. The 6- months exclusion criteria to avoid including participants who might still be in a crisis after the death is in line with established good practice (Andriessen, Mowll, et al., 2018, Andriessen, Krysinska, Rickwood, & Pirkis, 2020). When enrolling in the program, Feel the Magic asked the parents (without any obli- gation) whether they and their child/adolescent were interested to take part in an inter- view for evaluation of the program. If so, they were asked to consent for their contact details to be shared with the research team. Next, the researchers emailed the parents the plain language statement with details about the study and consent. If the parent and/or their child/adolescent agreed to take part, an interview via zoom or telephone was scheduled at a time convenient for them. Participants aged 7–9 and 10–13 years were interviewed together with a parent/guardian. Parents of adolescents aged 14–17 were offered the option for an individual interview for themselves and/or their adoles- cent. Both parent and adolescents aged 14–17 could take part whether or not their own adolescent or parent participated. Feel the Magic forwarded the plain language statement and consent information to the facilitators. Those interested in the study were required to contact the researchers. Interviews (by telephone or Zoom) were scheduled at a time convenient for the participant. Participants We contacted seventeen parents and three facilitators who had expressed interest in the study. Seven parents, four children, and all three facilitators, agreed to be interviewed (Table 1). The death by suicide, where reported (n ¼ 5), was between five and ten years (M ¼ 6.8, SD ¼ 1.72) prior to participating in the program, indicating the long-term impact of a suicide in this population. The deceased person was a father (n ¼ 3), a brother (n ¼ 1), a mother (n ¼ 1), and not reported (n ¼ 2). Data Collection In line with then valid COVID-19 restrictions, we conducted the semi-structured inter- views remotely using an interview guide developed for this study (Appendix, Table A1). The lead questions were adapted to the target group (children/adolescents, parents and facilitators). Children were accompanied by a parent. Interviews were conducted by an TABLE 1. Study participants. Children/adolescents (n ¼ 4) Parents (n ¼ 7) Facilitators (n ¼ 3) Age in years: M (SD) 12.22 (0.47) 45.17 (11.65) 50.33 (1.25) Gender: % female 75% 100% 67% Age group: N (%) 7–9 years (Program 1) 3 (100%) 1 (11%) 2 (28%) 10–13 years (Program 2) 5 (56%) 3 (44%) 14–17 years (Program 3) 3 (33%) 2 (28%) % do not add up to 100% as some parents participated in more than one program; % do not add up to 100% as facilitators facilitated more than one program. ARCHIVES OF SUICIDE RESEARCH 5 experienced research psychologist (K.K.) or a social worker with extensive experience in bereavement research (K.A.). The interviews took on average 29 minutes (range 15–49). Data Analysis Interviews were transcribed professionally, and transcripts subjected to a deductive the- matic analysis, based on the interview questions, according to the principles described by Braun, Clarke, Hayfield, and Terry (2019). This approach considered the experiences of the participants in the program and its perceived helpfulness. Thematic analysis involved an iterative process of systematically identifying and organizing patterns of meaning (i.e., themes) in the data set, starting with reading and rereading the data to produce initial codes. Next, initial codes were grouped in potential themes, which were revised against the data before we decided about the themes. These recursive steps of familiarization and coding of the data is necessary to answer the research question. We used NVivo12 (QSR, 2020) for coding and data management. Researchers K.K. and K.A. conducted the analysis and discussed progress with researcher D.C. Ethics Approval The Human Research Ethics Committee of The University of Melbourne approved the study (ID 2021-20779-17259-4, May 10, 2021). We obtained written consent from all participants, including assent from those below age 16, prior to the interviews. RESULTS The analysis yielded four major themes: (1) the importance of suicide-bereavement spe- cific support; (2) appraising the online environment; (3) expectations and outcomes of the program for participants and parents, and (4) parents’ experience of involvement in the program. In what follows, participant names have been replaced with numbers; C refers to child/adolescent participant, P refers to parent, and F refers to facilitator. Theme 1: The Importance of Suicide-Bereavement Specific Support Almost all parents, young people, and facilitators perceived suicide bereavement and its aftermath was “different”. Parents and facilitators indicated the need for suicide- bereavement specific activity and welcomed the Let’s Talk Suicide program. Given the perceived stigma around suicide bereavement, the parents and young people stressed that feeling connected with others in the similar situation and mutual understanding was crucial. It’s also nice when I go to camps in the Let’s Talk Suicide programs because it shows that there’s other people who are going through the exact thing. ( … ) because there’s lot of people who had—whose parents had also committed suicide and it was—that made them understand of how to bring it up and how to cope. (C06) Some parents reported that their children, who had participated in a regular Feel the Magic camp could have felt “different” from children bereaved by other causes. 6 K. KRYSINSKA ET AL. Nonetheless, other parents appreciated the general and open grief focus of the Feel the Magic camps and perceived the new program as a valuable addition rather than a replacement. In this context, one parent cautioned against creating “silos of grief”. Parents stressed the importance of the right timing of participating in the program. One parent reported apprehension that suicide-specific focus may be “very intense” for the children, especially in an online context, where a break, such as engaging in physical activities or connecting with friends in person, is not possible. It was quite intense. ( … ) like a bit of a double-edged sword in a way because it was good for them to know that all the kids in the program had a significant other that committed suicide. But it was also difficult in a way because you can’t get away from it. (P06) The program is tailored to three age groups and most parents and young people found the program material, including the language used, appropriate and well-tailored to the three age groups, though a few children found it challenging. Parents and young people flagged that the content of the program for the youngest (7–9 years) age group could be simplified. Sometimes they did say things that were a little unclear but I did understand it after a while and so I mostly participated. (C07) The language was probably a bit too much for her, a bit too complex. ( … ) It needs to be a bit more tailored to younger kids. (P06) Most parents of participants in the oldest age group (14–17 years old) observed hesi- tation and ambivalence in their children around participation. They attributed this to various factors, such as not knowing what to expect from the program, and anger regarding the loss by suicide. Some parents reported how they negotiated participation with their children, for example, by stressing the importance of the program or suggest- ing a “let’s try it” attitude. One parent thought that a bigger group size and more spe- cific profile of participants (gender, type of relationship to deceased person) may encourage teenagers to participate. Facilitators reported that participants in the oldest age group were the most difficult to engage and the most likely to drop out. One of the suggested strategies to encourage them was to build a connection before the program starts. The older age groups, they’re a lot more resistant to being there. They don’t want to be there, they’ve been sort of coerced and dragged because they just want to have a normal life, they don’t want to be unpacking this stuff. (F3) Theme 2: Appraising the Online Environment All participants were aware of the Covid-19 pandemic and related restrictions, which made it necessary to deliver the program online, even though they would have preferred an in-person camp. Still, participants reported several advantages of an online program, including easier access for those who would be unable to attend an in-person camp due to geographic distance or economic factors. Further, participation from home lowered some parents’ apprehension around letting their children go away to a camp. Most young people and parents were familiar with the Internet and the zoom soft- ware used to run the program and had a satisfying experience. They reported that the ARCHIVES OF SUICIDE RESEARCH 7 facilitators were very skillful and committed to engaging the participants and their parents online and delivering the program. Despite the inherent limitations of an online program, the facilitators reported they felt well prepared for the sessions. In my Zoom we drew a lot of stuff on the Zoom whiteboard. ( … ) we did the activity book that we got. ( … ) It was good, and my group was really nice and everyone got a chance to speak on what we were doing and stuff. (C05) They [co-facilitators] organised the meetings and we did some serious stuff and then we did some fun stuff in some ways. It was much less stressful and less I guess triggering than I thought it would be. They did a really good job. (C06) Reported problems with the online setting included technical issues, such as connec- tion dropping off, feeling uncomfortable when some participants turned their cameras off, and ensuring privacy when joining online from home on a weekend. One child needed her parent’s help for logging in. One parent cautioned that the online setting may be inappropriate for recently bereaved children, who may need a “more human touch which you don’t get with Zoom” (P07). Parents and young participants, who had previously participated in an in-person camp commented on the differences between the online and the in-person setting. They indi- cated the lack of physical activities in the online program, which allow to take a break from the more intense psychoeducational and counseling activities. In-person participa- tion could also support engagement and commitment to participating, and allows for 24/7 availability of staff and volunteers, which contributes to a “safe space” for the children. I think I would do it again if it was in real life, not over Zoom because I think I would get to learn a lot more. Because all of Camp Magic I did—it was group participation, you did it with other people but this one you kind of had to do it by yourself. (C05) The young participants and their parents noted that sharing physical space with other children during a camp allowed to create friendship and connections, which contributed to the overall positive camp experience, which could be a challenge in the online setting. When you go to a camp you meet other people and you get to have friendships, with other people. Where on Zoom you don’t really talk to other people other than the entire group. (C05) One parent pointed out that preparation to leave for the camp allows the children to get ready to immerse themselves in the camp and the topic of grief, while joining the online program could be experienced as quite sudden. The facilitators further commented that in person camps, for example provided “opportunities to add in physical activity in-between and for campers to do things like sharing meals and sharing the memorial ceremony”. (F3). The physical activities also cre- ated opportunities to “model regulation” in interactions with peers and facilitators in a more informal setting. Theme 3: Expectations and Outcomes of the Program for Participants and Parents Most parents expected that the program would allow their children to connect with peers bereaved by suicide, learn coping skills, gain confidence and learn a language to 8 K. KRYSINSKA ET AL. talk about their emotions, in particular, their grief. A few parents did not know what to expect. Parents, whose children already had participated in an in-person Feel the Magic camp (57%), were familiar with the organization’s model and activities. We pretty much knew how that was going to go and what it was going to look like. We were going in knowing that it will give tools and a language and education to the kids that is as useful as what they got out of the Feel the Magic camps. (P05) All young participants reported perceived benefits of their participation. This included meeting and connecting with peers bereaved by suicide, learning strategies how to live with grief, and how to talk about grief and loss. Children emphasized the helpfulness of the tools, psychoeducational materials, and skills learned to better express themselves. Well, I got to talk to a lot of other people about what happened with their lives and stuff. So, it was better in a way because you just—I knew barely anyone else who had gone through the same stuff as us, so you get to know more people that have gone through the same stuff. ( … ) We learned about new ways on how to cope with grief and coping mechanisms. We also got taught how to say—who you can trust to tell people about what happened and the best ways to tell people. (C04) Similarly, all parents reported that the program had met their expectations, and they saw the benefits of participation for both their children and themselves. Parents observed that their children were more confident to talk about the loss, their emotions, and had acquired a language to express themselves. All parents stressed the importance of learning strategies to deal with grief and being emotionally overwhelmed, and commented on the significance of connecting with other bereaved children. One parent reported successfully using some of the techniques the child had learned during the program. Another parent observed that the program may be “just a starting point”: it may help the child see that they are not alone and make them feel more at ease sharing their experience, which will open them up to considering receiving further support. Another parent reported that although one of her children did not participate, the conversations around the program had a positive impact on the child. All facilitators had observed changes in the young participants. They noticed how participants connected with their peers, opened up and shared their grief and emotions, as well as modeled strategies to cope with grief for others. Through grief, by bereavement, death, suicide, this challenging subject, we’re creating a safe environment where they can connect. It’s a tough topic, but we can connect through our pain, as well as through joyous things we have in our lives. (F2) Theme 4: Parents’ Experience of Involvement in The Program All parents were involved in the program along with their children. Both parents and facilitators acknowledged that the program focuses on supporting and providing the young people an opportunity to connect with peers. One parent pointed out that wid- ows and widowers, as “solo parents,” have limited time and their involvement should be minimal. Still, most parents found their level of engagement in the program appropriate ARCHIVES OF SUICIDE RESEARCH 9 and doable, and found the content of the parent sessions helpful and informative. They reported learning skills which can help them support their children. The lived experi- ence of the co-facilitators also made it easier to open up and connect during the parent evening. We did a mid-week session catch-up with the facilitators, to check in on how the kids were doing post their first virtual camp, and to see how they were faring. ( … ) With the help of a psychologist or something, to talk through some strategies to help the parents to negotiate those rocky times. (P03) Parents valued the ease of finding connection based on the shared experience of being a parent of a child bereaved by suicide, and were pleased to have an opportunity to talk about the challenges and strategies of supporting grieving children. Some parents were able to provide support and information to others, whose bereavement was more recent. One parent mentioned the conversation triggered an emotional response in her; however, she experienced that as a “positive thing”,a “proactive grief work” (P05). The facilitators reported noticing that the sessions allowed the parents to meet others in a similar situation, break through a feeling of isolation, and normalize their feelings. They observed that the program allowed some parents and their children to reconnect and find common language. Particularly, the sessions gave parents an opportunity to focus on their own needs, which can model self-care for their children. The parents, definitely the parents around this age [10–13-years old], they’re very self- forgetting and not caring for themselves, putting their kids first, working really hard, and they forget to care for themselves, and I really strongly remind them of that. (F2) DISCUSSION We investigated the experiences of parents, young people, and facilitators regarding their involvement in a new online suicide bereavement support program for children and adolescents. The analysis identified four themes focused on suicide bereavement specific support, the online environment experiences, expectations and perceived out- comes, and parents’ involvement in the program. Almost all study participants perceived suicide bereavement as “different” from bereavement by other causes and believed that support provided to children bereaved by suicide should be tailored to their needs. This aligns with the literature indicating that people bereaved by suicide, and clinicians working with this population, may strongly focus on grief features that are more pronounced in suicide grief (Andriessen, Krysinska, & Grad, 2017; Jordan, 2020). Consensus recommendations on how best to help bereaved adolescents include a few recommendations regarding adolescents bereaved by suicide in addition to recommendations regarding all bereaved adolescents (Ross et al., 2021). Of interest, some parents in our study appreciated the general grief focus of the Feel the Magic camps and for them the new program was an important addition to the suite of generalized grief camps, rather than a replacement. The study participants valued connecting with others with a similar bereavement, and the shared understanding, especially in the context of the perceived stigma around sui- cide bereavement, has been reported as a supportive and normalizing experience in other studies as well (Silven Hagstrom, € 2021). Study participants reported that the 10 K. KRYSINSKA ET AL. program reflected well their bereavement experience and in general met their needs, including the various support and psychoeducation needs across the three age groups. Nonetheless, the older adolescents (aged 14–17 years) were the most difficult to engage in the program. Study participants spoke about advantages and disadvantages of running the program online. Those who had previously participated in an in-person camp pointed out a lack of shared physical space which facilitates peer connection, and of physical activities which provide a respite from the grief-focused psychoeducational and counseling activ- ities. According to the literature (Clute & Kobayashi, 2013; Creed et al., 2001), outdoor play and recreation are inherently included in the grief camp framework. They contrib- ute to the participants’ experience of a “safe environment” (Andriessen, Krysinska, Rickwood, & Pirkis, 2022), and meet their “developmental need to ‘go in and out of grief’ to avoid suffering overly intense emotions” (Silven Hagstrom, € 2021, p. 11). The literature has indicated that, contrary to popular belief, young people generally prefer in-person contact with bereavement or mental health professionals over online support (Andriessen et al., 2022; Cus, Edbrooke-Childs, Ohmann, Plener, & Akkaya-Kalayci, 2021; Gibson, Cartwright, Kerrisk, Campbell, & Seymour, 2016), and the literature has reported mixed findings regarding the helpfulness of online suicide bereavement support (Lestienne et al., 2021). For example, a survey of a young people accessing an online mental health service during COVID-19 pandemic revealed that 94% of those who received services via telehealth reported this as a positive experience (Headspace, 2020). Other studies revealed strong preferences for receiving support in- person (Andriessen et al., 2022; Bradford & Rickwood, 2014). The diverging findings may confirm the notion that there is no “one size fits all,” and different support formats must be developed and evaluated to cater for the various needs of children bereaved by suicide. Reflecting results of previous grief camp studies (Clute & Kobayashi, 2013; Farber & Sabatino, 2007; Griffiths et al., 2022), both children/adolescents and parents were satis- fied with the program and the majority reported that their expectations were met. The young participants appreciated the opportunity to meet and connect with peers bereaved by suicide, a finding reflected by the parents. The importance of meeting other bereaved children is stressed in previous studies as the peer connection may reduce the feeling of isolation and normalize the grief experiences (Clute & Kobayashi, 2013; Creed et al., 2001; Metel & Barnes, 2011). Young participants reported that they had acquired new coping strategies and how to talk about their grief, which reflects outcomes of other grief camp studies (Bachman, 2013; Farber & Sabatino, 2007), including camps for young people bereaved by suicide (Silven Hagstrom, € 2021). This finding was also reported by parents and facilitators, who further observed an increased confidence in young participants to talk about the bereavement and their emotions. Parents and facilitators acknowledged that the program focuses on children and ado- lescents bereaved by suicide, and other programs are available for adults (Gehrmann, Dixon, Visser, & Griffin, 2020). Nonetheless, parents were involved in the program and in general were satisfied with their level of engagement and the skills they have learned. Evaluating a grief camp for families coping with suicide, Silven Hagstrom € (2021) also found that parents appreciated the educational elements of the program, were able to ARCHIVES OF SUICIDE RESEARCH 11 implement the new skills in daily practice, and felt more confident in supporting their bereaved children. Similarly, Creed et al. (2001) reported improved communication about the death between children who participated in a grief camp and their parents. Pfeffer et al. (2002) indicated that supporting parents enhances the beneficial effect of a group intervention for children and adolescents bereaved by suicide. The study findings should be considered within a few limitations. The sample size, in particular children and adolescents, was fairly small, and participants had experienced the suicide loss a few years before participation. Nonetheless, the interviews yielded a rich data set, which allowed for a deductive thematic analysis. Obviously, a larger sam- ple, including more males and fathers, might have allowed conducting an inductive ana- lysis (focusing more on implicit meaning of the data rather than on explicit content), and presenting findings for each group separately. Although the findings are promising, further studies with larger samples and longitudinal design are needed to confirm the findings of this study and to examine participants’ long-term experiences regarding the helpfulness of the program. The study did not apply recruitment quota by gender, and it is not unusual that sam- ples in studies on suicide bereavement support consist predominantly of female partici- pants (Andriessen, Krysinska, et al., 2019). Tentatively, we conceive three main reasons. Firstly, suicide is more frequent in men than in women. Also in this study, it was mostly the men/fathers who had died by suicide. Secondly, in general, women more often seek help than men. Thirdly, in a context of bereavement, mothers, more often than fathers, are likely to take up the caring role and responsibility for daily routine for their bereaved children (Silverman & Worden, 1993), and mothers, more often than fathers, worry about externalizing problems in bereaved siblings (Howard Sharp et al., 2020). Thus, it is conceivable that mothers are more inclined to reach out to a support service or engage in a study, indicating a clear need for further research specifically tar- geted at fathers/men. CONCLUSIONS The study examined the experiences of children/adolescents, parents, and facilitators regarding a new online suicide bereavement support program for children, and how they perceived its helpfulness. Overall, study participants were very positive about the program. They felt that it supported the bereaved children in their grief after suicide, helped to normalize their experiences, offered support from peers and professionals, and enhanced their language and skills to express themselves and deal with their emo- tions. Parents felt supported in their own grief and appreciated in their role of support- ing their bereaved children. Though longitudinal research is needed, the Let’s Talk Suicide program seems to address an existing gap in postvention services for children and adolescents bereaved by suicide. ACKNOWLEDGMENTS We are very grateful to the management and staff members of Feel the Magic, and to all partici- pants for sharing their experiences. 12 K. KRYSINSKA ET AL. AUTHOR CONTRIBUTIONS KK contributed to study design, recruitment, data collection, analysis, and writing and revising the manuscript. DC contributed to study design, analysis, and writing and revising the manuscript. KA contributed to study design, data collection, analysis, and writing and revising the manuscript. All authors approved the final version of the manuscript. DISCLOSURE STATEMENT No potential conflict of interest was reported by the author(s). FUNDING K.A. is supported by a National Health and Medical Research Council Early Career Fellowship [1157796]. AUTHOR NOTES Karolina Krysinska, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia. Dianne Currier, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia Karl Andriessen Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia. Correspondence concerning this article should be addressed to Dr Karl Andriessen, Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton VIC 3053, Australia. Email: karl.andriessen@unimelb. edu.au ORCID Karolina Krysinska http://orcid.org/0000-0002-7033-6904 Dianne Currier http://orcid.org/0000-0002-6614-271X Karl Andriessen http://orcid.org/0000-0002-3107-1114 REFERENCES Andriessen, K., Hadzi-Pavlovic, D., Draper, B., Dudley, M., & Mitchell, P. B. (2018). The adoles- cent grief inventory: Development of a novel grief measurement. Journal of Affective Disorders, 240, 203–211. doi:10.1016/j.jad.2018.07.012 Andriessen, K., Krysinska, K., Hill, N. T., Reifels, L., Robinson, J., Reavley, N., & Pirkis, J. (2019). Effectiveness of interventions for people bereaved through suicide: A systematic review of con- trolled studies of grief, psychosocial and suicide-related outcomes. 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Frontiers in Psychiatry, 12, 783066. doi:10.3389/fpsyt.2021.783066 ARCHIVES OF SUICIDE RESEARCH 15 Silverman, P. R., & Worden, J. W. (1993). Children’s reactions to the death of a parent. In M. S. Stroebe, W. Stroebe, R. O. Hansson (Eds.), Handbook of bereavement: Theory, research, and intervention (pp. 300–316). Cambridge, UK: Cambridge University Press. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. doi:10.1093/intqhc/mzm042 Appendix TABLE A1. Interview questions. You have participated in the Let’s Talk Suicide program. What did you expect from taking part in this program? Were your expectations met? What did you actually do in this program? What happened in the sessions? There were different sessions with different types of activities. Which activities did you like most? Why were these activities good for you? Were there any activities or things in the program that you did not like? All participants in the group have lost a parent or sibling by suicide. What was it like for you to be in a group like that? The program was offered online with sessions by Zoom. How did you go with that? There were two facilitators in the program. How did you relate with them? You participated in the program about two months ago. Do you feel that it helped you in any way? What have you learned from this program? Would you recommend this program to other bereaved children/adolescents?
Journal
Archives of Suicide Research
– Taylor & Francis
Published: Apr 22, 2023
Keywords: Bereavement; children; evaluation; intervention; suicide; support
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References
The adolescent grief inventory: Development of a novel grief measurement
Effectiveness of interventions for people bereaved through suicide: A systematic review of controlled studies of grief, psychosocial and suicide-related outcomes
“It changes your orbit”: The impact of suicide and traumatic death on adolescents as experienced by adolescents and parents
“Finding a safe space”. What makes help helpful for adolescents bereaved by suicide: A thematic analysis
Help-seeking experiences of bereaved adolescents: A qualitative study
“Don’t bother about me.” The grief and mental health of bereaved adolescents
The development of a sustainable, community-supported children’s bereavement camp
Youth suicide bereavement and the continuum of risk
When a parent dies – A systematic review of the effects of support programs for parentally bereaved children and their caregivers
Adolescent’s preferred modes of delivery for mental health services
Are children’s grief camps effective?
A weekend camp for bereaved siblings
The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research
“Smartphone apps are cool, but do they help me?”: A qualitative interview study of adolescents’ perspectives on using smartphone interventions to manage non-suicidal self-injury
A systematic review of controlled studies of suicidal and self-harming behaviours in adolescents following bereavement by suicide
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