Forgiveness Postvention with a Survivor of Suicide following a Loved One Suicide: a Case Study

This study aimed to examine the process of the changes that one survivor of suicide following a loved one's suicide experienced during the postvention. We first describe our rationale for using a forgiveness postvention, as well as the details of the postvention; then, we describe findings from a case study focusing on the key postvention moments identified through the single case postvention. Implications, limitations, and future directions are discussed. " We cannot change the past, but we can change our attitude toward it. Uproot guilt and plant forgiveness. Tear out arrogance and seed humility. Exchange love for hate—thereby, making the present comfortable and the future promising ". —Maya Angelou (n.d.)


Introduction
Suicide is a dramatic and traumatic death and among the most growing public health concerns in the world with increased 60% in the past 45 years [1].It is estimated that one million people a year die globally by suicide [2].In the United States alone, it is estimated that over 39,000 people die by suicide OPEN ACCESS a year, which is the 10th ranked cause of death in the USA [3].Survivors of suicide are family members and friends who lost their loved ones to suicide.For each suicide, it has been estimated at least six survivors of suicide are left behind [4], resulting in millions of survivors who are trying to deal with this heartbreaking loss of a loved one each year [5].
Most studies show that, compared with bereaved people because of other causes, survivors of suicide might experience severe emotional distress including guilt, anger, resentment, remorse, confusion, shame, hopelessness, and great distress over unresolved issues of why and what-ifs, resulting in a state of heightened stress [6][7][8][9].The social stigma associated with suicide can make it even more difficult for survivors to deal with their grief while causing them to feel terribly isolated [4,10].In addition, survivors of suicide are likely to exhibit anger toward the deceased, tend to blame others, and feel guilty themselves for the suicide loss [10][11][12].This state of heightened stress and the feelings of isolation can increase vulnerability to the psychological effects of suicide by 2 to 10 times that of the general population [9,13,14].
In addition, the nature of the relationship with the deceased has been found to influence the impact of the suicide loss on individuals, and closely related survivors seem to have significantly higher mean levels of depression and anxiety and lower levels of mental health and quality of life [15].In particular, survivors of suicide who lost their loved ones within one year are more likely to be experience suicidal ideation [16].
As described above, substantial research on survivors of suicides' bereavement experience has focused primarily on negative outcomes of survivors of suicide and has been treated as a clinical problem.However, an exclusive focus on negative outcomes provides an incomplete picture of the effects of suicide loss.A recent study shows that participants identified posttraumatic growth, positive change in the aftermath of a traumatic event, arising from losing an immediate family member to suicide in Korea after suffering the "most unimaginable pain" [17].All in all, survivors of suicide suffer extreme emotional distress and can also experience posttraumatic growth as a result of their painful loss.
According to Shneidman [18], postvention is a helpful act that comes after a suicide loss because it aims to support survivors through the grief process and to prevent suicide for future generations.Survivors of suicide might experience prolonged grief lasting three years or more [19] and survivors of suicide experience higher risk for suicide independent of the family's history of mental illness [20].However, considering the serious, enduring impact on the psychological health of survivors of suicide, postventions for survivors of the suicide of a loved one to reduce extreme emotional distress and promote posttraumatic growth are sparse.

Forgiveness Therapy
One promising area of treatment for survivors of suicide is forgiveness therapy (FT) because it aims at improving one's interpersonal (person-to-person) relationships and enhancing one's intrapersonal (self-focused) well-being.It was found through a correlational study that there existed a relationship between forgiveness of the self and suicidal behavior, which was mediated by depressive symptoms, such that greater forgiveness was associated with less depression and, consequently, less suicidal behavior [21].Additionally, a recent study on survivors of suicide done in South Korea showed that forgiving three parties: (1) anyone whom survivors of suicide believe is responsible for the death of the deceased; (2) the deceased; and (3) the survivors themselves was the ultimate goal for those who desired to experience healing from their deep wounds caused by their loved ones' suicide [22].
There is a lack of consensus among forgiveness scholars about what it means to forgive [23].For instance, McCullough, Worthington, and Rachal [23] define forgiveness as motivational changes where, for instance, forgivers become increasingly less motivated to retaliate and more motivated to show goodwill toward the person who hurt the forgivers.Worthington [24] distinguishes two types of forgiveness-decisional and emotional-where the former involves forgivers' changes in behavioral intentions and the latter involves replacing negative emotions with positive ones.Enright [25] defines forgiveness as an act of mercy practiced in the context of injustice; therefore, forgivers not only abandon their right to resentment, but also gradually foster goodness toward the people who hurt the forgivers such as benevolence, compassion, and even love.
In recent years, forgiveness researchers attempted to understand why there were such differing understandings of forgiveness.Differing perspectives on forgiveness might reflect one's primary scholarly backgrounds, especially theology or psychology [26], or the meaning of forgiveness might depend on which form of forgiveness (e.g., divine vs. interpersonal) is being discussed [27].The difference in opinions might result from individual cultural differences; for instance, those with a collectivistic worldview tend to emphasize interpersonal interactions after forgiving [28], and also the relationship closeness with the person who hurt the forgivers might influence one's conceptualization of forgiveness [29].
Despite a wide range of definitions as well as possible moderators of one's conceptualization of forgiveness, it should be recognized that forgiveness researchers are not far from each other in their understanding of forgiveness.First of all, there is a high consensus on what forgiveness is not; forgiveness is different from pardoning, absolving, tolerating, accepting an apology, or reconciliation [12].Furthermore, most forgiveness researchers would agree that forgiveness is not an event but a process that involves prosocial changes in behavior, cognition, emotion, and/or motivation toward the offending party [30][31][32].
For consistency in our discussion, we adopt Enright and his colleagues' definition of forgiveness that has been used as the basis of multiple intervention studies carried out over the past two decades: A willingness to abandon one's right to resentment, negative judgment, and indifferent behavior toward one who injured us, while fostering the undeserved qualities of compassion, generosity, and even love toward him or her ( [33], pp.46-47).
The construct of self-forgiveness deserves mention as it was found to be one of the areas where suicide survivors see themselves struggling.Despite some arguments against the construct of self-forgiveness such as the implausibility of one person being both the judge and the defendant, it seems that self-forgiveness is a construct similar to person-to-person forgiveness (See Vitz and Meade for their arguments against the construct of self-forgiveness; see [34] for a defense of the construct of self-forgiveness).Self-forgiveness is the moral virtue of forgiveness, in this case, practiced toward the self; one accepts one's wrongdoing, tries to abandon one's anger toward the self, and develops positive affect, behavior, and cognition toward the self [33].One of the major differences between self-forgiveness and interpersonal forgiveness is that self-forgivers also seek forgiveness from other people whom they have offended as the self-forgivers broke their own moral standards.In other words, self-forgiveness is valid when those practicing self-forgiveness truly acknowledge that they did something wrong and are in need of others' forgiveness.
The process in which one engages in forgiving has scientific support, showing that people can effectively forgive with emotional benefits to the forgiver.Although there are potential moderators measuring the effectiveness of FT such as treatment duration and treatment modality (e.g., group vs. individual), the Enright process model of FT (see Table 1) that builds on the definition of forgiveness as introduced above is recognized as the most effective model of FT [2].The Enright process model of FT has four phases in the following order: (1) The Uncovering Phase of Forgiveness; (2) The Decision Phase of Forgiveness; (3) The Work Phase of Forgiveness; and (4) The Discovery Phase of Forgiveness.Thus, forgivers are expected to go through the four phases as rationally expected and also scientifically proven, but the model is not supposed to be taken as an unvarying, step-like sequence; instead, the model assumes that the process of forgiveness is flexible and that individual variations do exist [32].During the first phase of uncovering anger (Units 1-8), forgivers evaluate the defense mechanisms that they have been consciously or unconsciously exploiting in dealing with their pain and unpleasant feelings such as guilty and shame.During the second phase of deciding to forgive (Unites 9-11), forgivers realize that what they have been doing in response to the pain did not lead to a resolution and consider forgiveness as an option.During the third phase of working on forgiveness (Units 12-15), forgivers try to working on seeing what happened in a global context, that is, larger than the context in which they experienced the pain so that they may develop empathy and compassion toward the person who hurt the forgiver and may strive to give a gift to the person who hurt the forgivers.Lastly during the fourth phase of discovery there can be healing from emotional pain (Units 16-20).Forgivers realize the paradox of forgiveness by experiencing benefits through giving mercy, generosity, and love to the person [35].The objective of the present research based on the Enright's [12] process model of forgiveness is to explore, through both quantitative and qualitative data, the process of how and why survivors of suicide change and the effectiveness of forgiveness postvention designed to help improve the well-being of survivors of suicide by alleviating negative psychological symptoms such as suicidal ideation and posttraumatic stress and improving positive psychological symptoms such as posttraumatic growth.
To help survivors of suicide deal with their psychological challenges, three kinds of forgiveness postvention were introduced: (1) Forgiving others, the aim of which is to forgive anyone whom the survivors of suicide believe are responsible for any part of this death (for example, a helping professional who failed to diagnose the symptoms associated with suicide); (2) Forgiving the deceased: Forgive the deceased for their decision to kill oneself, all the changes that they thrust into the lives of the survivors, and all the complications their absence may create in the future; (3) Self-forgiving for survivors of suicide themselves: Forgive the self for any part that survivors of suicide feel they may have played in the death of their loved ones.

Research Design
The current study employed case study methodology, which is an appropriate methodology to explore an understudied area [36].Multiple data sources such as a questionnaire to access complex trauma, field notes by the intervener, and data from ongoing interviews with the participant about her experience of the forgiveness intervention were used to understand the phenomenon in depth [36].This study was approved by the Institutional Review Boards (IRB) at a university.The researchers passed out flyers to friends and asked those friends to talk with their acquaintances.Announcements were put in newspapers.A survivor of suicide who wanted to participate voluntarily in the study was chosen.
The first author was the intervener who has extensive knowledge in the forgiveness process model and volunteer experiences working with survivors of suicide.The second author, a doctoral level licensed psychologist, supervised the forgiveness postvention throughout the sessions.The following case illustrates the application of forgiveness postvention for a survivor of suicide coping with her son's suicide.The entire postvention was based on the book, The Forgiving Life [12].Following pretesting, the research participant engaged in 1-h, weekly FT sessions for 18 weeks focused on each forgiveness topic based on the Enright forgiveness process model (8) meeting with the same intervener in a clinical and translational research core (CTRC) at a university.

Measures
A correlation research shows that the relationship between forgiveness of self and suicidal behavior was mediated by depressive symptoms, such that greater forgiveness was associated with less depression and, consequently, less suicidal behavior [21].Research on forgiveness therapy has shown that forgiving reduces emotional stress and also improves positive emotion [37][38][39][40][41]. Thus, suicide ideation, posttraumatic stress disorder, and posttraumatic growth scales were administered and they are described below.
Beck Scale for Suicide Ideation (BSS).The 21-item Beck Scale for Suicide Ideation [42] assesses the current and immediate intensity of attitudes, behaviors, and plans for suicide-related behavior with the intent to end life among psychiatric patients on a 3-point scale of 0 (no ideation) to 2 (to strong ideation).Total scores range from 0 to 42.The higher the score, the more suicidal ideation a person is reporting, and no specific cut-off scores exist to determine severity or guide patient management.
The Posttraumatic Stress Disorder Checklist (PCL).The survivor of suicide completed the 17-item Posttraumatic Stress Disorder Checklist (PCL) [43] scale.The PCL assesses the 17 DSM-IV symptoms of PTSD on a scale of 0 (not at all) to 3 (almost always).Total scores could range from 17 to 85.The higher the score, the more posttraumatic symptoms a person has, and a cut-off of 50 on the PCL is a good predictor of a PTSD diagnosis.
Posttraumatic Growth (PTG).Posttraumatic Growth was measured by the 21-item Posttraumatic Growth Inventory [44] on a 6-point scale from 0 (I did not experience this change as a result of my crisis) to 5 (I experienced this change to a very great degree as a result of my crisis).PTG has five subscales, including; new possibilities (five questions; e.g., I developed new interests), relationship with others (seven questions; e.g., A sense of closeness with others), personal strength (four questions; e.g., I'm able to do better things with my life), spiritual change (two questions; e.g., I have a stronger religious faith), and appreciation for life (three questions; e.g., Appreciating every day).Total PTG score could range from 0 to 105.Higher scores suggest greater PTG.

An FT Case Example
Names in this case example have been changed to protect confidentiality.Nancy, a woman in her 60s, lost her son to suicide three years ago.Her son, Brett, was 23 years old and married with three children.He killed himself while he was extremely intoxicated after drinking at a bar with his parents-in-law and his wife.
The first session was focused on building rapport with Nancy and obtaining information about her relationship with Brett; his suicide; her marital history; her son's marital history; Brett's mother-in-law, whom Nancy believes is partially responsible for her son's suicide; and Nancy's understanding of the definition of forgiveness (what it is and is not).The intervener learned that Nancy already lost her first son to cancer when he was three years old, and then she had Brett 12 years later.After his birth, she divorced her husband.Brett was, in Nancy's view, a miracle after having multiple losses of close family members including her first son, mother, and sister.She mentioned that losing a son by suicide was much harder than losing a son by cancer because of severe emotional distress and the constant questionings that resulted.Nancy especially exhibited extreme anger toward Brett's mother-in-law, whom she believed was at least partially responsible for his suicide, as described below.It was a day when Nancy was supposed to have dinner with her son.However, his mother-in-law asked him to cancel the appointment with Nancy and spend time with her family instead.According to Nancy, the mother-in-law tends to be neglectful and enjoys having parties.She has 10 children with different fathers, and the children did not go to school but stayed at home teaching each other.The daughter-in-law is the oldest child who takes care of her siblings instead of her mother attending to this task.Nancy watched a video clip that was recorded at the bar where her son, his wife, and her parents-in-law were drinking before her son's suicide.Even though her son was extremely intoxicated, his mother-in-law encouraged him to drink more even though waiters at the bar refused to give him more drinks.In the video clip, Brett said that he was going to die, but the mother-in-law just made fun of him.Later at Brett's home, his wife, Lisa, and parents-in-law found Brett dead, but they did not call Nancy.Instead, Nancy received a horrible phone call at 5:30 a.m. from a policeman.Nancy believes that the mother-in-law's encouragement to drink made him kill himself and that her not calling her deprived Nancy of her final moments with her son.Since then, Nancy has felt scared when she needs to receive phone calls and has difficulty sleeping because Brett killed himself while she was sleeping.The intervener also learned that it was hard for Nancy to admit that she was angry toward the deceased, but she was struggling with feeling anger toward Brett because of his final action.Nancy also was struggling with feeling anger toward herself because she was sleeping while her son killed himself.As a result, she now is the sole surviving member of the family who is left to deal with severe emotional distress, especially anger toward the mother-in-law, her son Brett, and herself.
In early sessions, Nancy went through the uncovering phase of forgiveness toward the mother-in-law.Nancy mentioned that she couldn't understand the mother-in-law, her lifestyle, and her neglectful parenting style.Nancy explained that Sarah, the mother-in-law, has 10 children with different fathers and she enjoys going parties and leaving her children at home.After Brett's funeral, Sarah went to a party again a week later and pushed her daughter, Lisa, to go on a date with a new man.Nancy mentioned that she does not understand Sarah, who is not a typical and stable mother and has a different life culture.Nancy said that whenever she thinks of Sarah, she feels angry because she believes she cannot see her son again as a result of Sarah's actions.Nancy mentioned how unfair it is that Sarah has all the children even though she is neglectful and irresponsible as a mother, while she had only one, but she lost him.Whenever Nancy has to meet Sarah because of their grandchildren, Sarah is a constant reminder for Nancy of her loss and pain.
Throughout the sessions, Nancy learned that one negative event, for example, Sarah's mistreating Nancy's son, complicated her life, and she believes that she needs to forgive her not to lose, in an emotional sense, all the other aspects of life.However, she was not sure whether she could go through the forgiveness process.The intervener validated her fear by saying that the forgiveness process does not add more pain but shows her how much pain she is in now.The turning point in the sessions occurred when Nancy brought up her childhood issue with her abusive father.Nancy's father was abusive and controlling toward his children, including Nancy and her mother.He asked Nancy's mother to leave the home and did not take care of his children, failing to provide them with enough food, and abused them emotionally, verbally, physically, and sexually.Nancy mentioned that she had issues with low self-esteem and abandonment because of her father's abuse.Throughout the sessions, Nancy realized why she was so angry toward the mother-in-law: because Sarah is a reminder of her abusive childhood experience and this brought back all the low self-esteem and abandonment issues.Sarah's decision not to call Nancy after Brett's suicide brought up these issues."Do I not deserve to have some final moments with my son?" Nancy tried to understand her father and his life, and she remembered that her grandfather had schizophrenia.The relationship between her father and her grandmother was cold.One day in the middle of the sessions, Nancy was informed by her older sister that Nancy's grandfather on her father's side killed himself when Nancy's father was young, approximately her grandson's current age.Nancy mentioned that her grandson has anxiety issues after Brett's suicide.Knowing that Nancy's father did not have any warm figure around him and knowing that no one was sad when his father passed away helped her to develop compassion toward her father, and learning that Nancy's father was also struggling with the suicide loss like her grandson is now helped her develop compassion toward her grandson, which greatly helped with the release of her anger.Further she replaced feelings of anger with compassion, which facilitated the process of forgiveness toward Nancy's father.
Nancy's process of forgiving her father facilitated the process of forgiveness for Brett's mother-in-law.One day, when Nancy found out that her grandchildren loved being with her but not with Sarah, Nancy realized that Sarah might not know the sincere joy of life.Since then, Nancy replaced her feelings of resentment with compassion.Nancy was not endorsing her father's abuse and Brett's mother-in-law's actions, but she wanted to stop transmitting negative experiences and angry affect to the grandchildren after she learned that negative experiences could be transmitted inter-generationally.She discovered the new purpose of her life: being a better grandmother who does not transmit the pain but love to her grandchildren.There is a cascade effect inherent to the forgiveness process for her.Once she learned how to forgive her father and Brett's mother-in-law, she began to forgive her son and herself more easily.Nancy mentioned that Brett's final action was not right, but she released her feelings of anger toward her son while appreciating the meaning of his existence to her and that he would not intend to hurt anyone else as a result of the tunnel vision caused by alcohol.Finally, Nancy released her feelings of resentment toward herself after acknowledging that she could not control all aspects of her son's life and how much she loved him and tried to raise him well in order to not follow her father's abusive parenting style.
In the final session, Nancy mentioned that she was able to sleep well for the first time since her son's death.She also mentioned that she had spread the effect of forgiveness to others and had suggested that they read the book she used for forgiveness postvention.She told the intervener that she had a coworker who makes trouble for her and that now she understands her coworker's feelings behind her behaviors without feeling anger anymore.She stated that the forgiveness postvention has changed her life and that she can "live with a new heart".
At pretest, Nancy demonstrated negative outcomes resulting from the suicide of her son, including PCL (55), suicide ideation (16), and low levels of posttraumatic growth (63).At posttest, Nancy demonstrated considerable improvements in her post-traumatic stress symptoms, progressing from above cut-off to below the cut-off (31).She also transitioned from low posttraumatic growth (63) to high posttraumatic growth (92) and from high suicide ideation (16) to low suicide ideation (2).Nancy maintained these improvements at her three-month follow-up (posttraumatic stress (33), posttraumatic growth (95), and suicide ideation (1).

Discussion
This is the first study that conducted a forgiveness postvention for a survivor of suicide that intended to reduce the severe emotional distress caused by other people and herself.This current case study enabled the researchers to not only examine the efficacy of a forgiveness postvention but also to answer "how" and "why" type questions to understand the process of change that occurred.This study showed that FT provides an effective model for this particular survivor of suicide, promoting posttraumatic growth and reducing posttraumatic stress and risk of suicide ideation.As FT has been applied to coping with trauma in general, this study provides preliminary, pilot evidence that FT might also specifically be used for survivors of suicide who lost a loved one to suicide by dealing with their issues in interpersonal relationships and intrapersonal challenges.
In addition, this is the first study to implement FT toward the goal of forgiving multiple people.Survivors of suicide usually need to forgive more than one person as a suicidal loss often involves multiple people.An interesting finding of the current study, which should be followed up in a future study, is that there is a cascade effect inherent to the forgiveness process.Once Nancy learned how to forgive her father, she was able to forgive other people much easier and faster.This phenomenon represents cumulative consequences of working on the forgiveness process that result in spreading the effects of forgiveness across other people.Forgiveness postvention with suicide survivors might be able to promote positive cascades of forgiving multiple people in the context of suicide loss.
Descriptions of the postvention components, as occurred in this investigation, may aid in the application of postvention techniques and thus in improved psychological service in this relatively sparse area of postvention.In spite of the interesting hypothesis-forming findings of the current study, it has a limitation to be noted.The findings regarding this process for one individual with her own particular circumstances and characteristics cannot be broadly generalized to other survivors of suicide.Given the exploratory nature of this study, further research for forgiveness postvention is needed to assist in the design and evaluation of forgiveness postventions.More empirical data are needed about effective family interventions for suicide survivors to maximally assist this vulnerable and high-risk population.

Conclusions
In conclusion, the findings of the current study suggest that forgiveness postvention holds promise for the promotion of psychological well-being.Furthermore, this study describes a concrete clinical pathway for postvention clients who are coping with the suicide of a loved one.Because suicide is a worldwide problem, this work is likely to be useful internationally.
Survivors of suicide are in need of much help because the person who kills himself puts his psychological skeleton in the survivor's emotional closet-he sentences the survivor to deal with many negative feelings and, more, to become obsessed with thoughts regarding his own actual or possible role in having precipitated the suicidal act or having failed to do anything about it ( [18], p. x).
A suicide postvention holds promise for helping clients reduce negative feelings and thoughts which, if left untreated, might overwhelm their lives.With further research in this vital area, forgiveness postvention for survivors of suicide may be one way that restores hope to clients who have lost hope.

Table 1 .
The process model of forgiveness.
[12]Uncovering Phase of Forgiveness 1. Are you denying your wounds or exaggerating them? 2. Have you faced your wounds and admitted their existence?3.Have you examined the degree of shame or guilt you may be carrying as a result of this wound?4.Have your wounds affected your health? 5. Have you been thinking, over and over, about the person and the event?6.Do you compare your situation with that of the one who hurt you? 7. Has the suicide caused a significant change in your life? 8. Has the suicide altered your worldview?17.Discover your need for forgiveness.18.Discover that you are not alone.19.Discover the purpose of your life.20.Discover the freedom of forgiveness.Note: From ([12], pp.168-97); adapted with permission.