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Graduate School of Professional Psychology: Doctoral Papers and Masters Projects Graduate School of Professional Psychology
8-2019
Cultural Factors Affecting Suicide-Specific Grief in the Latinx Community: A Systematic Literature Review of Studies
Raquel Meade University of Denver
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Recommended Citation Meade, Raquel, "Cultural Factors Affecting Suicide-Specific Grief in the Latinx Community: A Systematic Literature Review of Studies" (2019). Graduate School of Professional Psychology: Doctoral Papers and Masters Projects. 348. https://digitalcommons.du.edu/capstone_masters/348
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SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 2
Abstract
Introduction. In 2017, suicide was the 9th leading cause of death for all ages of the Latinx population living in the United States (National Center for Injury Prevention and Control,
Centers for Disease Control and Prevention, 2018). These statistics point to the number of individuals from the Latinx community left to grieve a death by suicide and the need to further understand suicide-specific grief in this community. The purpose of the present systematic literature review was to (1) identify the cultural factors affecting grief in Latinx individuals, (2) identify themes of suicide-specific grief, and then (3) describe the way in which the identified cultural factors may influence suicide-specific grief in the Latinx population residing within the
United States. Method: A systematic literature review was conducted using three databases and search terms relevant to suicide-specific grief and the Latinx population. One hundred and sixty- seven studies were identified, of which 49 were included in the full review process following the application of inclusion and exclusion criteria. Results: Out of the 49 studies, 15 (30.6%) of them identified two Latinx cultural factors in the context of grief: familismo and religion. Forty- seven (96.0%) studies identified six themes of suicide-specific grief: stigma; emotional dysregulation; making sense of the death; sense of relief; posttraumatic growth; and social support. Conclusions: The two identified Latinx cultural factors, familismo and religion, affect suicide-specific grief in Latinx individuals, both in positive and negative manners. Limitations exist related to the studies’ sample size and composition. Future research should continue to explore the relationship between Latinx cultural factors and suicide-specific grief.
Keywords: Suicide, Latinx, grief, religion, familismo, stigma SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 3
Table of Contents Abstract...... 2
Introduction...... 4
Purpose Statement...... 5
Methods...... 5
Selection of Studies...... 5
Inclusion and Exclusion Criteria...... 6
Results...... 8
Latinx Cultural Factors...... 9
Familismo...... 10
Religion...... 10
Themes of Suicide-Specific Grief...... 12
Stigma...... 12
Emotional Dysregulation...... 13
Making Sense of the Death...... 14
Sense of Relief...... 15
Posttraumatic Growth...... 15
Social Support...... 16
Discussion...... 17
Limitations of the Systematic Literature Review...... 22
Future Directions and Implications...... 24
Conclusion...... 25
References...... 28
Appendix A...... 41 SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 4
Cultural Factors Affecting Suicide-Specific Grief in the Latinx Community: A Systematic
Literature Review of Studies
Introduction
Death is universal, as is death by suicide. The Centers for Disease Control and Prevention
(CDC) define suicide as a “death caused by injuring oneself with the intent to die” (“Preventing
Suicide,” 2018, p. 1). According to the World Health Organization, 800,000 people die by suicide in the world every year (“Suicide data,” n.d.). In the United States, approximately 47,173 individuals died by suicide in 2017; this amounts to 129 individuals per day (Drapeau &
McIntosh, 2018). Although suicide is underreported in part due to stigma, these statistics point to the gravity of suicide and the quantity of people it affects.
Despite the universality of death, the way individuals grieve, perceive, and make sense of death varies considerably. A death by suicide further differentiates grief (de Groot, de Keijser, &
Neeleman, 2006; Gall, Henneberry, & Eyre, 2014; Nam, 2016; Young et al., 2012). Although grief is not a pathological response, but a normative process, the grief following a death by suicide is associated with higher levels of emotional dysregulation and increased feelings of abandonment, shame, and stigma (Jordan, & McIntosh, 2011; Nam, 2016; Thompson, 2017).
According to Hauser (1987), a death by suicide insinuates the likelihood of irregularities in the grief process.
Suicide-specific grief is further differentiated by culture, such as the culture of the Latinx population residing within the United States (Hauser, 1987). Approximately 58.9 million individuals who identify as Latinx reside in the United States (US Census Bureau, Population
Division, 2018). Given that suicide was the 9th leading cause of death in 2017 for the Latinx population of the United States, it is important to consider if suicide-specific grief manifests SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 5 differently given this population’s emphasis on familial interdependency and religious values, amongst other cultural factors which can impact the grieving and meaning-making process
(National Center for Injury Prevention and Control, Centers for Disease Control and Prevention,
2018).
Purpose Statement
While grief in the Latinx population is adequately documented in the literature, information regarding suicide-specific grief in the context of Latinx cultural factors is sparse.
This study was undertaken with the aim of filling this gap in the literature, which is important due to the ever-growing Latinx population in the United States and the need for culturally- informed mental health treatment. The goals of the present study were to systematically review the literature to (1) identify the cultural factors affecting grief in Latinx individuals, (2) identify themes of suicide-specific grief, and then (3) describe the way in which the identified cultural factors may influence suicide-specific grief in the Latinx population residing within the United
States.
Methods
Selection of Studies
This systematic literature review was completed using three databases: PsychINFO,
ProQuest Dissertation & Theses Global, and Latin American & Caribbean Health Sciences
Literature (LILACS). Each of these databases was searched using the following search terms:
1. (“survivors of suicide”) AND (“grief” OR “bereavement” OR “mourn” OR “traumatic grief”) 2. (“grief” OR “bereavement” OR “mourn” OR “traumatic grief”) AND (“Latino” OR “Hispanic”) 3. (“survivors of suicide”) AND (“grief” OR “bereavement” OR “mourn” OR “traumatic grief”) AND (“Hispanic” OR “Latino”) SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 6
For the purpose of this study, Latinx individuals are defined as individuals who are of
“Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race” (Ennis, Ríos-Vargas, & Albert, 2011, p. 2). In addition, the term “Latinx” is used instead of “Latino/a,” as the former is an inclusive term without gender biased.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria were identified in order to systematically select pertinent studies (see Table 1, p. 6). The categories of inclusion and exclusion criteria included participants, location, language, publication date, and type of study. Studies eligible for inclusion were published within the last ten years (2009 and forward), and published in peer-reviewed journals. This range of publication was set in an effort to capture the recent trends in immigration
(e.g. unauthorized immigration was at its highest in 2007) and make the results more applicable to the current Latinx population (Passel & Cohn, 2018). The searches were conducted by this doctoral research paper’s author in January of 2019. Studies were included if they were published in either English or Spanish language, as the author is fluent in both languages. In addition, this increased the opportunity to include literature regarding Latinx cultural factors.
Table 1. Inclusion and Exclusion Criteria.
Category Inclusion Criteria Exclusion Criteria Individuals who identify as Latinx; Individuals living outside of the individuals living in the United States or United States or outside of Latin Participants Latin America grieving a death, including, America; individuals not but not limited to, a death by suicide grieving a death Studies conducted outside of the Studies conducted in the United States or in Location United States or outside Latin Latin America America Languages other than English or Language English or Spanish Spanish Year Published on or after 2009 Published before 2009 Quantitative and qualitative (cross-sectional Grant proposals, literature Methodology mixed methods, cohort studies, and single reviews, personal narratives, and case studies). program development
SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 7
Types of studies included were quantitative (e.g. cross-sectional studies, mixed methods studies and cohort studies) and qualitative. Studies were excluded if they did not present original findings (i.e. literature reviews) or were published in a non-peer reviewed journal. Grant proposals, personal narratives, and program developments were also excluded.
Participants of the eligible studies included individuals of the Latinx community living in the United States or Latin America, and grieving any type of death, including, but not limited to, a death by suicide. This was permissible because studies related to non-suicide deaths still provided relevant, general information on Latinx cultural factors and, overall, there was a significant scarcity in studies that were specific to suicide-related grief in the Latinx population.
Participants were male or female, and all age groups were included.
In addition to including Latinx individuals living either in the United States or Latin
America, participants of the eligible studies were also individuals of any other ethnicity (e.g.
Caucasian, African American, Native American, Asian, Pacific Islander, or Bi-racial) who lived in the United States and were grieving a death by suicide. This was allowed so as to include general information about suicide-specific grief for individuals living in the United States.
Individuals living outside of the United States or outside of Latin America were excluded from the review in an effort to reduce confounding variables related to foreign cultures, and increase specificity to the Latinx population residing within the United States.
The author comprised a list of all the articles resulting from the searches, and then applied the inclusion and exclusion criteria to systematically select the eligible studies. Abstracts that appeared to discuss grief, including suicide-specific grief, and met the inclusion criteria were selected. Then, these studies were read and evaluated by the writer for final approval. Relevant data was extracted (see Table 2, Appendix A) and used to draw conclusions. Each article was SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 8 only reviewed by one individual, the author of this doctoral research paper. This is acknowledged as a limitation and will be discussed in further detail in the “Limitations” section of this paper.
Results
The systematic literature review initially identified 167 articles using the search terms in each of the three databases, PsychINFO, ProQuest Dissertation & Theses Global, and LILACS.
Of these 167 studies, 100 articles were excluded after an initial screening of the abstract. Of the
100 articles excluded, 24 were excluded for not meeting location inclusion criteria, 13 were excluded for not meeting methodology criteria, and 67 were excluded for not meeting participant inclusion criteria (e.g. participants were not grieving a death). Sixty-seven studies passed the initial screening and then underwent a full-text article review, in which the inclusion and exclusion criteria were applied to determine eligibility. During this screening step, 11 articles were excluded for not meeting methodology inclusion criteria, one article was excluded for not meeting location inclusion criteria, one article was excluded for not being available online, and five were excluded for not meeting participant inclusion criteria. Of note, no studies were included from LILACS database.
Forty-nine studies were included in the final review (see Figure 1, p. 9). Of these 49 studies, 24 (49.0%) were cross-sectional studies, 17 (34.7%) were qualitative, three (6.1%) were randomized controlled studies, three (6.1%) were mixed methods, one (2.0%) was a cohort study, and one (2.0%) was a case control study. The 49 studies are summarized in Table 2 (p.
41). The results are divided into two categories: (1) Latinx cultural factors (familismo and religion); and (2) themes of suicide-specific grief (stigma; emotional dysregulation; making sense of the death; sense of relief; posttraumatic growth; and social support). SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 9
Figure 1. Flowchart of the selection of studies for the systematic literature review.
These two categories of results correspond with the search terms, as the first search term
[(“survivors of suicide”) AND (“grief” OR “bereavement” OR “mourn” OR “traumatic grief”)] led to studies that highlighted themes of suicide-specific grief, and the second and third search terms (p. 5) led to studies that highlighted Latinx cultural factors. In addition, the author used thematic analysis to identify these two Latinx cultural factors and six themes of suicide-specific grief. This thematic analysis involved reading and re-reading the retrieved full-text articles, manually coding the material to identify preliminary themes, and then revising the themes to ensure that they captured “internal homogeneity and external heterogeneity” between the articles
(Krysinska & Andriessen, 2015, p. 26). As the author was the only individual to complete this thematic analysis, this will be noted as a limitation and further discussed in the Limitations section.
Latinx Cultural Factors
Of the 49 studies, 15 (30.6%) of them identified and discussed two Latinx cultural factors, familismo and religion, in the context of grief (Berardi, 2018; Ener, 2015; Feigelman, SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 10
Jordan, & Gorman, 2009b; Ford, 2016; Hawthorne, 2012; Hunt, 2013; Jones, 2018; Krysinska,
Andriessen, & Corveleyn, 2014; Krysinska, & Andriessen, 2015; Lichtenthal, Neimeyer, Currier,
Roberts, & Jordan, 2013; Monserud & Markides, 2017; Simon-Parsons, 2012; Vandecreek &
Mottram, 2009; White, 2013; Youngblut, Brooten, Blais, Kilgore, & Yoo, 2015). It is important to note that one (3.9%) study reported that level of acculturation was not significant in influencing grief; therefore, this cultural factor was not included in the results (Simon-Parsons,
2012).
Familismo. Familismo was cited by four (8.2%) studies as a cultural factor that affects grief. Familismo is the concept of family “interconnectedness and cohesion” (Leidy, 2012). It emphasizes loyalty and interdependence; the family’s needs take priority over individual needs
(Leidy, 2012). One study identified that individuals of the Latinx community experience distress when they perceive themselves to have not met familial obligations, such as caretaking for a family member (Youngblut et al., 2015). Monserud and Markides (2017) reported that a higher level of perceived social support during grief was correlated with more depressive symptoms, as it led individuals to feel more dependent on others. Another study found that a strong connection to family served as a protective factor during grief (Simon-Parsons, 2012). Similarly, Ener
(2015), found that parents of the Latinx community identified their children’s behaviors to be less stressful while the family was grieving a death, while parents who identified as Caucasian endorsed a higher level of parental stress. Ener (2015) noted that this may be in part due to the
Latinx cultural value of family relationships.
Religion. Thirteen (26.5%) studies discussed aspects of religion as they relate to grief for the Latinx population (Berardi, 2018; Feigelman et al., 2009b; Ford, 2016; Hawthorne, 2012;
Hunt, 2013; Jones, 2018; Krysinska et al., 2014; Krysinska, & Andriessen, 2015; Lichtenthal et SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 11 al., 2013; Monserud & Markides, 2017; Simon-Parsons, 2012; Vandecreek & Mottram, 2009;
White, 2013). Nine (18.4%) studies found only positive aspects of religion, two (4.1%) studies identified both positive and negative aspects, and two (4.1%) studies found only negative aspects of religion. It is important to note that much of the Latinx community in the United States identify as Roman Catholic. In 2013, 68% of Latinx individuals identified as Roman Catholic and 64% of those Latinx individuals attended church services regularly (Suro, Escobar,
Livingston & Hakimzadeh, 2007). In addition, most of Latin America identifies as predominantly Catholic (Paulson, 2014).
When religion was cited in the studies as being a positive mechanism, themes clustered around how it helps individuals cope with grief, whether it be through rituals, maintaining a relationship with the deceased, or believing in an afterlife (Feigelman et al., 2009b; Krysinska et al., 2014; Lichtenthal et al., 2013). One study reported that religion facilitates meaning-making of the death (Krysinska et al., 2014). Similarly, Hunt (2013) found that religion allowed Latinx individuals to find comfort in maintaining a relationship with the deceased because of the belief that there is an after-life. Another study found that Latinx individuals fuel grief into “restoration focused tasks,” such as Day of the Dead altars, attending church services, and other religious rituals (Berardi, 2018, p. i).
Monserud and Markides (2017) found that depressive symptoms related to grief improved after attending religious services. Two studies identified an increase in religious involvement after experiencing a death, which led to personal growth (Vandecreek, & Mottram,
2009; Feigelman et al., 2009b). According to Diaz (2017), religious involvement decreases the
“severity” of the difficult emotions correlated with grief. This was also reported by Krysinska SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 12 and Andriessen (2015), who found that Latinx individuals grieving suicide asked God for forgiveness, which led to increased feelings of peace and relief during grief.
Religiosity was also found to, at times, be a negative mechanism in the grieving process.
Specifically, religiosity was found to exasperate grief-related mood and behavioral symptoms, such as distress and rumination. One study found that individuals of the Latinx community grieving a death by suicide wondered whether the deceased was going to heaven, as suicide is perceived as a sin in the Catholic faith (Vandecreek & Mottram, 2009). White (2013) found that
Latinx individuals grieving a death by suicide experienced an increase in feelings of confusion and distress because of their religious beliefs and their difficulty making sense of the death in the context of God’s will. Hawthorne (2012) also found similar results, stating that Latinx individuals’ religious beliefs intensified grief and led to mood symptoms. Finally, two studies found that individuals grieving a death by suicide experienced a decrease in level of religiosity
(Jones, 2018; White, 2013).
Themes of Suicide-Specific Grief
As discussed in the introduction, the grief following a death by suicide can be differentiated from the grief following other types of death (de Groot et al., 2006; Gall et al.,
2014; Nam, 2016; Young et al., 2012). This systematic literature review found 47 (96%) studies that discussed the distinctiveness of suicide-specific grief, with differences falling into six general themes: stigma; emotional dysregulation; making sense of the death; sense of relief; posttraumatic growth; and social support. It is important to note that one study included in this review reported that suicide-specific grief was similar to the grief following other types of violent deaths, in that there were similarities in isolating behaviors and social stigma (Feigelman et al., 2009a). The six themes related to suicide-related grief are summarized below. SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 13
Stigma. Fifteen (30.6%) studies identified stigma, or a label of dishonor and shame, as a distinct feature of suicide-specific grief (Ahmedani, 2011). Three studies provided specific evidence for the negative effects of stigma on grief, which were described as an increase in emotional dysregulation (Cammarata, 2012; Feigelman et al., 2009c; Feigelman, Jordan, &
Gorman, 2011). The term “emotional dysregulation,” which was originally coined by the psychologist Dr. Marsha Linehan, is used repeatedly throughout this doctoral research paper to refer to an emotional response that is marked by distress and difficulty effectively and independently managing it (Lasek, 2014).
Three other studies reported that stigma led to a decrease in communication about the suicide, which was related to an in increase in distress (Groff, 2015; Jones, 2018; White, 2013).
Two studies found that religious beliefs contributed to the stigma surrounding suicide (Krysinska et al., 2014; Van, 2011). Three studies discussed the negative effects of stigma on interpersonal functioning, which included social isolation and deterioration of relationships (Ford, 2016; Lynn,
2011; Saatci; 2013). Finally, two studies concluded that stigma perpetuates “disenfranchised grief,” or grief that is not acknowledged openly in society (Andersson, 2012, p. 7; Sandage,
2010).
Emotional dysregulation. Thirty-eight (77.6%) studies found that suicide-specific grief is marked by an increase in emotional dysregulation characterized by a range of emotions, including blame, guilt, anger, abandonment, or complicated grief. Five (10.2%) studies cited shame to be present in suicide-specific grief, which led to discomfort in acknowledging or discussing the suicide (Cammarata, 2012; Feigelman et al., 2011; Mayton & Wester, 2018;
Saatci; 2013; Vandecreek & Mottram, 2009). SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 14
Fifteen (30.6%) studies identified blame and guilt to be a part of the emotional dysregulation experienced during suicide-specific grief (Baddeley et al., 2015; Bottomley et al.,
2018; Feigelman, Jordan, & Gorman, 2011; Ford, 2016; Hunt, 2013; Jones, 2018; Krysinska &
Andriessen, 2015; Powell & Matthys, 2013; Rabalais, Wilks, Geiger & Bates, 2017; Sandage,
2010; Saatci, 2013; Supiano, 2012; Tal et al., 2017; Van, 201; White, 2013). Nine (18.4%) studies specifically identified that survivors of suicide loss assigned blame and responsibility to themselves, which led to feelings of guilt as they felt that they could have stopped the suicide
(Bottomley et al., 2018; Ford, 2016; Hunt, 2013; Jones, 2018; Krysinska & Andriessen, 2015;
Sandage, 2010; Tal et al., 2017; White, 2013; Van, 2011). Ten (20.4%) studies found that anger was another significant emotion present in the emotional dysregulation of suicide-specific grief.
One (2.0%) study found feelings of abandonment to be present during suicide-specific grief
(Jones, 2018).
Twenty-eight (57.1%) studies found that suicide-specific grief was connected to significant mental health concerns, such as suicidal ideation, Prolonged Complex Bereavement
Disorder, Posttraumatic Stress Disorder (PTSD), or Major Depressive Disorder (MDD). Mitchell
& Terhorst (2017) found that higher grief scores in survivors of suicide loss were associated with more PTSD symptoms. Another study reported that 66% of the sample of survivors of suicide loss had high scores on measures of complicated grief (Hill, 2012). Furthermore, one article discussed how suicide is traumatic in nature, and how trauma symptoms in survivors of suicide loss can negatively disrupt grief (Gonzalez & Bell, 2016).
Making sense of the death. Fifteen (30.6%) studies identified survivors of suicide loss to have difficulty with making sense of the death (Berardi, 2018; Bottomley et al., 2018; Jones,
2018; Krysinska & Andriessen, 2015; Ford, 2016; Lynn, 2012; Mitchell, Sakraida, Kim, Bullian SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 15
& Chiappetta, 2009; Moore, 2012; Powell & Matthys, 2013; Saatci, 2013; Sancimino, 2010;
Simon-Parsons, 2012; Supiano, 2012; Van, 2011; White, 2013). Given the abrupt nature of a death by suicide, survivors of suicide loss experience significant shock and confusion; three studies found these feelings to contribute to survivor’s difficulty with making sense of the death
(Jones, 2018; Saatci, 2013; White, 2013). One study found that a perceived lack of closure contributes to difficulty with meaning-making (Powell & Matthys, 2013). Three studies found that survivors of suicide loss engage in behaviors aimed at maintaining a relationship with the deceased in an effort to make sense of the death (Bottomley et al., 2018; Krysinska &
Andriessen, 2015; Van, 2011).
Sense of relief. Four (8.2%) studies found that survivors of suicide loss experienced a sense of relief in knowing that the deceased was no longer suffering from emotional pain (Hunt,
2013; Krysinska & Andriessen, 2015; Powell, & Matthys, 2013; Sandage, 2010). Hunt (2013) identified that this sense of relief provides a positive reframe of the death for those who are grieving. Powell & Matthys (2013) found that survivors of suicide loss experienced relief by reading the note left by the deceased, as it provided an intimate look at the deceased’s painful emotional experience and an opportunity for the survivor to better understand the emotional pain.
Posttraumatic growth. Fourteen (27.5%) studies identified posttraumatic growth to be present in suicide-specific grief (Berardi, 2018; Bottomley et al., 2018; Drapeau, Lockman,
Moore & Cerel, 2018; Feigelman et al., 2009b; Ford, 2016; Hidalgo, 2017; Hunt, 2013; Jones,
2018; Lichtenthal et al., 2013; Moore, 2012; Sancimino, 2010; Simon-Parsons, 2012; Supiano,
2012; White, 2013). One study reported that survivors of suicide loss experienced an increase in appreciation for life, compassion, and empathy towards others who have also experienced a death (Lichtenthal et al., 2013). However, Moore (2012) found that posttraumatic growth scores SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 16 were low in parents grieving a suicide when compared to parents grieving other types of death, suggesting that posttraumatic growth may occur later in suicide-specific grief. Another study found that a more severe level of grief, such as the level seen in suicide-specific grief, signifies a greater level of posttraumatic growth (Hidalgo, 2017).
Social Support. This systematic literature review found trends related to the social support received from friends and family of the suicide survivor. Three (6.1%) studies identified positive aspects of social support, specifically that it provided validation and healing during grief
(Groff, 2015; Hunt, 2013; Spino, Kameg, Cline, Terhorst, & Mitchell, 2016). Sixteen (32.7%) studies found that survivors of suicide loss perceived the support they received following the suicide as inadequate, or, even worse, harmful (Andersson, 2012; Feigelman et al., 2009a;
Feigelman et al., 2009c; Feigelman et al., 2009b; Feigelman et al., 2011; Ford, 2016; Groff,
2015; Lynn, 2012; Macor, 2018; Saatci, 2013; Sancimino, 2010; Supiano, 2012; Tal et al., 2017;
Vandecreek, & Mottram, 2009; Van, 2011; White, 2013).
Of these 17 studies, five of them discussed insensitive comments made to survivors of suicide loss regarding the death (Feigelman et al., 2009a; Feigelman et al., 2009c; Supiano,
2012; Vandecreek, & Mottram, 2009, White, 2013). Macor (2018) found that participants reported feeling neglected and overlooked by people in their support network, and resorted to relying on themselves to cope with the suicide. Another study found that survivors of suicide loss tend to isolate themselves for an extended period (Saatci, 2013). Vandecreek & Mottram (2009) reported that two out of ten participants reported experiences in which they received hurtful, religious-based comments related to the deceased being in hell for their suicide. Another study reported that those providing interpersonal support to survivors of suicide loss were SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 17 uncomfortable with the topic of suicide and expressed their discomfort through humor, which felt inadequate to those grieving the suicide (Supiano, 2012).
Discussion
After reviewing 49 studies, this systematic literature review identified two cultural factors specific to Latinx grief and six themes of suicide-specific grief. With this assembly of information, this systematic literature review concluded that Latinx cultural factors affect suicide-specific grief, both in positive and negative manners.
Familismo is one of the Latinx cultural factors identified by this systematic literature review that affects suicide-specific grief in Latinx population. Familismo is usually perceived as a protective factor for the Latinx community, but its presence and practice can increase stigma and shame in suicide-specific grief. A death by suicide can be perceived as a failure in the context of familismo because the family failed to maintain interdependency and protect the deceased (Pantin et al., 2003). As Youngblut and colleagues (2015) concluded, failure to meet family obligations leads to emotional distress, and the emotional distress following a suicide may be marked by increased shame if the family perceives themselves to have a role in the suicide.
Furthermore, familismo implies strong family connections, but these connections can be perceived as overwhelming and suffocating during grief, which can lead to further emotional distress (Monserud & Markides, 2017). This conclusion is also supported by another study in this review that found that survivors of suicide loss tend to isolate themselves, a behavior that may also be seen in Latinx individuals if they are feeling overwhelmed by familial support (Saatci,
2013). It is also possible that the family is being an ineffective source of support to one another due to their own grief, shame, and distress, which related to findings by Macor (2018) who SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 18 reported that survivors of suicide loss would rather rely on themselves than on family during suicide-specific grief.
A study by Zayas, Lester, Cabassa, and Fortuna (2005) corroborates the conclusion that familismo may negatively affects suicide-specific grief. This study revealed that when parents of the Latinx community actively implement familismo, they restrict individual autonomy and implement an authoritarian style of parenting seen as culturally normative. This style of familismo-influenced parenting negatively affects the family’s ability to adapt and practice flexibility (Zayas et al., 2005). This research suggests that this parenting rigidity and familial inflexibility that comes with familismo may also affect suicide-specific grief by restricting a
Latinx individual’s freedom to grieve in a personalized manner that meets the needs of each individual.
Familismo can create a sort of rigidity within the family that limits family member’s independency, as well as their ability to adequately express their emotions. This further decreases the likelihood that a member of the family will openly discuss his or her grief regarding a death by suicide, which perpetuates stigma, one of the themes of suicide-specific grief. Literature by Nolle and colleagues (2012) corroborates the finding that familismo can negatively affect an individual in the Latinx community; their work on suicidality amongst
Latina adolescents found that familismo influenced feelings of failure in the context of family relationships and, consequently, increased suicidal ideation (Nolle, Gulbas, Kuhlberg, & Zayas,
2012). As suggested by this study and the studies of this systematic literature review, familismo within the Latinx population can at times perpetuate a negative perception of suicide and thus increase emotional dysregulation during grief. In conclusion, familismo may lead to an overall increase in emotional dysregulation and, specifically, an increase in shame, increase in isolating SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 19 behaviors, and decrease in communication amongst Latinx individuals experiencing suicide- specific grief.
Regarding the positive effects of familismo, two studies of this systematic literature review found that familismo is a protective factor in grief and facilitates healing (Ener, 2015;
Simon-Parsons, 2012). Feeling connected to family and peers can provide endless opportunities for support and validation of the difficult emotions that arise during suicide-specific grief, whether it be shame, anger, guilt, or confusion. The healing facilitated by familismo may also lead to posttraumatic growth, one of the six identified themes of suicide-specific grief.
However, it is important to note that due to the emotional dysregulation present in suicide-specific grief, posttraumatic growth may occur later in the grief trajectory when compared to grief following other types of death (Moore, 2012). This was suggested by a study that found that posttraumatic growth scores were low in parents grieving a suicide when compared to parents grieving other types of death. The study was able to conclude that post- traumatic growth may occur later in the grief-trajectory through comparative analysis of data with longitudinal studies (i.e. longitudinal studies found that posttraumatic growth increases when participants provided self-reports at different time marks). Hidalgo (2017) similarly reported that greater grief was significantly related to greater personal growth in children.
This systematic literature review also pointed to the influence of religion, specifically
Catholicism in the Latinx population, on suicide-specific grief. Catholics perceive suicide as a sin. An individual taking the power to end his or her own life is judged in this manner because
Catholics believe that only their God has the power to do this (Hovey, 1999). Individuals who identify as Catholic also believe in an afterlife that consists of a heaven and hell. Those who sin, such as those who have died by suicide, are believed to be condemned to hell by God. As a result SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 20 of these beliefs, individuals who identify as Catholic are expected to show less suicidal behaviors in general (Stack, 1992).
Religious beliefs in Latinx individuals negatively affect suicide-specific grief because they can lead to shame, cognitive dissonance, and further emotional dysregulation. Vandecreek and
Mottram (2009) found that Latinx individuals became preoccupied with whether or not the deceased is going to heaven. This rumination can lead to difficulty making sense of the death and emotional dysregulation, two themes of suicide-specific grief identified by this review. Given that suicide is perceived as a sin in the Catholic faith, the grief that accompanies may be experienced as confusing: sadness is felt for the loss, yet shame or anger is felt for the sin of suicide. In addition, the suicide-specific grief may be repressed, or hidden, if the death is not accepted by most Latinx individuals in the community of the survivor of suicide loss.
According to Hackney and Sanders (2003), the concept of religiosity influences a religious community to follow norms and a moral code, while dismissing behavior that threatens the gift of life, such as suicidal behavior. This proposes that suicide, which threatens the gift of life and disobeys the moral code of the population of Latinx individuals who identify as Catholic, is denounced and perceived negatively, therefore, fueling stigma and affecting the expression of suicide-specific grief. Several studies included in this review pointed to the difficulty of making meaning of a suicide death; this may be exacerbated for Latinx individuals because of religious beliefs.
On the contrary, religious beliefs in individuals of the Latinx community may also improve grief by facilitating connections, coping, and meaning-making. Furthermore, religion may further increase post-traumatic growth already seen in suicide-specific grief. Through religion, Latinx individuals pray, place faith that the deceased is at peace and with God, and maintain a SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 21 relationship through rituals, such as Day of the Dead altars (Krysinska et al., 2014). Day of the
Dead, observed on November 1st of every year, is a day of celebrating and honoring the dead through the use of altars, which are decorated with pictures, flowers, and food (Tellez-Giron,
2007). To celebrate the belief that the dead are present on this day, music is played, tombstones are decorated, and church services are held (Tellez-Giron, 2007). It would be useful for future studies to examine Day of the Dead altars for suicide deaths, and whether the stigma related to suicide affects the motivation to make an altar for the deceased and celebrate the day.
Stigma, another one of the six themes of suicide-specific grief, is also important to discuss as a result of this review. Stigma comes hand-in-hand with suicide-specific grief. Familismo and religion, the Latinx cultural factors described thus far, perpetuate an overall stigmatized perception of suicide in the Latinx community. The stigma surrounding suicide conveys negativity and shame, and it is regrettably reinforced by guilt. Survivors of suicide loss experience an increased amount of guilt due to their struggle with understanding the death and blaming themselves for the death. Furthermore, these survivors receive less support (Jones,
2018; Sudak, Maxim, & Carpenter, 2008).
Stigma is also perpetuated by a community’s curiosity about the death. A survivor of suicide loss is likely to be asked questions about the manner in which the death was caused and may feel inclined to, or ashamed by, sharing details. This was noted by several studies in this systematic literature review. According to White (2013), many survivors of suicide loss reported receiving hurtful comments from others. Another study found that parents of children who died by suicide shielded the siblings from the details of the suicide, which led siblings to seek information elsewhere (Macor, 2018). This secrecy from the parents may imply stigma and SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 22 shame. The studies of this review suggest that suicide is negatively perceived, despite amount of social support received.
Limitations of the Systematic Literature Review
Limitations are present within this systematic literature review and weaken the generalizability of the results. To begin, the database searches and the assessment for eligibility of studies was completed by only one reviewer. Adding an additional reviewer for this process would be useful to assess the decision-making process of the original reviewer and ensure the accuracy of the screening, or that the appropriate articles were included in the final selection. It is possible that the original reviewer did not include appropriate articles. A similar limitation also arises when considering that only one individual, the author, completed the thematic analysis used to identify the two cultural factors and six themes of suicide-specific grief. The thematic analysis lacks inter-rater reliability and adding another reviewer would further ensure accuracy of the results.
Another limitation related to the inclusion criteria was the range of publication dates,
2009-2019. This limited the number of articles included in the results, and widening the publication range may have provided additional information regarding Latinx cultural values and suicide-specific grief. In addition, the sample sizes of many of the studies were small and lacked diversity of participants. Sixteen (32.7%) studies had a sample size of less than 20. A majority of the 49 studies had a primarily Caucasian sample. In fact, only two studies had a sample size made up of more than 50% Latinx individuals (Berardi, 2018; Hidalgo, 2017). Five (10.2%) studies had a sample made up of entirely Caucasian individuals (Bottomley et al., 2018; Mitchell
& Terhorst, 2017; Mitchell, Sakraida, Kim, Bullian, & Chiappetta, 2009; Powell, 2013;
Vandecreek & Mottram, 2009). Eleven (22.4%) studies did not include demographic information SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 23 about ethnicity (Anderson, 2010; Ford, 2016; Hill, 2012; Jones, 2018; Krysinska, Andriessen, &
Corveleyn, 2014; Krysinska & Andriessen, 2015; Moore, 2012; Saatci, 2013; Sancimino, 2010;
Supiano, 2012; Van, 2011). Moreover, several of the studies had a sample comprised mostly of women, with a few of them being comprised solely of women; this also skews the results and affects the generalizability.
Fifteen (29.4%) of the studies were cross-sectional, which affects the ability of this systematic literature review to claim causality in the results. Several studies identified using convenience samples, which creates bias and decreases representation of the population. For example, some participants were volunteers or help-seeking individuals, which would not be representative of the general population of people experiencing grief, especially if most of the general population is combatting stigma. Another limitation relates to sampling method, as some studies did not have randomized sampling.
Several studies included in the review utilized the same database (Feigelman, et al.,
2009a; Feigelman, et al., 2009b; Feigelman, et al., 2009c; Feigelman, et al., 201; Krysinska et al.,
2014; Krysinska & Andriessen, 2015; Mitchell & Terhorst, 2017; Mitchell et al., 2009; Sandler,
Ma, Tein, Ayers, Wolchik, Kennedy, & Millsap, 2010; Sandler, Gunn, Mazza, Tein, Wolchik,
Kim, … Porter, 2018), which is being noted as a limitation despite the studies producing distinct results and each discussing relevant topics. This is considered to be a limitation because it may affect the generalizability of this review’s results considering the same population was used.
Another limitation relates to the way information was obtained by the some of the selected studies. Eleven (22.4%) studies used self-report measures, which rely on subjective reports, thus affecting the reliability of the self-report answers and, consequently, the results.
One study excluded individuals who could not read or write in English, which may have SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 24 excluded several individuals of the Latinx community, such as immigrants or other participants whose second language is English (Spino, Kameg, Cline, Terhorst, & Mitchell, 2016).
It is important to note that language abilities and level of acculturation are often related
(e.g. immigrants from Latin America with a higher level of acculturation may also be more advanced in the English language), which signifies that studies may be unintentionally sampling a specific sample of Latinx participants, such as those who are proficient in English. For example, Worthy (2006) concluded that immigrants from Latin America often chose to stay at home and in jobs that “sheltered them from the necessity of learning English” (p. 151). Such individuals may have less access to resources and opportunities to participate in such studies.
This is considered a limitation as the results of this systematic literature review may only be generalizable to a certain sample of the Latinx population.
In addition, only two cultural factors were identified in this review, which signifies the lack of literature concerning other cultural factors of the Latinx population, such as machismo and marianismo, two gender-based cultural factors (Vasquez & Rosa, 2011). The results are limited in this regards as there are other Latinx cultural factors present in suicide-specific grief that were not accounted for by this review. Lastly, the small number of individuals from the
Latinx population included in the studies of this systematic literature review is also a limitation as it affects generalizability. Future studies regarding this topic should further categorize the
Latinx population by country of origin, immigration status, and acculturation level to further specify the findings.
Future Directions and Implications
The results of this systematic literature review illustrate the intricate relationship between suicide-specific grief and the cultural factors of the Latinx population, a relationship that has not SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 25 been adequately described by the literature. Given the novelty of this information, future research is necessary to further investigate the cultural factors of the Latinx population in the context of suicide-specific grief. Future research is also needed for identifying other cultural factors, besides familismo and religion, that may be present in the grief trajectory, how these cultural factors affect the grief trajectory, and which individuals of the Latinx population are affected. Gender, relation to the deceased, level of religiosity, and level of acculturation are a few factors that may act as confounding variables in the trajectory of suicide-specific grief.
Given the emotional dysregulation that may occur during suicide-specific grief, these results can also inform mental health treatment. These results can be used as a guideline for valuable topics to discuss and explore with individuals of the Latinx community who are engaged in mental health treatment. Bringing awareness of these cultural factors to mental health providers can provide a deeper understanding and comprehensive conceptualization of clinical presentations, as well as the ability to provide culturally-sensitive interventions and recommendations for coping strategies. For example, a psychologist working with a grieving child of the Latinx population may want to increase the frequency of parent collateral sessions so as to increase the level of communication amongst the family and manage stigma and secrecy related to the suicide death. However, it is also important to assess and respect the family’s grief reaction to build rapport and normalize their reactions in the context of the Latinx culture.
This information can also be disseminated in, for example, graduate psychology courses that focus on culturally-competent mental health treatment. These results will enhance a graduate student’s knowledge of the implications of the cultural factors of the Latinx community on suicide-specific grief.
Conclusion SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 26
The gravity of suicide and the quantity of people it affects is evident in the literature. A death by suicide signifies that there are family, friends, and acquaintances that have been affected by the loss and thus may be experiencing grief. This grief, however it manifests, is a journey that is unique to each person and unique to how the individual died. Death by suicide carries profound implications regarding stigma, religious beliefs, and personal perceptions.
Suicide is a complex and stigmatized issue that affects those who die by suicide and those who are left to grieve the suicide. The grief that ensues is vulnerable to many cultural factors.
Within the Latinx community, these cultural factors include familismo and religion, both of which have potentially positive or negative effects on suicide-specific grief. Six themes of suicide-specific grief were also identified, which were stigma, emotional dysregulation, making sense of the death, sense of relief, posttraumatic growth and social support. These six themes were used to describe the way in which the Latinx cultural factors would affect suicide-specific grief.
This review concluded that familismo may lead to an overall increase in emotional dysregulation and, specifically, an increase in shame, increase in isolating behaviors, and decrease in communication amongst individuals of the Latinx population residing within the
United States and experiencing suicide-specific grief. Familismo may also improve grief as it implies an already-existing support system, validation of emotional experience, and opportunity for posttraumatic growth. Religion, specifically Catholicism, may also increase emotional dysregulation, shame, and ruminative and isolating behaviors. However, religion also provides healing during grief, as it facilitates a sense of relief and positive coping through the use of prayer, meaning-making, and rituals, such as Day of the Dead altars. SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 27
This systematic literature review also examined the presence of limitations. Sample sizes varied and lacked diversity in gender, ethnicity, and sub-types of the Latinx population. The number of participants who identified as Latinx was small, and future research should include larger sample of individuals from the Latinx community and include comparison groups. In addition, the screening of eligible studies and the thematic analysis of the selected studies was completed by only one reviewer, which may have affected reliability of studies selected. Future research should further examine the relationship between cultural factors of the Latinx population and suicide-specific grief. References
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SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 41
Appendix A
Table 2
Summary of Studies Included in the Systematic Literature Review
Outcome of Interest: Author Sample (1) Latinx cultural # Study Design Population and Year Size factors, (2) factors of suicide-specific grief
Survivors of suicide loss, most of whom were a parent to the Rabalais, et deceased (n=44, 24.3%). Predominately female (n=137, 73.3%), 1 al., 2017 Cross-sectional 187 2 Caucasian (n =172, 92.0%) and married (n=64, 34.4%). Most
reported their religious status as other Christian (n = 92, 51.7%)
Tai et al., Bereaved individuals aged 18–95, including 58 whose loss was 2 Cross-sectional 395 2 2017 due to suicide and 74 whose was due to an accident or homicide.
All Caucasian and most were female ( n= 43). Relationships to the deceased included spouses (n = 9), parents (n = 6), children Mitchell et 3 Cross-sectional 60 (n = 5), siblings (n = 7), in-laws (n = 18), niece/ nephew (n = 1), 2 al., 2017 and friends (n = 14).
Survivors of suicide loss, most of whom were female (n=276) Drapeau et 4 Cross-sectional 307 and Caucasian (89%). Participant’s ages ranged from 20 to 84 2 al., 2018 years (M = 48.81).
Survivors of suicide loss who were mostly females (75%) and Spino et al., 5 Cross-sectional 44 Caucasian participants (73%). Sample also consisted of 22.7% 2 2016 African-American and 4.5% Hispanic.
Krysinska et 250 online memorials written by survivors of suicide for those 6 Qualitative 250 1, 2 al., 2014 who died by suicide
Parents who lost children to various death causes: 48 to drug- related deaths and overdoses, 462 to suicide, 24 to natural death Feigelman 7 Cross-sectional 571 cases, and 37 to mostly accidental death cases. The sample was 2 et al., 2011 85% females and most respondents were middle-aged (73% aged 46-65).
Survivors of suicide loss who were part of a suicide support Mayton et 8 Qualitative 5 group at a local hospice setting. There were five participants 2 al., 2018 (two males; three females) who were mostly Caucasian (n = 3). SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 42
130 violent death survivors who were engaged in therapy at a community health care clinic in the Pacific Northwest or in Baddeley et 9 Cross-sectional 130 Southern California between 2001 and 2011. The participants 2 al., 2015 were mostly female (n=100) and Caucasian (n=109). Seven participants identified as Hispanic.
Bottomley 10 Qualitative 8 Survivors of suicide loss, all of whom were Caucasian females. 2 et al., 2018
Parent survivors of child loss, most of whom were Caucasian Feigelman Mixed 11 540 (n=506) and female (n=458). Six percent were from all other 2 et al., 2009a Methods races.
Krysinska et 250 online memorials written by survivors of suicide for those 12 Qualitative 250 1, 2 al., 2015 who died by suicide.
Bereaved parents who were recruited from two Southeastern Lichtenthal 13 Cross-sectional 155 United States chapters of The Compassionate Friends. The 1, 2 et al., 2013 majority were Caucasian (n = 143).
Oexle et al., Survivors of suicide loss, most of whom were Caucasian (n=187) 14 Cross-sectional 195 2 2018 and female (n=180).
Parent survivors of child loss, most of whom were Caucasian Feigelman 15 Cross-sectional 540 (n=506) and female (n=458). Six percent were from all other 2 et al., 2009b races.
Powell et 16 Qualitative 45 Sibling survivors of suicide loss who were all Caucasian. 2 al., 2013
Supiano et Mixed 17 9 Nine participants in a suicide loss support group. 2 al., 2012 Methods
Survivors of suicide losss, all of whom were Caucasian and Mitchell et 18 Cross-sectional 60 mostly female (43%). 2 al., 2009
Vandecreek Survivors of suicide loss, all of whom were female and 19 Qualitative 10 1, 2 et al., 2009 Caucasian.
Parent survivors of child loss, most of whom were Caucasian Feigelman 20 Cross-sectional 540 (n=506) and female (n=458). Six percent were from all other 1, 2 et al., 2009c races. SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 43
Sandage et Case Control Two family members who experienced a loss by suicide and 21 2 2 al., 2010 Study identified as Caucasian.
Gonzalez et Qualitative 22 1 7-year-old Hispanic Female 2 al., 2016 (Case Study)
Young adults grieving a death; 67% were European American, 16% Hispanic American, 7% African American, 3% Native Randomized American, 1% Asian American or Pacific Islander, and 6% Sandler et Controlled 23 244 other. Thirteen percent were grieving a suicide or homicide. 2 al., 2018 Study
Survivors of suicide: 516 were bereaved by suicide and 235 were exposed to one or more suicides. Participants included 72% Feigelman Caucasian, 16.9% African American, 10.4% other, and 14.6% 24 Cross-sectional 1432 2 et al., 2018 Hispanic.
Young adults grieving a death; 67% were European American, Randomized 16% Hispanic American, 7% African American, 3% Native Sandler et Controlled 25 244 American, 1% Asian American or Pacific Islander, and 6% 2 al., 2010 Study other. Thirteen percent were grieving a suicide or homicide.
Monserud et Mexican Americans, 65 years or older, who were grieving any 26 Cohort Study 385 1, 2 al., 2017 type of death.
Grandparents grieving a death of a grandchild. Twenty-four Youngblut 27 Cross-sectional 136 percent were Hispanic, 38 % Black/African American, and 38 1, 2 et al., 2015 % White.
28 Jones, 2018 Qualitative 9 Adults who lost a parent to suicide. Eight were females 1, 2
Survivors of suicide loss, 25 years of age and older with no psychiatric diagnosis related to the death of the loved one. Most 29 Sooy, 2016 Cross-sectional 45 participants were Caucasian (71.1%) and 17.8% were Hispanic. 2
Six female survivors of suicide. Five were Caucasian and 1 was 30 Ford, 2016 Qualitative 6 1, 2 African American. SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 44
Moore, 31 Cross-sectional 154 Parents grieving their child’s death by suicide 2 2012
32 Hunt, 2013 Qualitative 6 Six survivors of suicide loss, ages 30-64. 1, 2
Survivors of suicide loss, most of whom were Caucasian (85.3%), female (75.9%), and between the ages of 51-65 Cammarata, 33 Cross-sectional 191 (43.5%). Hispanics accounted for 3.7% of participants. 2 2012
Sibling survivors of suicide loss who were at least 25 years old at Macor, the time of the interview and experienced the loss while they 34 Qualitative 5 2 2018 themselves were between ages of 12 and 21.
50 adult survivors of suicide loss who responded to Internet Randomized advertising, posted flyers, and newspaper advertising in a large 35 Hill, 2018 Controlled 50 2 city in the Midwest. Study
4 survivors of suicide loss between the ages of 18 and 40, all of 36 Saatci, 2013 Qualitative 4 whom were Caucasian. 2
Participants between the ages of sixteen and twenty-five years at the time of bereavement. Of the male participants, two self- Andersson, identified as African American and one female identified as 37 Qualitative 26 2 2012 African American, while the rest of sample identified as White.
Nine survivors of suicide loss who were mothers and all 38 Lynn, 2011 Qualitative 9 Caucasian. 2
Survivors of parental suicide that occurred when they were in Sancimino, 39 Qualitative 8 late adolescence or young adulthood. 2 2010
Survivors of suicide loss, most of whom were female (90.5%). The average age was 49.89, and most reported losing a child to Anderson, 40 Cross-sectional 201 suicide (53.2%). 2 2010
SUICIDE-SPECIFIC GRIEF IN THE LATINX COMMUNITY 45
41 Van, 2011 Qualitative 3 Three female survivors of suicide loss. 2
Fifteen sibling survivors of suicide loss. Ten identified as Caucasian, two identified as Jewish, and three identified as Bi- 42 White, 2013 Qualitative 15 racial. 1, 2
Survivors of suicide loss. The majority were Caucasian (n = 26, 79%), and 9% (n = 3) as Asian, 3% (n = 1) as Black or African 43 Groff, 2015 Cross-sectional 33 American, 3% (n = 1) as Native Hawaiian or Pacific Islander, 2 3% (n = 1) as Hispanic, and 3% (n = 1) as “other”.
165 adult participants grieving any type of death. Participants Cross-sectional were 18 years of age and older living and/or working in the (Between- Silicon Valley area and self-identified as European American or Berardi, group quasi- 44 165 Latino American and that have experienced the death of a 1, 2 2018 experimental relative or close friend within the last 2 years. 54.5% identified design) as Latinos.
Simon- Two participants, one identified as Latino and one identified as Parsons, Mixed 45 2 African American. They both experienced the death of an 1, 2 2012 Methods immediate family member.
Participants who had experienced the death of a friend or family member within the last three years. Fifty-five percent identified Norris-Bell, as White/Caucasian, 15.3% as Asian, 14.4% as Latino/a, 14.4% 46 2012 Cross-sectional 229 2 as Black/African American, and 10.4% as multi-racial/other.
Children who experienced the death of a parent, grandparent, Hidalgo, brother, or sister within the past two years. The majority 47 Cross-sectional 97 2 2017 identified as Hispanic (64%).
167 bereaved parents, which included 116 mothers and 51 fathers (30 couples). Sixty-seven parents had an infant who died Hawthorne, in the NICU and 52 had a child who died in the PICU. There 48 Cross-sectional 167 1 2012 were 64 Hispanic parents, 67 African American parents, and 36 Caucasian parents.
67 males and 31 females between the ages 3 and 11 years old (M = 6.28). The majority of participants identified as Caucasian (67%, n = 66), 10% (n = 10) as African American, 10% (n = 10) 49 Ener, 2015 Cross-sectional 98 as Hispanic/Latino, 6% as Bi-racial (n = 6), 4% as Native 1 American (n = 4), and 2% as Asian (n = 2).