Suicide has an adverse psychological impact on people who are left behind. People bereaved by the suicide of someone experience common reactions of grief such as sadness, yearning, guilt, anger, and physical reactions. Reference Stroebe, Hansson, Schut, Stroebe, Hansson and Schut1 People who lost a loved one to suicide experience a higher level of shame, stigma, responsibility, and rejection than those bereaved by other types of death. Furthermore, they also tend to hesitate to seek support and discuss their loss. Reference Pitman, Osborn and King2,Reference Sveen and Walby3 Large-scale disasters disrupt peoples’ mental health in the affected areas, and when suicide is committed in this situation, the negative impact on the bereaved people becomes even greater. Psychological interventions are essential to mitigate such an impact on the disaster/suicide survivors. Postventions (involving aiding the grieving process and reducing the incidence of suicide contagion through psychological support Reference Andriessen4 ) could be effective for the mourning process and recovery of the bereaved. Reference Linde, Treml and Steinig5 Various postvention programs have been developed for specific settings, including workplaces.
Japan was struck by the Great East Japan Earthquake (GEJE) on March 11, 2011. The government reported 15,899 deaths and 2526 persons missing, with 1,22,000 houses destroyed due to the disaster. 6 The prefectures of Iwate, Miyagi, and Fukushima in northeastern Japan were severely damaged. Disaster Mental Health Care Centers (DMHCCs) were set up in these prefectures to promote community mental health. Reference McIntosh, Bolton, Andriessen, Andriessen, Krysinska and Grad7 The Miyagi DMHCC consisted of multidisciplinary mental health professionals who provided various services in the disaster-affected areas, including mental health support for local aid worker organizations. Aid workers (eg, health-care personnel, community and government workers, and rescue workers) were exposed to intense and chronic psychological stress because of the catastrophic state persisting several months after the GEJE. These workers had to continue their work despite their difficulties as local survivors. Hence, numerous overwork-related issues occurred in many organizations, such as excessive sick leave and sudden retirement. Among these issues, work-related suicide became a primary concern for mental health interventions. The Miyagi DMHCC provided group postvention support in these suicide-affected workplaces. This study features the field activities of these group postventions and presents future implications in postdisaster mental health support programs.
Postvention Overview
Several postvention support components were developed by the Miyagi DMHCC, including group support, individual counseling, outreach, and online support. Reference McIntosh, Andriessen, Krysinska and Grad8 The postventions consisted of the following basic elements: (a) 3 to 5 times biweekly group discussions, (b) individual counseling sessions for the selected participants, and (c) pre-/postintervention assessments of psychological status.
After receiving worker suicide reports from aid worker organizations, the Miyagi DMHCC staff visited their workplaces. They assessed the scale of the postvention, that is, number of participants in each intervention group, frequency of group discussions, period of postventions, and selection of evaluation methods. Although the maximum number of group participants was limited to 8 per group, they were divided into several groups if the total number exceeded 8. The participants were clearly informed that the primary purpose of the postvention was to protect individual mental health, maintain the functions of the workplace, and set the objectives for each session. This study was approved by the Miyagi DMHCC Ethics Committee (2022-1).
Between 2011 and 2021, postventions were conducted in 14 workplaces—6 office work departments, 4 human support departments, 2 firefighters’ departments, 1 child care department, and 1 waste disposal department. The average number of participants in each group discussion session was 6, and the number of times each case was discussed was 3.5 times (range: 1-5).
Observations From the Postvention Group Discussions
The postvention participants expressed varied emotions such as sadness, loneliness, anxiety, fear, and anger. Although the participants were briefed regarding the session’s purpose initially, they spontaneously started speaking about their experiences of the GEJE during postvention. As a result, 2 traumatic events were addressed in the postvention —the GEJE disaster experience and the suicide of their colleagues.
Three major topics surfaced through the postvention sessions. First, their colleagues’ suicides reminded many participants of the GEJE. They shared their GEJE experiences and feelings as follows: “I was reminded of the GEJE,” “We also felt hopeless at that time,” “We felt fears as we did not know when we would die,” and “I never told others before that I lost my loved ones in the GEJE.” Second, some expressed their feelings of helplessness through their aid work activities in postdisaster situations as follows: “This feeling is similar to that of the GEJE,” “Nobody showed appreciation despite the sacrifice we made to help the survivors,” and “Helping survivors may be meaningless.” Third, a few reported complicated feelings associated with their work roles. For example, they felt victimized for being exploited and felt anger toward their workplaces, criticizing the organizations for not protecting their well-being in distressful situations. Others reported that their colleagues died by suicide due to overwork. Hence, they thought of quitting their current jobs before facing the same struggles.
In most cases, the participants grieved the experiences of loss and distress they suffered during the GEJE at the beginning of the group discussions. Later, they moved on to speak about their colleagues’ suicides. After this process, they were better equipped to cope with the death of their colleagues.
Discussion
The observations of the postdisaster postvention were rare compared with postventions in nondisaster settings. Reference Thomas, Rainey, Andriessen, Krysinska and Grad9 In this study, the suicide of the workers’ colleagues triggered memories of the participants’ experience of the GEJE and instigated them to question the meaning of their work. Previous studies have reported that many postvention participants are reminded of their previous personal traumatic events (eg, others’ suicides, traffic accidents, and experienced violence) in the face of suicide. Reference McIntosh, Andriessen, Krysinska and Grad8 It is generally challenging for the participants to share their prior experiences of trauma during group discussions because of the stigma/avoidance associated with their traumatic experiences. However, based on this study’s observations, the participants did not hesitate to share their experiences of the GEJE, creating a distinct group dynamic. Possible reasons for this are that the workers were well acquainted with each other, had experienced the GEJE together, and could relate to each other’s traumatic experiences.
During the group discussion, several participants complained about their workplace not taking protective measures to safeguard their workers during the disaster. These complaints are common in the postvention in overworked workplaces. Reference McIntosh, Andriessen, Krysinska and Grad8 It is essential for workplace managers to address the distress of their workers regularly. However, under extreme situations such as the GEJE, it is difficult for managers to handle every situation, provide appropriate support, and mitigate workers’ distress. Therefore, these workplaces seek multi-layered mental health support from external organizations. The observations suggest that postdisaster mental health professionals must acquire postvention skills and be aware of the complicated collective dynamics occurring in the workplace. Although this report was supported by the postvention, some training would be available for prevention or preparedness. Regular discussion of mental health among workers is also vital.
There might be cultural differences in how individuals express their feelings during group discussions. Considering that the group discussion in this study is in the context of Japanese culture, the relationships between the collective tendency, passiveness, and the reluctance to express oneself in fear of being considered impolite should be addressed. In this study, the participants were unable to express their frustration through disaster support for a long time. They might have suppressed their feelings to avoid being considered rude to complain and criticize others in the disaster-affected areas. This psychological dynamic might be stemming from the Japanese culture, and additional studies should be conducted to test this hypothesis.
The procedure for such support should be performed after understanding the situation and culture of each workplace. After receiving a support request, we visited the workplace and interviewed the manager regarding the situation. The support team discussed balancing groups and individual interventions and provided brief psychoeducation by using a leaflet in each group session; these covered the themes of psychological symptoms after grief, what happens in the workplace, and what we can do in the future. In the postevent period, the leader’s actions are crucial to maintaining the condition of the workplace. Integrity is the most important encouragement, and leaders must be sincere in telling the facts they know.
This study has several limitations. First, although a few studies suggest that suicide postvention helps bereaved people, a consensus has not yet been reached. Reference Andriessen, Krysinska and Kõlves10 While many workers reported benefits from these postventions, cross-sectional and longitudinal data would be required to evaluate their efficacy. Second, the postvention activities were semi-structured but were neither rigorous nor homogenous. Additional reports to discuss the postvention structures will be needed. Third, information about other types and the amount of support required for the bereaved workers remains unknown.
Conclusions
The Miyagi DMHCC conducted postvention in several workplaces after a colleague’s suicide in the 2011 disaster-affected areas. The workers were exposed to 2 types of psychological traumas—the GEJE disaster experience and the suicide of their colleagues. The workers needed to share their GEJE disaster experiences to help them cope with their colleagues’ suicide through group discussions. Further studies should be conducted to gain additional evidence and improve services for postdisaster postventions.
Acknowledgments
We thank Eiji Suzuki (Department of Psychiatry, Tohoku Medical and Pharmaceutical University) for critically reviewing the manuscript draft.
Author contributions
Conception and design of the study: Naru Fukuchi. Acquisition and analysis of data: Naru Fukuchi and Akiko Obara. Drafting the manuscript: Naru Fukuchi, Akiko Obara, and Jun Shigemura. All authors read and approved the final version of the manuscript.
Competing interests
None.
Funding
None.
