Psychological Trauma:

Theory, Research, Practice, and Policy

© 2019 American Psychological Association 2019, Vol. 11, No. 8, 895–904
1942-9681/19/$12.00 http://dx.doi.org/10.1037/tra0000456

With a Little Help From My Friends: A Follow-Up Study on the

Contribution of Interpersonal Characteristics to Posttraumatic Growth
Among Suicide-Loss Survivors
Yossi Levi-Belz
Ruppin Academic Center, Emek Hefer, Israel

Objective: The study of suicide-loss survivors—specifically the study of healing processes in this
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

population—is scant. This study represents an effort to extend this field by developing a comprehensive
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understanding of the underlying interpersonal facilitators of posttraumatic growth (PTG) among suicide-
loss survivors in an 18-month longitudinal design. Our aim was to examine the key interpersonal factors
that influence positive growth among survivors over time. Method: Participants included 156 suicide-loss
survivors (132 women and 24 men), aged 18 to 70. Participants completed several questionnaires, tapping
the interpersonal factors of self-disclosure, social support, thwarted belongingness, and perceived
burdensomeness at T1 (baseline). Moreover, participants were assessed on PTG levels twice: at T1 and
again at T2 (18 months later). Results: Belongingness, self-disclosure, and social support were found to
be facilitators of increasing PTG levels at T2. Structural equation modeling analysis revealed that
self-disclosure and social support mediate the relationship between belongingness and PTG (T2), beyond
the contribution of PTG at T1. Conclusions: On the basis of these findings, it can be inferred that the
interpersonal factors of belongingness, self-disclosure, and social support play important roles in
facilitating PTG among suicide-loss survivors. Thus, basic psychoeducational interventions specifically
designed to foster self-disclosure and acquire support can help suicide-loss survivors achieve PTG
following their traumatic loss.

Clinical Impact Statement

The capacity to share personal feelings as well as to perceive social support and belongingness from
others have been recognized as important for facilitating growth among those bereaving the suicide
of a loved one. Thus, psychotherapies and support groups are encouraged to seek out ways to enhance
these interpersonal behaviors and thus, establish a buffer against the shame and guilt that typically
characterize survivors. These interventions may open a window for positive change after the
traumatic event.

Keywords: posttraumatic growth, suicide-loss survivors, self disclosure, social support, longitudinal

More than 1 million people worldwide die by suicide annually. rience, as suicide-bereaved individuals experience higher levels of
It is estimated that for each death by suicide, over 100 individuals depression, anxiety, suicidal ideation and attempts (Cerel et al.,
are affected by the death, with 25 of them being profoundly 2016; Maple, Cerel, Sanford, Pearce, & Jordan, 2017), relative to
impacted and bereaved (Cerel, 2016). This phenomenon extends the nonexposed population.
well beyond immediate family and kinship groups and into the Although limited, the research literature on suicide bereavement
broader community (Maple et al., 2018). Serious, deleterious has typically focused on the psychopathology associated with this
health outcomes have been found to be associated with this expe- experience of loss, with a major focus on complicated grief
(Kõlves & de Leo, 2018; Maple et al., 2017). Recently, a research
track has emerged exploring personal growth within the context of
a traumatic events (Tedeschi & Calhoun, 2004). The understand-
This article was published Online First March 25, 2019. ing that suffering and distress have the potential to yield positive
This work was supported by the American Foundation for Suicide change is thousands of years old. Tedeschi and Calhoun (2004)
Prevention under Grant PRG-2-083-14. pioneered the concept of posttraumatic growth (PTG), a construct
This study is dedicated to my dearest friend, Dafni Assaf, who was one
of positive psychological change that occurs in the wake of strug-
of the greatest leaders of the suicide prevention program in Israel.
Correspondence concerning this article should be addressed to Yossi
gling with a highly challenging, stressful, and traumatic event.
Levi-Belz, Department of Behavioral Sciences and The Lior Zsfaty Center PTG does not refer to a mere recovery from a stressor, but to the
for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek development of a level of adaptive functioning higher than that
Hefer 40250, Israel. E-mail: [email protected] existing prior to its occurrence (Park, 1998).
895
 896 LEVI-BELZ

The literature has amply documented personal challenges and between at least two individuals perceived by the provider or
traumatic experiences that have acted as facilitators of personal recipient to be intended to enhance the well-being of the recipient”
growth, such as PTSD, life in captivity, cancer, HIV infection, (Shumaker & Brownell, 1984, p. 13). Many studies have docu-
transportation accidents, and bereavement (e.g., Joseph & Linley, mented the beneficial results of receiving informal social support
2008). Thus, the opportunity to achieve PTG following exposure during the bereavement process (Riley, LaMontagne, Hepworth, &
to suicide is very compelling, given the risk of adverse outcomes Murphy, 2007), and it is viewed as a factor that can enhance PTG
associated with this exposure. Still, the suicide-loss survivors’ (Scrignaro, Barni, & Magrin, 2011). Hence, social support is likely
domain seems to be neglected as a whole (Shahtahmasebi, 2016), to be a facilitator of growth processes. Taking together, the inter-
with only scant data reported on the possibility of growth after the personal factors of self-disclosure and social support appear to
death of a loved one by suicide. Importantly, to date, no study has have an important role in mitigating mental health problems and in
examined longitudinal trajectories of PTG among those exposed to facilitating PTG among family members and friends affected by
suicide with the aim of understanding how PTG develops and what suicide loss.
facilitates it over time. To understand the nature of interpersonal perceptions and ex-
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The very few studies that have assessed PTG among suicide- periences, we also focused on two fundamental interpersonal di-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

loss survivors have identified several variables that enable growth mensions: perceived burdensomeness (PB) and thwarted belong-
in this population (e.g., Lee, Kim, Kim, & Enright, 2017; Snihu- ingness (TB), delineated in the interpersonal theory of suicide
rowych, 2006). Some authors have reported that demographic (Van Orden et al., 2010). The interpersonal theory of suicide posits
variables, such as age, education, and religion, as well as time that these two dimensions are the necessary proximal causal in-
since loss, were related to higher PTG among suicide-loss survi- teractive risk factors for suicidal desire (Joiner et al., 2009). More
vors (Feigelman, Gorman, & Jordan, 2009; Pan, Liu, Li, & Kwok, specific to this study, Joiner (2007) emphasized that PB and TB
2016; Smith, Joseph, & Das Nair, 2011;). Among other psycho- comprised the heart of interpersonal interaction, as they represent
logical characteristics, resilience was found to inversely predict a specific perception of one’s interpersonal surrounding. PB rep-
PTG scores (Moore, Cerel, & Jobes, 2015), whereas high levels of resents the view that one’s very existence burdens family, friends,
grief intensity were found to positively predict PTG levels (Levi- and/or society. This construct comprises beliefs that the self is so
Belz, 2017). From a cognitive point of view, low preoccupation flawed as to be a liability on others and affectively overloaded
with the deceased as well as positive adaptive strategies of coping cognitions of self-hatred with related feelings, such as self-blame
with stress were also found to play an important role in facilitating and shame (Van Orden et al., 2010). One may assume that when
growth among survivors (Levi-Belz, 2015; Levi-Belz, 2017). suicide-loss survivors feel themselves a burden on society or feel
Several studies conducted by our group indicated that interper- self-hatred, their prospect of recovery and growth may be dramat-
sonal factors can contribute to higher levels of PTG following ically impaired. TB is the experience of alienation from others,
suicide loss (Levi-Belz, 2015) and that these characteristics may with an emphasis on the painful feeling of being outside the
help suicide-loss survivors attain PTG levels that characterize the family, friends, and other valued groups (Van Orden et al., 2010).
PTG of those bereaving following other types of traumatic loss Thus, TB appears to capture deep interpersonal experiencing and
(Levi-Belz, 2016). The main interpersonal predictors of PTG may impede facilitation of PTG.
found to contribute to PTG were self-disclosure and social support Only a single study has examined the relationships between TB,
(Lev-Ari & Levi-Belz, 2018; Levi-Belz, 2016; Levi-Belz & Lev- PB, and PTG among suicide-loss survivors (Lev-Ari & Levi-Belz,
Ari, 2018). In the current study, we sought to understand the 2018). It was found that the both constructs contributed to PTG:
contribution of these interpersonal features to the course of change TB contributed directly to PTG, and PB contributed through an
in PTG 1 year after index measurement. Whereas PTG has been interaction with attachment style. However, no studies have yet to
demonstrated, its robustness over time remains unclear. examine the role of PB and TB and their contribution to PTG over
Self-disclosure refers to the process by which persons let them- time in relation to suicide-loss survivors.
selves be known by others (Jourard, 1971). Numerous studies have Generally, suicide-loss survivors suffer from blame, social
shown that authentic self-disclosure to at least one significant other stigma, and feelings of detachment (Jordan, 2001; Peters, Cun-
person is a prerequisite for healthy adjustment (Smyth, Penne- ningham, Murphy, & Jackson, 2016). Together, these cognitions
baker, & Arigo, 2012) and even as a buffer against suicidal and feelings may have a shattering effect on the foundation of their
behavior (Gvion & Levi-Belz, 2018). A recent report by Feigel- interpersonal relationships (Sveen & Walby, 2008) and as a result,
man, Cerel, and Sanford (2017) demonstrated that high levels of may diminish their ability to recover and grow. Thus, understand-
disclosure concerning the death event (suicide as well as accidental ing the dynamics of the two basic dimensions of PB and TB in
deaths) were significantly associated with diminished grief diffi- impeding or facilitating (in their absence) PTG in this population
culties and a lessening of mental health disturbance. Given that warrants our examination.
feelings of shame and guilt typically characterize suicide-loss Importantly, PB and TB are known in their facilitation of several
survivors (Jordan & McMenamy, 2004), it can be assumed that aversive outcomes, such as loneliness, low perceived social sup-
disclosing intimate feelings and thoughts should facilitate personal port and low interactivity with others. For example, individuals
growth by providing new perspectives about the self and the experiencing TB often feel they “have no one to turn to” (Van
suicide event and by helping to create constructive and affirmative Orden, Cukrowicz, Witte, & Joiner, 2012, p. 581) and thus, the
narratives of the changes that occur. prospect of self-disclosure is substantively diminished. Moreover,
Self-disclosure was also found to be associated with perceived TB is characterized by high levels of disconnection, which may
social support, which, in turn, is linked to PTG (Levi-Belz, 2015). produce low levels of perceived social support. Given the impor-
Social support has been defined as “an exchange of resources tance of social support and self-disclosure in its association with
 POSTTRAUMATIC GROWTH AMONG SUICIDE-LOSS SURVIVORS 897

PTG among suicide-loss survivors (Levi-Belz & Lev-Ari, 2018), it a similar proportion reported medium and high SES levels (38,
invites a comprehensive examination of the entire interpersonal 24%). Almost all participants had completed at least 12 years of
process that may facilitate PTG in this population. schooling (n ⫽ 155, 98.1%).

The Present Study Suicide-Related Demographic Information

Neimeyer, Cerel, and Maple (2017), in their recommendations A suicide-loss survivor was defined as an individual who had
for further research on suicide loss, highlighted the importance of lost a family member or other close friend due to suicide (Cerel et
exploring outcomes of suicide loss, beyond the sole focus on al., 2016). For the study sample, kinship to the deceased included
bereavement. Thus, we demonstrated in several studies that PTG 29 parents (18.6%), 26 children (16.7%), 43 siblings (27.6%), 16
among suicide-loss survivors is a reasonable outcome (Levi-Belz, spouses (10.3%), 13 (8.4%) other family relatives, and 29 (18.6%)
2015, 2016). In the present study, we continue to pursue the best friends. All participants reported that the suicide was devas-
understanding of the factors that may enhance PTG among tating for them, ranging from extremely devastating (48, 30.8%),
to very devastating (87, 55.7%), to devastating (21, 13.4%), as
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

suicide-loss survivors, following Tedeschi and Calhoun (2004),

presented on a five-point Likert-type scale.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

who indicated that PTG can be achieved only when several psy-
chological characteristics are present. The time elapsed since the suicide varied, with a mean length of
Built upon our findings from previous studies, our current aim 80 months (ranging from 6 to 200 months). Twenty-eight partic-
was to examine the extent to which key interpersonal characteris- ipants (18.6%) had lost their significant other within 24 months
tics (defined as TB, PB, self-disclosure, and social support) will prior to T1, 39 (25%) within 24 to 48 months, 45 (29%) within 48
influence PTG among survivors over time. Thus, in this study, we to 72 months, and the remainder (44, 28%) for 6 years or more
focused on a longitudinal examination of interpersonal interactions years prior to T1.
and perceptions that may lead to sustained levels of growth levels
of growth 18 months after baseline. To the best of our knowledge, Procedure
this is the first attempt to investigate PTG and its facilitators
The ethics committee at the Ruppin Academic Center approved
among suicide-loss survivors in a longitudinal design.
the study. Recruitment of the participants took place at two main
The following two hypotheses were posited for this study: settings. At the T1 measure, most of the participants were recruited
through a nonprofit organization, For Life, which is the official
1. Self-disclosure and social support will be positively as- agency for suicide-loss survivors in Israel. Other participants were
sociated with PTG at baseline (T1) assessment and will recruited through the Israeli suicide-loss survivors’ official forum
positively contribute to PTG on the follow-up assessment (“People whose loved ones died by suicide”) or through the social
(T2, after 18 months), beyond the baseline levels of PTG. media group of suicide-loss survivors in Israel.
All potential participants were informed of the risks and com-
2. Self-disclosure and social support will mediate the rela-
pensation procedures prior to participation. They were promised at
tionships between TB, PB, and PTG in follow-up.
the outset that questionnaire data would be completely anonymous,
with no personal identifying information collected.
Method All participants were given a recruitment letter outlining the
purpose, method, and procedure. All the informants were provided
Participants with the researcher’s contact details. The participants were assured
of anonymity, confidentiality, and their right to withdraw from the
Participants comprised 189 suicide-loss survivors, who took part study at any time. Participants agreeing to participate were re-
in the first measurement point of the study (T1), conducted in 2015 quired to affirm their willingness to participate by signing an
and 2016. Of these, 156 (82.5%) participated in the second assess- informed consent form and then completed the questionnaire on-
ment (T2), 18 months after T1. Regarding the 33 dropouts, 20 line (using Qualtrics online survey software). At the conclusion of
could not be located, and 13 did not respond to a letter of invitation the questionnaire, the participants were asked if they consent to be
for the second phase. No significant differences were found in approached in the future for follow-up. At T2 (18 months after
demographic and psychological characteristics between those who T1); those participants consenting to be approached for follow-up
participated in T2 and those who did not. were requested to complete a short questionnaire at T2, incorpo-
Thus, the current study’s sample at T2 comprised 156 suicide- rating the main study variables. Following completion of the
loss survivors (132 women, 24 men), aged 18 to 70. Exclusion online questionnaire, participants were compensated with a gift
criteria were being under age 15 at the time of the suicide, and the voucher for their participation in T2 assessment (approximate
inability to speak and write in Hebrew or English (proficiency in value: $US25).
either language was an inclusion criterion).
The mean age of our sample was 40.8 (SD ⫽ 14.58). Of the
Measures
sample, 18% were under 25, whereas another 25% were above age
52. In terms of family status, 61 (39%) of the participants were All study measures were completed by the participants for the
single, and 72 (46%) were married. Regarding religiosity, most of index measurement at T1. The PTG measure was completed also
the participants reported being secular (115, 73%), and 30 (19%) at T2.
were traditional. Regarding socioeconomic status (SES), 36 (23%) PB and TB. The Interpersonal Needs Questionnaire (Joiner et
of the participants reported very low SES, 39 (25%) low SES, and al., 2009) is a10-statement inventory used to assess TB (e.g.,
 898 LEVI-BELZ

“These days, other people care about me” [reversed]) and PB (e.g., reflect higher levels of growth. The PTGI introduction and its
“These days, I feel like a burden on the people in my life”), with items reference the specified suicide event: “For each of the
five items presented for each subscale. Respondents indicate to statements below, please indicate the extent to which this change
what extent the described statements are true for them on a occurred in your life as a result of the suicide of _______.” Among
seven-point Likert-type scale, with higher scores reflecting higher 926 adults who experienced a wide range of traumatic events,
TB and PB. In younger and older adults and in clinical and internal consistency was strong (Cronbach ␣s ⫽ ⬃90; Taku, Cann,
nonclinical samples, these two constructs were distinct but related Calhoun, & Tedeschi, 2008). Internal consistency for the current
and had high reliabilities (Van Orden et al., 2012). Moreover, both sample was very strong at T1 (Cronbach’s ␣ ⫽ .96) as well as at
perceived burdensomeness and thwarted belongingness had con- T2 (Cronbach’s ␣ ⫽ .93).
vergent validity with related interpersonal constructs: Social worth In addition to the preceding measures, we assessed demographic
and death ideation converged with perceived burdensomeness, and characteristics, including country of origin, family status, religious
loneliness and social support converged with thwarted belonging- orientation, age, gender, income level, and educational level.
ness (Van Orden et al., 2012; Van Orden et al., 2010). Internal Moreover, specific data concerning the suicide loss were collected
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consistency for the current sample was strong for both PB (␣ ⫽ for each participant, including time elapsed since the suicide,
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.96) and TB (␣ ⫽ .85). participant’s age at suicide occurrence, the relationship to the
Self-disclosure. The 12-item Distress Disclosure Index (DDI; person who died by suicide (parent, spouse, child, sibling, close
Kahn & Hessling, 2001) was used to measure individuals’ ten- relative, or best friend) and participation in a psychotherapy sup-
dency to conceal or disclose personally distressing information port group for suicide-loss survivors.
(e.g., “When I feel upset, I usually confide in my friends, and I
prefer not to talk about my problems” [reverse scored]). The DDI
Data Analysis
is a five-point Likert-type scale, with responses ranging from 1
(strongly disagree) to 5 (strongly agree). Higher scores represent The relationships between the study variables and PTG at
higher levels of disclosure. Confirmatory factor analysis and of the follow-up (T2) were examined by a series of analyses of variance,
DDI suggested a single construct, with high levels of internal Pearson correlation tests, and hierarchical multiple regression anal-
consistency (Kahn & Hessling, 2001) and test–retest reliability as ysis. The significance level for all statistical tests was set at .05. All
well as evidence for construct validity (Kahn et al., 2012). Cron- analyses were conducted using the Statistical Package for the
bach’s alpha coefficient for this sample was .90. Social Sciences (SPSS, 2011). To assess our mediation integrated
Perceived social support. The degree of perceived support model to predict PTG at T2, we used the structural equation model
derived from family, friends, and others was measured using the (SEM) strategy, using AMOS software (2015). To obtain a full
Multidimensional Scale of Perceived Social Support (MSPSS; representation of the model, a combined rule for model fitness with
Zimet, Dahlem, Zimet, & Farley, 1988). This 12-item, seven-point the following accepted values was defined: a nonsignificant chi-
Likert-type scale assesses three sources of support in three sub- square test, the normed fit index (NFI) ⬎ 0.95 (Bentler & Bonett,
scales (four items per subscale): family (e.g., “My family really 1980), the comparative fit index (CFI) ⬎ .95 (Bentler, 1990), and
tries to help me”), friends (e.g., “I can count on my friends when root mean square error of approximation (RMSEA) ⬍ .06 (Browne
things go wrong”), and a significant other (e.g., “I have a special & Cudeck, 1993).
person who is a real source of comfort to me”). Higher scores on The data were screened for missing values. The percentage of
each of the subscales indicate higher levels of perceived support, missing values in the studied variables ranged from 0% to 13.5%.
and a sum of the three scales yields a global score for satisfaction The percentage of missing data on each variable was as follows:
with perceived support. Following numerous studies (e.g., Levi- TB (13.5%), PB (8%), self-disclosure (5%), social support (3%),
Belz, Gvion, Horesh, & Apter, 2013; Levi-Belz & Lev-Ari, 2018) PTG-T1 (2%), and PTG-T2 (0%). The missing data pattern anal-
and the high internal consistency in these studies as well as in the ysis revealed one main pattern of missing data: Participants miss-
current study, we used the combined mean score of all 12 items. ing the PB variables were also missing the TB variable (n ⫽ 11;
The MSPSS has shown adequate test–retest reliability in prior 7%). This may have occurred because both these variables were
studies and good internal consistency in several different samples positioned at the end of the questionnaire battery at T1.
(Cecil, Stanley, Carrion, & Swann, 1995; Levi-Belz & Lev-Ari, Thus, due to the percentage of missingness in some variables,
2018; Zimet et al., 1988). Moreover, the MSPSS has shown we chose to impute missing data. To decide whether the data were
adequate construct validity in Zimet et al. (1988) and Eker and missing at random, we conducted a Little’s missing completely at
Arkar (1995), who found the global perceived support score to random test (Little, 1988). The analysis revealed that the data were
correlate negatively with measures of depression and anxiety in a not missing completely at random, ␹2(16) ⫽ 44.09, p ⫽ .03.
university sample and in a psychiatric patient sample (see also According to supplementary t tests, the absent data was surmised
Osman, Lamis, Freedenthal, Gutierrez, & McNaughton-Cassill, to be indeed related to the observed data in one main place:
2014; Rueger, Malecki, Pyun, Aycock, & Coyle, 2016). Cron- Participants with missing values of TB or PB received lower
bach’s alpha reliability coefficient for the current sample was .95. scores in social support than did participants with present data in
Posttraumatic growth. Posttraumatic Growth Inventory TB or PB. Hence, we cautiously assumed that the data were
(PTGI; Tedeschi & Calhoun, 1996) comprises 21 statements (e.g., missing at random—that is, missingness is associated with vari-
“I changed my priorities about what is important in life”), each ables in the model other than the missing variable.
scored on a five-point Likert-type scale, ranging from 1 (I didn’t The missing data were handled with a maximum-likelihood
experience this change at all) to 5 (I experienced this change to a (ML) module in AMOS software. Compared with conventional
very great degree), generating a mean PTGI score. Higher scores methods, such as arithmetic mean, listwise or pairwise deletion,
 POSTTRAUMATIC GROWTH AMONG SUICIDE-LOSS SURVIVORS 899

the ML method has been recommended as optimal for computing support significantly predicted PTG-T2, beyond the contribution
missing data to avoid bias (e.g., Schafer & Graham, 2002). of the all other variables, and accounted for another 4% of the total
variance. Both social support and self-disclosure contributed sig-
Results nificantly to PTG-T2.

Interpersonal Characteristics as Predictors of PTG in Structural Equation Model

Follow-Up Among Suicide-Loss Survivors
To fully understand the mediational role of the interpersonal
Preliminary analysis. To test the hypothesis that interper- characteristics in the relationship between PTG at T1 and at T2
sonal characteristics could account for a high proportion of PTG at (follow-up), an SEM was used to predict the PTG 18 months after
T2, correlations between the study variables were calculated. The index measurement. The chi-square goodness-of-fit index of the
means, standard deviations, and intercorrelations for all variables mediating model revealed an excellent fit with the data, ␹2(3) ⫽
are presented in Table 1. The matrix shows that all of the psycho- 3.75; p ⫽ .58; CMIN/DF ⫽ .75, NFI ⫽ .99, CFI ⫽ .99, RMSEA ⫽
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

logical variables were significantly related to PTG, both at T1 and .00. The statistically significant path coefficients are provided as
This document is copyrighted by the American Psychological Association or one of its allied publishers.

at T2. The two PTG scores were positively associated with self- standardized estimates in Figure 1. As shown in Figure 1, the two
disclosure and social support and negatively associated with the dimensions of TB and PB contributed indirectly to PTG, through
TB and PB dimensions of the interpersonal theory of suicide. A the self-disclosure and social support paths. Self-disclosure and
relatively strong positive association was found between PTG in social support contributed to PTG at follow-up, both directly and
T1 and the PTG at the follow-up (T2). indirectly, through PTG at T1. Together, these variables accounted
Hierarchical analysis. To determine whether the interpersonal for 44% of the variance in PTG at follow-up. Demographic vari-
characteristics of TB, PB, self– disclosure and social support contrib- ables, including time elapsed because suicide could not be statis-
ute to PTG at the follow-up, above and beyond the PTG at baseline, tically entered into the model because of their weak association
a hierarchical regression analysis (Cohen, Cohen, West, & Aiken, with PTG measurements in our sample.
2003) was applied. A regression equation was constructed with
PTG-T2 as the dependent variable. To statistically control for the time
Discussion
since suicide and the PTG-T1 levels, these variables were entered first
into the equation: time since suicide in Step 1 and PTG-T1 in Step 2. In the present study, we aimed to examine the role of interper-
In the next two steps, the interpersonal variables were entered into the sonal characteristics of TB, PB, self-disclosure, and social support
equation: For Step 3, the main effects for the TB and PB variables in PTG among suicide-loss survivors 18 months after baseline
were entered, and for Step 4, the main effect for the self-disclosure measurement. To achieve this, we followed up a group of 156
and social support variables was entered. This specific order of steps suicide-loss survivors and observed changes in their PTG levels.
enabled us to better interpret the variance explained by each interper- Our findings highlight the importance of several interpersonal
sonal component separately. characteristics to the course of PTG: Beyond the trajectory of PTG,
Overall, the total set of variables explained 47% of the variance self-disclosure, social support, and TB were found to be facilitators
for PTG-T2, F(6, 147) ⫽ 21.54, p ⬍ .000. As it can be seen in of enhanced PTG levels at T2. Congruent with our hypotheses, TB
Table 2, in Step 1, time since suicide did not significantly con- was found to negatively contribute to PTG at follow-up, while
tribute to PTG-T2. In Step 2, PTG at baseline contributed 37% to self-disclosure and social support positively contributed to
the variance. At Step 3, a model incorporating the main effect of PTG-T2 levels. Moreover, self-disclosure and social support were
TB and PB accounted for an additional 6% of the variance and found to act as mediators of the relationship between TB and PTG
significantly predicted PTG, beyond the PTG at T1 and time since T1 as well as between belongingness and PTG-T2. Together, TB,
suicide. TB was significantly negatively correlated to PTG-T2, but self-disclosure, and social support accounted for 10% of the vari-
PB’s association with PTG-T2 failed to reach statistical signifi- ance in PTG-T2 after controlling for the contribution of PTG-T1.
cance. In the final step, the main effect of self-disclosure and social On the basis of these findings, we may infer that belongingness,

Table 1
Descriptive Statistics and Bivariate Correlations Between Study Variables (N ⫽ 156)

Measure 1 2 3 4 5 6 7

1. Time since loss (years) —

2. Thwarted belongingness (TB) .19 —
3. Perceived burdensomeness (PB) ⫺.01 .56ⴱⴱⴱ —
4. Self-disclosure ⫺.03 ⫺.28ⴱⴱⴱ ⫺.53ⴱⴱⴱ —
5. Social support .11 ⫺.31ⴱⴱⴱ ⫺.62ⴱⴱⴱ .42ⴱⴱⴱ —
6. PTG-T1 ⫺.03 ⫺.17ⴱ ⫺.37ⴱⴱⴱ .55ⴱⴱⴱ .44ⴱⴱ —
7. PTG-T2 .14 ⫺.29ⴱⴱⴱ ⫺.46ⴱⴱⴱ .49ⴱⴱⴱ .49ⴱⴱⴱ .56ⴱⴱⴱ —
M 9.8 1.44 2.52 3.48 5.56 3.61 3.85
SD 9.10 1.06 1.31 .85 1.29 1.21 .67
Note. PTG ⫽ posttraumatic growth; T1 ⫽ baseline; T2 ⫽ 18 months after baseline.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
 900 LEVI-BELZ

Table 2
Hierarchical Multiple Regression Analysis Predicting PTG-T2 (N ⫽ 156)

Step Predictor ␤ SE B t R2 ⌬R2 F change p

1 Time since loss (years) .13 .00 1.68 .02 .02 2.82 ns
2 PTG-T1 .51 .03 9.53ⴱⴱⴱ .37 .36 90.75 .000ⴱⴱⴱ
3 Perceived burdensomeness (PB) ⫺.06 .04 ⫺.84 .43 .06 7.01 .001ⴱⴱⴱ
Thwarted belongingness (TB) ⫺.20 .04 ⫺2.56ⴱⴱ
4 Self-disclosure .16 .06 1.96ⴱ .47 .04 3.87 .023ⴱ
Social support .17 .04 2.05ⴱ
Note. PTG ⫽ posttraumatic growth; T2 ⫽ 18 months after baseline; T1 ⫽ baseline; ns ⫽ not significant.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

self-disclosure, and social support all appear to play an important have a healing effect in at-risk populations (Brown & Heimberg,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

role in facilitating PTG among suicide-loss survivors, beyond the 2001; Levi-Belz et al., 2014) and play a critical role in facilitating
trajectory of PTG. constructive cognitive processes (Frattaroli, 2006), which can in
The study results are in line with several studies that have turn, enhance personal growth among survivors. Thus, engaging in
documented the protective and positive effect of interpersonal interpersonal interaction can lead to a greater likelihood of mod-
interaction on healing from various kinds of traumas and distress ifying personal perceptions and cognitions that may facilitate a
(e.g., Riley et al., 2007). Concerning growth, Tedeschi and Cal- more positive acceptance of self and thus, lead to a greater capacity
houn (2004) noted that interpersonal activities, such as disclosing to grow. From an alternate perspective, sharing of emotional feelings
feelings and interacting with other people, may affect the likeli- can generate a cathartic effect (Stiles, 1987), sometimes described as
hood of a positive aftermath to traumatic events. Many studies “getting it off my chest,” which is acknowledged as one of the
have reported a beneficial effect of these variables on PTG in benefits of self-disclosure (Farber, 2006). Thus, our findings stress the
different populations (Neimeyer & Hogan, 2001; Scrignaro et al., importance of social interactive behaviors, such as talking and shar-
2011). Among these studies, some even found that belongingness ing, on suicide-loss survivors’ adjustment and growth.
as well as social support had a positive effect on PTG levels among
The solidarity experience reflected in low levels of TB may also
suicide-loss survivors (Levi-Belz & Lev-Ari, 2018).
help suicide-loss survivors reduce emotions of guilt and blame,
thus, creating an opening to other emotions and experiences. In
The Interpersonal Role in Facilitating PTG Among general, several authors have emphasized that belongingness
Suicide-Loss Survivors makes a unique and positive contribution to coping with stressors
How the key role of most of the interpersonal characteristics can (Choenarom, Williams, & Hagerty, 2005) and serves as a protec-
be explained? Several suggestions warrant review. First, talking tive factor against psychopathology and suicide (Van Orden et al.,
and expressing personal thoughts and feelings are recognized to be 2010). This appears to be true regarding the healing processes of
features of essential grief work that the bereaved need to do to suicide-loss survivors as well. Suicide-loss survivors often face
confront the new situation (Pennebaker, Zech, & Rimé, 2001). As social stigma, deriving from the idea that at least partially, they
Lepore, Silver, Wortman, and Wayment (1996) suggested, social bear some responsibility for the suicide (Cvinar, 2005). These
sharing of grief may be a strategy to facilitate emotional desensi- perceptions can lead to disconnection and detachment of the sur-
tization. Moreover, communicating personal feelings can even vivors from their surroundings as well as to pathological states of

Figure 1. Serial mediational integrated model for PTG in follow-up.

 POSTTRAUMATIC GROWTH AMONG SUICIDE-LOSS SURVIVORS 901

depression and complicated grief (Levi-Belz & Lev-Ari, 2018). Another limitation concerns the nature of the questionnaires
Belongingness, viewed as one of the fundamental human psycho- used in our study. The use of self-report measures, though very
logical needs (Baumeister & Leary, 1995), may comprise a buffer common in trauma studies, entails the risk of reporting bias
against stigma experiences. (e.g., social desirability), a factor that would be particularly
As can be seen in the study’s SEM, belongingness may be relevant when addressing the sensitive issue of PTG following
enhanced by engaging in self-disclosure and receiving social sup- suicide. Future studies should consider gathering data from
port, interactive phenomena that can accord feelings of being multiple informants, such as the participants’ significant others,
connected to and loved by a person’s surroundings. When survi- and use objective measures, such as observation of actual
vors feel secure enough to share personal information with others functioning. Moreover, although our study focused on the loss
(once sensing belongingness), emotional aspects of the trauma are of an immediate family member to suicide, the measures we
likely to be revealed, leading to feelings of intimacy and togeth- used were not tailored to the population of suicide-loss survi-
erness. The knowledge that one can rely on the support of friends vors. Thus, similar findings could be reflective of individuals
and family members and that the individual is not compelled to having experienced other types of trauma. Future research
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

should make a rigorous effort to identify factors specific to

face a lonely future may help soften the blow of the loss and
This document is copyrighted by the American Psychological Association or one of its allied publishers.

suicide-loss survivors (e.g., guilt, shame), thereby facilitating

perhaps avert the deleterious effects of bereavement, thus enhanc-
the design of more specific therapeutic interventions for this
ing the likelihood of PTG (Stroebe, Schut, & Stroebe, 2005). This
group.
notion is fully reflected in Harry Stack Sullivan’s (1953) state-
The lack of presuicide assessment of personal and interper-
ment:
sonal functioning limits our ability to infer causality. Thus, one
What I am, at any given moment in the process of my becoming a person, cannot negate the contention that current reports of PTG are
will be determined by my relationships with those who love me or refuse related to pretrauma circumstances that may have contributed to
to love me, with those whom I love or refuse to love. (p. 18) our findings and were not directly related to the suicide-related
experience. Last, our assessments did not encompass the entire
Surprisingly, PB was not found to facilitate PTG over time in time elapsed since suicide—specifically, the months immedi-
our sample. PB was found to have a strong negative relationship ately following the suicide. Therefore, we were unable to mon-
with PTG among suicide-loss survivors, both at T1 and at T2. itor fluctuations in the course of PTG, as well as changes in
However, no significant unique contribution to PTG at T2 was interpersonal relationships and as well as other life events.
found when PB was entered together with TB in the hierarchical Related to that, time since loss varied among participants,
regression and in the integrated model. Thus, it can be inferred possibly precluding the possibility of generalizing the results.
that while the feeling of burdensomeness is related to dimin- However, using time since loss as a covariate allowed us to
ished PTG potential, the experience of belongingness is much partly surmount this limitation.
more central in this relationship. This conclusion is in line with
other studies on this topic (Lev-Ari & Levi-Belz, 2018). As Conclusions and Implications
noted, the sense of belongingness allows suicide-loss survivors
to self-disclose themselves and to feel supported by others, The current study is the first to examine the longitudinal
which are essential psychological factors in PTG in general trajectory of PTG among suicide-loss survivors and the effect of
(Tedeschi & Calhoun, 2004) and in PTG among suicide-loss interpersonal characteristics in this trajectory. We achieved this
survivors specifically (Levi-Belz, 2015). A plausible suggestion by assessing PTG at two time points separated by an 18-month
is that low levels of PB cannot facilitate PTG as well as can gap. Key findings indicated that factors of TB, self-disclosure,
self-disclosure and social support, beyond the belongingness and social support account for the increase in PTG levels among
suicide-loss survivors a year and a half after the baseline
experience. Future studies should examine the unique role of
measurement.
TB in other related consequences of suicide among suicide-loss
The study findings have both theoretical and practical implica-
survivors, such as adjustment or complicated grief (Levi-Belz
tions. Theoretically, these results highlight the importance of in-
& Lev-Ari, 2019).
terpersonal relationships in the grieving process of suicide-loss
This study has several methodological limitations. One lim-
survivors. We found interpersonal attributes to be particularly
itation concerns the voluntary nature of the participants. Most pertinent to assessing the prospects of adopting a psychological-
of the participants were members of either the nonprofit orga- growth view of a particularly traumatic event. We can thus surmise
nization for suicide-loss survivors or of the Internet forum that PTG among suicide-loss survivors comprises a highly inter-
dedicated to dealing with suicide loss. It may be that suicide- personal process. As to practical implications, feelings of thwarted
loss survivors who feel more isolated endure greater difficulty belongingness are often distorted perceptions rather than based on
in general and are less inclined to join or subscribe to a group facts (Joiner & Van Orden, 2008). Thus, basic psychoeducational
devoted to dealing with loss. As such, in terms of ecological interventions, specifically designed for suicide-loss survivors
validity, the current sample may be overrepresentative of indi- (Wittouck, Van Autreve, Portzky, & van Heeringen, 2014), may
viduals having PTG potential and thus, its generalizability help survivors acquire support and gain perspective on their situ-
needs to be considered with caution. A broader, more represen- ation, particularly for those experiencing high thwarted belonging-
tative sample of suicide-loss survivors from the community ness levels. It appears that these survivors have difficulty ap-
would likely provide a fuller understanding of PTG among proaching others for help and feel less supported by their
survivors and the factors related to its impact. surroundings. Psychotherapy protocols, such as the expert com-
 902 LEVI-BELZ

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.1027/0227-5910/a000252 Accepted February 21, 2019 䡲
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