Introduction

Viewing the body after a sudden death is often said to be helpful for bereaved family members [1], [2]. Chapple and Ziebland [1] found that relatives, bereaved through suicide or other traumatic deaths, who had chosen to view the body seldom regretted doing so. They also found that the relatives often had numerous reasons for viewing the body and mentioned the need for checking the identity, to care for the deceased and to say goodbye. These findings were based on 80 in-depth interviews conducted in Great Britain between 2007 and 2008, four months to nine years after the loss. The benefits of viewing the body after an unexpected death may also be explained by applying grief theories and the notion that facing the dead person facilitates the grief process by bringing reality to the death and by providing an opportunity for closures [1], [3], [4]. There are also relatives who do not want to view the body; some want to remember the person as he or she was when being alive, others want to spare themselves from a fearful sight and unwanted memories [1]. The fear of unwanted memories is also an explanation to why health care professionals sometimes are unwilling to show a disfigured body [5]. Research on the assumed (positive and negative) psychological effects of viewing the body after a suicide loss is however sparse.

In this population-based study we used the personal identification numbers and the nationwide high-quality registers to identify a large sample of unselected suicide-bereaved parents in Sweden. We thereafter used a detailed questionnaire with psychometric scales and study-specific questions to test our hypotheses: parents that viewed their childs body in a formal setting seldom regretted the experience, and that viewing the body was associated with lower levels of psychological morbidity two to five years after the loss.

Methods

Data collection and measurements

We developed the study design from the routines established by the Division of Clinical Cancer Epidemiology [6], [8]–[10]. Using qualitative methods, we formed study-specific questions on the basis of seventeen in-depth interviews with suicide-bereaved parents [9]. Psychological outcomes were measured by: The two-item Generalized Anxiety Disorder scale (GAD-2) [11], [12] and The nine-item depression scale of the Patient Health Questionnaire (PHQ-9) [13], [14]. We used study specific questions, with space for free comments, to assess circumstances related to the suicide and the viewing (presented in table 1,2). Furthermore, we used four questions with follow-up questions (presented in table 3) to asses if the parents had viewed the body in a formal setting and if it had been during dignified circumstances. To assess the prevalence of nightmares, intrusion and avoidance related to the child's death we used the study specific questions presented in table 4. All questions, including the psychometric scales, were tested in a preparatory study that included 46 suicide-bereaved persons from our study population [9]._ENREF_1 We contacted all eligible parents by an introductory letter followed by a telephone-call to obtain consent to send a questionnaire. Parents of the same child were contacted separately and each individual received a questionnaire of their own. We started the data collection in August 2009 and the last questionnaire was returned in December 2010 [9].

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Table 1. Sociodemographic characteristics of the suicide-bereaved parents.

https://doi.org/10.1371/journal.pone.0101799.t001

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Table 2. Circumstances related to the suicide.

https://doi.org/10.1371/journal.pone.0101799.t002

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Table 3. Suicide-bereaved parents experience of viewing the body at formal settings.

https://doi.org/10.1371/journal.pone.0101799.t003

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Table 4. Psychological outcomes among the parents that viewed and did not view the body.

https://doi.org/10.1371/journal.pone.0101799.t004

Results

Secondary outcomes

Viewing the child in a formal setting was associated with a statistically significantly higher risk of having relived the child's death through nightmares (relative risk 1.61, 95 percent confidence interval 1.13 to 2.32) and intrusive memories (relative risk 1.20, 95 percent confidence interval 1.04 to 1.38) at least occasionally during the preceding month. No statistically significant difference was found concerning anxiety (GAD-2, score ≥ 2) (relative risk 1.02, 95 percent confidence interval 0.74 to 1.40) and depression (PHQ-9, score ≥ 10) (relative risk 1.25, 95 percent confidence interval 0.85 to 1.83) (Figure 1, Table 4). The psychological morbidity related to viewing the body in a formal setting was found both among those who reported that they had seen the body at the site of death and those who had not (data not shown in table). Not seeing the body at all or only seeing the body at the site of the death (not in a formal setting) was not associated with elevated risks of psychological outcomes 2-5 years after the loss (Table S1).

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Figure 1. Psychological outcomes among the parents that viewed and did not view the body.

https://doi.org/10.1371/journal.pone.0101799.g001

Discussion

This is the first large population-based study on psychological reactions to viewing the body after a suicide. We found that by and large everyone of the 460 parents that had viewed their deceased child in a formal setting did not regret the viewing when asked two to five years after the loss. Of equal importance, more than half of the 202 parents who did not view the body did not wish that they had. In contrast to what we hypothesized, we found that those parents who had viewed the body in a formal setting had a statistically significantly higher risk of reliving the child's death through nightmares (relative risk 1.61, 95 percent confidence interval 1.13 to 2.32) and intrusive memories (relative risk 1.20, 95 percent confidence interval 1.04 to 1.38). We found no statistically significant difference concerning anxiety (relative risk 1.02, 95 percent confidence interval 0.74 to 1.40) and depression (relative risk 1.25, 95 percent confidence interval 0.85 to 1.83) (Table 4).

Our findings that most parents who viewed the body do not regret doing so correspond with findings from previous studies [1], [2]. As in Chapple and Ziebland's study [1], only a few persons stated that they regretted viewing of the body. In our study regrets were often followed by a comment that expressed shock over how their loved ones had changed. Providing information on what to expect has been stressed as an important element in reducing distress and regrets due to viewing the body after a traumatic death [1], [2], [15]. Interestingly, in our study, regrets were most often associated with death by poisoning rather than a violent method of suicide. The written comments also showed that the regrets mainly concerned witnessing a decomposed body rather than a body that was disfigured by the suicide. Possible explanations might be that after a violent death the relatives are better informed on what to expect and the body is more often shielded. The violently bereaved parents might also expect the worst. Our findings suggest it is always important to inform the parents about the body's appearance and about options for the viewing, whatever the mode of death. Health care personnel are often encouraged to carefully prepare the environment and the body before the viewing [2], [16], [17]. However, after an as of yet unverified suicide, cleaning the body may be delayed due to an ongoing police investigation. In our study, most parents reported that they perceived that the viewing took place during dignified circumstances, which suggests that complicating factors like an unprepared or damaged body might be accepted if the bereaved are carefully informed and supported during the viewing.

Our finding that the majority of the persons that did not view the body did not wish they had, agrees with previous findings [1], [2]. There are also some who did not view who afterwards wish that they had. Chapple and Ziebland [1] showed that some respondents changed their mind regarding what they thought was best for them and that some, afterwards, were ambivalent about whether their decision was the best one. One explanation might be that these individuals may hold a belief that viewing is necessary for a healthy recovery, a view suggested by some respondents in our study as well as in the grief literature. Dublin and Sarnoff's_ENREF_2_ENREF_2 review [2] from 1986 concludes that bereaved persons should be offered the opportunity to view the body but also stress that those who are reluctant or unwilling to do so must be supported by being told that their decision was the right one for them.

Our hypothesis that those who viewed the body in a formal setting would have lower levels of psychological morbidity than those who did not view was not supported by our findings. In contrast, viewing was associated with a higher risk of reliving the child's death through nightmares and intrusive memories, although no differences could be found regarding anxiety, depression or avoidance two to five years after the death (Table 4). Research on the psychological effects of viewing the body after a suicide loss is sparse. We found two studies that explored how confronting the body (at the scene of the death and at a formal setting) affected the level of grief difficulties among suicide-bereaved relatives [18], [19]. In this paper we chose to restrict the discussion to findings concerning viewing in the formal setting. Callahan's study [18] included 210 persons who had lost a family member or a close friend to suicide. The bereaved were all participants in suicide support groups and data were collected in Michigan (1989 to 1993) and Chicago (1995 to 1996) with the average elapsed time since loss being four years. Callahan hypothesized that “Not seeing the deceased's body at the funeral or memorial service” was associated with higher levels of grief as measured by the Grief Experience Questionnaire but found no impact on the overall level of grief. Feigelman and co-workers_ENREF_12 [19] studied a sub-group of 462 parents who had lost their son or daughter to suicide during a time span of less than a year to more than 10 years. An abbreviated version of the Grief Experience Questionnaire was used for the outcome measures and the parents were identified by suicide support groups in the USA. Feigelman and co-workers hypothesized that the suicide-bereaved who had viewed the body prior to the burial or cremation (n = 189) would experience higher levels of grief difficulties than those who had not viewed the body prior to the burial or cremation (n = 96) (the parents that had seen the body at the site of the death were not included in any of the groups). Feigelman and co-workers found that those who had not viewed had a lower level of grief difficulties than those who had viewed. Our findings on the psychological effect of viewing the body in a formal setting are in line with Callahan and Feigelmans's findings, thus challenging the notion that viewing the body is necessary for a healthy grief recovery.

Our study has several strengths; one is the large sample of suicide-bereaved parents, all identified through nationwide high-quality registers. Another is the high participation rate among both men and women. Some individuals were parents of the same child but all were contacted separately and received their own questionnaire. Some parents may have discussed their answers with the other parent, but our experiences from the in-depth interviews and the validation interviews were that the parents primarily described their own experiences and that the mother and fathers experiences often differed from each other's. Our study also has limitations. The opportunity and decision to view or not to view the body are influenced by numerous factors, some of them known, others not. We have no quantitative data on whether the parents wanted and/or had the choice to view the body at the time of death. However, the written comments to the questions suggest similar to previous studies that the decision often was influenced by other persons and circumstances surrounding the body [1], [5]. Ideally additional data concerning “viewing the body” would include information from different sources (observations and self-rated), immediate reactions and a range of mental health outcomes measured at different times of follow-up. However, due to methodological issues this was not possible. For example, collecting longitudinal data and adding more question would most likely have compromised the response rate and thereby the validity of the study. For similar reasons we also lack information about possible confounders' related to different personality and coping strategies, since existing inventories were considered too immense and the study-specific questions from the preparatory study imprecise [9]. Data was collected retrospectively. Thus some of the answers may be affected by recall-induced problems such as issues concerning whether the parents perceived that the viewing of their child took place under dignified circumstances. However, most of our outcomes concern how the parents feel today or how they have felt during the last month or the last two weeks and thus are not influenced by memory-bias. Some answers might have been affected by defence mechanisms, e.g. a too painful memory could be suppressed or replaced by a less painful one. During the in-depth-interviews and the validation interviews, however, we did not find that the parents had difficulties in answering questions regarding sensitive issues such as where they saw the body of their dead child. We therefore consider the recall-induced problems to have a minor if any effect on the effect measures presented in this paper.

We addressed the threats to validity by employing epidemiological methods as transferred to this field by the hierarchical step-model for study design, analysis and data interpretation [20]. Efforts to reduce the problem of misclassification included a thorough preparatory study, developing and testing the questions and the psychometric scales in close collaboration with parents from the study-population [9]. When choosing scales we considered psychometric properties, relevance to our research questions and whether the format of the scale was suitable for our questionnaire. We chose the psychometrically tested scales PHQ-9 and GAD-2 because they have been used and tested in similar study-populations and have shown high reliability and validity despite of their compactness [11], [14]. We used psychometrically validated measures when possible. However, since most concepts in this study have not previously been studied we had to design ad hoc questions that we validated through a comprehensive preparatory study [6], [9].

Our main outcomes were measured by psychometric as well as study-specific questions and we have no reason to believe that the ones who viewed the body and the ones that did not view differ systematically in their response to these questions [21]. It is likely that the fundamental manifestations of grief are universal but still, generalisation to other populations may be compromised by culture-specific issues. For ethical and methodological reasons we could only include Swedish speaking parents in this survey. However, some of our findings might be as trustworthy in other populations and settings. We have therefore described our research process and data in detail so that other researchers and clinicians can decide whether our findings are applicable for them in their settings [6], [9].

In summary, in this Swedish population-based study, we found that by and large everyone that had viewed their deceased child in a formal setting did not regret doing so. We also found that the majority of the parents that did not view their deceased child did not wish that they had. We found no support for the position that viewing the body in a formal setting had a positive effect on the psychological outcomes, two to five years after the loss. This is the first larger population-based survey on the subject and the study needs to be repeated in other settings and study populations ideally using longitudinal design. More qualitative and observational studies are also warranted to capture the complexity of the subject. Although no recommendations can be made, our findings suggest that it is the bereaved person that should make the decision to view or not to view the body and that the officials may support the parents in their decision by carefully informing about the child's appearance and how the viewing may be altered, for example, by shielding parts of the body. Facilitating mental preparation and a thoughtful caretaking may also reduce the significant minority of parents that reported that they regretted the viewing or that they perceived the viewing as less than dignified. For parents that seek advice, the officials may also tell them that previous research suggests that most parents that want to see their child do not regret doing so and that viewing often is perceived as helpful although not necessary for a healthy recovery.

Supporting Information

Acknowledgments

We thank the parents who participated in the study, for their willingness and bravery, we also thank Else Lundin and Jonna Lindsjö at Karolinska Institutet for their administrative support in the study, and PhD Lawrence Lundgren, Professor Emeritus, University of Rochester, for linguistic revision of the manuscript.