Preamble

Suicide Exposure: Negative Impacts and Postvention

Zhou Zhongying¹,², Wu Caizhi², Yun Yun²,³, Xiao Zhihua²,⁴, Tong Ting²,⁵
¹(Centre for Mental Health Education, Wuhan Sports University, Wuhan 430074, China)
²(Key Laboratory of Adolescent Cyberpsychology and Behavior (CCNU), Ministry of Education; Key Laboratory of Human Development and Mental Health of Hubei Province; School of Psychology, Central China Normal University, Wuhan 430079, China)
³(Centre for Mental Health Education, Zhengzhou Business University, Zhengzhou 450000, China)
⁴(Mental Health Education and Counseling Center, Sichuan Police College, Luzhou 646000, China)
⁵(NO.1 Middle School Affiliated to Central China Normal University, Wuhan 430070, China)

Abstract

Suicide exposure—defined as contact with others' suicidal behaviors—can have severe negative impacts on vulnerable populations, including those bereaved by suicide, individuals with mental disorders or suicide risk, and adolescents and young adults. While previous research has highlighted the potential harm of suicide exposure, empirical studies examining methods for identifying vulnerable populations, mechanisms underlying negative impacts, and suicide postvention approaches and their effectiveness remain severely limited. This article systematically reviews and redefines the concept of suicide exposure, summarizes vulnerable populations' negative psychological reactions to suicide events along with corresponding trauma/grief maintenance mechanisms and suicide contagion mechanisms, and examines existing suicide postvention methods, guidelines, and their effectiveness and limitations, aiming to lay the groundwork for localized suicide exposure research and postvention practice. Future research should employ qualitative inquiry, longitudinal quantitative analyses, and artificial intelligence to explore classification systems and risk prediction models for vulnerable populations, and to develop specialized evidence-based intervention protocols grounded in a clearer understanding of the mechanisms underlying negative outcomes.

Keywords: suicide exposure, suicide bereavement, negative impacts, suicide contagion, suicide postvention
Classification Number: R395

Suicide is a recognized major public health problem. Globally, over 720,000 people die by suicide each year. Suicide incidents not only cause significant losses to families and society, but suicide exposure also triggers cascading reactions across families, friends, colleagues, communities, and society at large (WHO, 2025). Statistics indicate that each completed suicide exposes at least 135 people, with approximately 25 experiencing significant impacts (Cerel et al., 2019). Based on these figures, tens of millions of people are affected by suicide deaths annually, with even greater numbers impacted by suicide attempts. With the increasing prevalence of new social media platforms, suicide exposure is no longer limited to contact with the suicidal behaviors of relatives, friends, or acquaintances (Bell & Westoby, 2021). Some widely publicized real suicide incidents or fictional suicide stories have even broader impact. Examples include the suicide of a middle school student in Jiangxi, China, and the suicide storyline of the protagonist in the Netflix series 13 Reasons Why, both of which generated widespread public attention. Both experts and the general public worry that extensive dissemination of suicide incidents may trigger strong negative effects, such as inducing or exacerbating negative emotions among relatives or those aware of the incident, and causing the extreme effect of suicide contagion.

Research on suicide exposure primarily originated from concerns about suicide-bereaved groups and suicide contagion phenomena. Suicide-bereaved individuals are those affected by the loss of a relationship due to a loved one's suicide death, referred to as "suicide bereaved." Related concepts include suicide survivors and suicide loss survivors. Mental health practitioners should pay attention to suicide-bereaved individuals and provide support and assistance to those bearing the tragic consequences of suicide death (Cerel et al., 2014). Meta-analyses show that 4.31% of the general population was exposed to the suicide death of a family member or friend in the past year, with a lifetime exposure rate of 21.83% (Andriessen, Rahman, et al., 2017). Among adolescents, exposure to the suicide death of relatives or friends is approximately 7%–17% (Swanson & Colman, 2013; Chan et al., 2018). In China, 6.6% of adolescents and over 10% of college students have been exposed to the suicide death of relatives or friends (Liu, Wang et al., 2020; Zhao et al., 2013). Compared to other bereaved individuals, suicide-bereaved persons are more likely to experience psychological pain lasting for years or even a lifetime (Kaur & Stedmon, 2022; Spillane et al., 2018).

Suicide contagion refers to the process by which a suicide incident triggers subsequent suicidal behaviors in others within a similar timeframe or geographic area. Related terms include the Werther Effect, suicide cluster, suicide imitation, and suicide suggestion. Joiner (1999) categorized suicide clusters into two types: mass clusters and point clusters. Mass clusters primarily involve widespread suicide clustering in a similar timeframe triggered by media dissemination of real or fictional suicide incidents, such as reports of celebrity suicides or depictions of protagonist suicides in films and television dramas. Point clusters primarily involve localized suicide contagion in similar geographic spaces due to actual suicide incidents, such as suicide clusters within communities, schools, or families. Substantial evidence indicates that erroneous and repetitive media reporting on suicide is associated with temporary increases in suicide rates (Niederkrotenthaler et al., 2020; Niederkrotenthaler et al., 2021). The World Health Organization has specifically developed media guidelines for suicide reporting, calling for appropriate ways to report suicide information (WHO, 2023). Suicide "point cluster" phenomena are also relatively common, as illustrated by cases such as Foxconn employee suicides in China and over 16 adolescent suicide deaths in a small U.S. community within 15 years (Abrutyn et al., 2020).

Both suicide bereavement and suicide contagion research highlight concerns about the negative impacts of exposure to suicidal behaviors, particularly increased suicide risk. Numerous scholars have listed suicide exposure as a risk factor for suicidal ideation and behavior, and have extensively explored the association between suicide exposure and negative mental health outcomes, suicide contagion mechanisms, and postvention interventions. The World Health Organization and the International Association for Suicide Prevention have explicitly stated that suicide postvention for those exposed to suicide is as important as suicide prevention and intervention before suicide incidents occur, forming an indispensable component of comprehensive suicide prevention systems (Andriessen, Krysinska & Grad, 2017). However, in mainland China, only a few scholars have investigated the association between suicide exposure and self-harm behaviors, suicidal ideation and behavior, and the trauma/grief status of close relatives of suicide decedents (Li, 2013; Yao et al., 2022; Zhao et al., 2013; Liu, Wang, et al., 2020). Professionals in education, healthcare, and public health institutions have limited knowledge about suicide exposure and its negative impacts, and postvention practice is almost nonexistent. Chinese scholars urgently need to strengthen academic research and practical accumulation in the field of suicide exposure to address this hidden public mental health challenge. This article provides a knowledge framework for the domestic public and stakeholders to correctly understand and reasonably respond to suicide incidents and effectively mitigate the negative impacts of suicide exposure by reviewing the concept and classification of suicide exposure, research findings on vulnerable populations and their negative impacts, and discussing the current status and limitations of research on mechanisms of negative impact and postvention methods, thereby offering research ideas for subsequent psychoeducation, identification of vulnerable individuals, and intervention.

1 Definition and Classification of Suicide Exposure

Early definitions of suicide exposure primarily referred to contact with information about others' suicide deaths in real life, but the conceptualization was unclear and often used interchangeably with suicide-bereaved individuals. For example, Maple et al. (2017) viewed suicide-exposed individuals as those who had contact with others' suicide deaths, including relatives of the deceased. Andriessen, Rahman, et al. (2017) defined suicide-exposed individuals as those who experienced the suicide of a family member or friend, or personally knew someone who died by suicide (knowing about celebrities or online figures who died by suicide was not considered "personally" knowing the deceased). Jang et al. (2020) defined suicide-bereaved individuals as victims who experienced the suicide death of a sibling, parent, spouse, or immediate family member living together. These definitions all treat suicide exposure as an objective phenomenon with narrow scope, including only those who knew the deceased.

Cerel et al. (2014) further expanded the definition of suicide-exposed individuals by proposing the Continuum of Survivorship Model (CSM model), which classifies suicide-exposed individuals based on the degree of impact from the suicide incident and the type of relationship with the deceased. The outermost layer, "suicide-exposed individuals," includes all who know or confirm that a suicide death has occurred, encompassing people in the deceased's domains (family, school, workplace, social circles), emergency responders, fans, and netizens. The second layer, "suicide-affected individuals," refers to those who suffer psychological pain due to the impact of the suicide death, including relatives and strangers affected by the suicide of a significant other (such as witnesses and depressed adolescents in nearby communities). The third layer, "short-term suicide-bereaved individuals," refers to those who experience psychological pain and have an intimate/attachment relationship with the deceased, primarily family members, partners, close friends, and colleagues. A minority of short-term suicide-bereaved individuals develop into "long-term suicide-bereaved individuals" (the innermost layer), who have an attachment relationship with the deceased and struggle long-term with clinical symptoms caused by the loss. Cerel et al.'s (2014) definition of long-term suicide-bereaved individuals is similar to Jordan and McIntosh's (2011) definition of suicide survivors—individuals who experience high levels of self-perceived psychological, physical, and/or social pain for a considerable period after exposure to others' suicide deaths. Both definitions focus on real suicide death incidents and combine objective indicators (whether one experienced suicide exposure) with psychological indicators (whether there is an attachment relationship and long-term psychological pain) to define suicide-exposed individuals, acknowledging that professionals frequently exposed to suicide incidents and even those unrelated to the deceased may be severely affected. To date, the CSM model is a widely recognized and cited definitional model for suicide exposure, but it neglects some individuals who, despite lacking intimate relationships with the deceased, still experience high levels of psychological pain. Bhullar et al. (2021) used latent profile analysis to test the CSM model and found a fifth group—individuals with low intimacy with the deceased but high impact, whose impact scores did not differ from short-term suicide-bereaved individuals but were lower than long-term suicide-bereaved individuals. Qualitative research also found that individuals who did not know the deceased could still experience severe negative reactions and even engage in suicidal behavior (Sanford et al., 2023; Mirick & Berkowitz, 2023).

Furthermore, besides limiting suicide exposure to contact with real individuals' suicide deaths, many researchers have also focused on suicide contagion risks from exposure to fictional suicide stories in films, television dramas, or literary works (virtual exposure) (Bridge et al., 2020), or studied the impact of exposure to others' suicide attempts (Hill et al., 2020; Hvidkjær et al., 2021), or distinguished suicide exposure as direct or indirect based on whether one had real-life contact with the deceased (Davidson et al., 1989; Haw et al., 2013). Wolford-Clevenger et al. (2019) included others' disclosure of suicidal ideation, preparation, and methods to individuals within the scope of suicide exposure, and distinguished direct exposure (such as witnessing others' suicidal behavior) from indirect exposure (such as hearing about it or seeing discussions and reports about others' suicidal behavior on online media). However, they considered participation in suicide-related communication as suicide exposure, which is overly broad and risks losing research focus.

To maintain research focus, this article follows the concerns of most studies by limiting suicide exposure to exposure to suicidal behaviors, while expanding beyond the CSM model's restriction to real suicide deaths. We define suicide exposure as "having contact with the suicide death or suicide attempt of a real or fictional character, and knowing basic information about the suicidal person, time, location, method, and outcome." We redefine "suicide-affected individuals" as "those who experience short-term or long-term psychological pain due to exposure to the suicide death or suicide attempt of a real or fictional character." Psychological pain includes trauma and grief reactions, emotional contagion, and suicide contagion. The term "suicide-bereaved individuals" used below is limited to those who have kinship or intimate/attachment relationships with the deceased and experience psychological pain due to the suicide death of relatives or friends, primarily referring to family members, romantic partners, or close friends. Suicide-bereaved individuals are subsumed under suicide-exposed individuals and suicide-affected individuals. Based on previous research, suicide exposure types can be partially subdivided according to exposure channel, content, target, and event authenticity (Table 1 [TABLE:1]):

Table 1 Types of Suicide Exposure
- Direct Exposure: Direct contact with the deceased, including knowing the deceased and witnessing the suicide scene
- Indirect Exposure: No direct contact with the deceased; learning about their suicidal behavior through intermediaries, such as through others' accounts, online information, or news media
- Suicide Death Exposure: Exposure to suicide death behaviors of real or fictional characters
- Suicide Attempt Exposure: Exposure to suicide attempt behaviors of real or fictional characters
- Relative/Friend Suicide Exposure: Exposure to suicidal behaviors of relatives or other close contacts
- Non-Relative/Stranger Suicide Exposure: Exposure to suicidal behaviors of acquaintances or strangers
- Real Character Exposure: Exposure to suicidal behaviors of real individuals, such as family, friends, community neighbors, netizens, or public figures
- Fictional Character Exposure: Exposure to suicidal behaviors of fictional characters in games, novels, or films/television dramas

2 Vulnerable Populations and Their Negative Impacts

Not all suicide-exposed individuals experience significant negative impacts. Due to practical and ethical considerations, it is difficult to directly manipulate independent variables to verify causal relationships between suicide exposure types, characteristics of exposed individuals, and negative reactions. Existing research primarily uses quantitative methods to compare negative psychological indicators between suicide-exposed and non-exposed individuals (Andriessen et al., 2016; Beyraghi et al., 2023) and among suicide-exposed individuals with different characteristics (Maple et al., 2017; Bahamón et al., 2023), or employs correlation and regression analyses to infer negative impacts on suicide-exposed individuals (Hill et al., 2020; Feigelman et al., 2024; Pitman et al., 2024). Qualitative studies have also collected information on cognitive and emotional reactions of suicide-exposed individuals (Sanford et al., 2023; Mirick & Berkowitz, 2023). Among these, suicide-bereaved individuals, adolescents and young adults, individuals with mental disorders or suicide risk, and occupational suicide-exposed individuals have received particular attention.

2.1 Suicide-Bereaved Individuals

Suicide bereavement is a traumatic experience. The sudden and violent nature of a loved one's suicide death and the complex sociocultural meanings embedded in suicidal behavior place suicide-bereaved individuals in multiple predicaments. Among suicide-bereaved individuals, 90% of immediate family members, 88% of partners or spouses, 59% of extended family members, and 50% of friends and classmates report being significantly affected (O’Connell et al., 2023), with immediate family members showing higher rates of psychiatric symptoms (McDonnell et al., 2022). Cerel et al. (2016) argue that psychological closeness to the deceased better predicts adverse mental health outcomes than kinship status, suggesting that the focus on suicide-bereaved individuals should shift from relationship type to emotional connection depth.

Like other bereaved individuals, suicide-bereaved individuals experience separation distress and traumatic distress resulting from traumatic loss (Andriessen et al., 2020; O’Connell et al., 2023). However, suicide-bereaved individuals face more complex meaning-making and responsibility attribution dilemmas, as their fundamental cognitive frameworks regarding life value, interpersonal connection, and responsibility are severely challenged. This manifests in two main aspects: first, an obsessive search for "why"—suicide-bereaved individuals have a stronger need to find reasonable explanations for the death (McGill et al., 2023; Kaur & Stedmon, 2022); second, excessive assumption of "responsibility"—believing they bear significant responsibility for their loved one's suicide death (Cerel & Sanford, 2018; Kaur & Stedmon, 2022), interpreting the suicide as an accusation or abandonment directed at themselves (Spillane et al., 2018; Goulah-Pabst, 2023), and feeling fearful about their responsibility (Kõlves et al., 2020). Consequently, the core experiences of suicide-bereaved individuals are guilt and blame (self-blame, blaming others, and feeling blamed) (Shields et al., 2017). Immediate family members or partners of the deceased also experience high levels of shame and anger (Andriessen et al., 2020), with high comorbidity rates of post-traumatic stress disorder (PTSD) and prolonged grief disorder (PGD). Numerous studies also show increased rates of depression, anxiety symptoms, and suicidal ideation and behavior among suicide-bereaved individuals (Cerel et al., 2016; O’Connell et al., 2023; McDonnell et al., 2022). A study of relatives of suicide decedents in Germany found that 12.4% had complex PTSD (CPTSD), 5.0% had PTSD, 22.0% had PGD, and 41.6% had moderate or higher levels of depressive symptoms (Hofmann & Wagner, 2024). Among relatives of suicide decedents in rural China, 22.4% had PTSD, primarily among parents and female spouses of the deceased (Li, 2013). After controlling for baseline characteristics, bereaved individuals whose spouse died by suicide had twice the suicide death risk of other bereaved individuals, and suicide-bereaved individuals with depression had four times the suicide death risk of other bereaved individuals (Pitman et al., 2024). Mothers bereaved by child suicide and suicide-bereaved individuals under 25 show more prominent mental health and suicide risks (McDonnell et al., 2022). Mothers of suicide decedents reported rates of suicidal ideation, suicide plans, and suicide attempts at 60%, 24%, and 5%, respectively (Westerlund et al., 2020). Children of suicide decedents show higher rates of suicidal behavior than children of decedents who died from other causes, and the younger the child was when the parent died by suicide, the greater their subsequent odds of suicide death, suicide attempt, and hospitalization (Andriessen et al., 2016). This further demonstrates that stronger intimate/attachment relationships with the deceased increase the likelihood of developing into "long-term suicide-bereaved individuals."

Long-term suicide-bereaved individuals face long-term challenges in psychological reconstruction and social adaptation. This complex and turbulent process damages their mental health and increases suicide risk while inevitably reducing their quality of life. Suicide death triggers reconstruction of bereaved individuals' family and social relationships, with common occurrences of family communication barriers, conflicts, and intimate relationship ruptures (Kaur & Stedmon, 2022). They both crave connection and fear further loss (Azorina et al., 2019; McGill et al., 2023), which exacerbates their social isolation, psychological pain, and social adaptation difficulties (Andriessen et al., 2016). Suicide-bereaved individuals also face increased risks of engaging in high-risk behaviors (smoking, alcohol abuse, substance misuse), unemployment and financial difficulties (Erlangsen et al., 2017; McDonnell et al., 2022; Feigelman et al., 2024), and increased risks of hypertension, diabetes, cancer, and mortality (Erlangsen et al., 2017; Spillane et al., 2018). Therefore, helping suicide-bereaved individuals cope with real-life crises is also crucial.

2.2 Adolescents and Young Adults

Adolescents and young adults (ages 10–24), due to their immature psychosocial functioning, high impulsivity, high sensitivity, and susceptibility to peer influence on behaviors and values, have long been considered vulnerable populations for suicide contagion (Abrutyn & Mueller, 2014; del Carpio et al., 2021). Research confirms that suicide contagion primarily occurs among adolescents and young adults, with the 15–24 age group showing suicide contagion rates 2–4 times higher than other age groups, while rates among those over 24 are very low (Gould et al., 1990). Conservative estimates suggest that approximately 10% of adolescent suicides or attempts can be attributed to suicide exposure and contagion (Hawton et al., 2020). Adolescents and young adults have diverse pathways of suicide exposure, potentially having direct contact with relatives' or friends' suicidal behaviors while also easily being indirectly exposed to others' suicidal behaviors and related audio-visual content through offline social networks and online social media (Kline et al., 2022).

Like suicide-bereaved individuals described above, young suicide-bereaved individuals show increased risks of new-onset mental disorders, social adaptation difficulties, externalizing behaviors, and suicide (Andriessen et al., 2016). However, their psychosocial developmental level limits the meaning-making process, making it more challenging to address the question of "why" (Cerel & Sanford, 2018; Mirick & Berkowitz, 2023), requiring more intervention and guidance. Unlike suicide-bereaved individuals who suffer psychological pain based on emotional connections, adolescents and young adults' exposure to peers' or same-age individuals' suicidal behaviors does not require emotional connection as a necessary condition. Simply "knowing about peers' or same-age individuals' suicide" can trigger contagion of emotions, suicidal ideation, and behavior (Mueller & Abrutyn, 2015), and may even better predict future suicidal behavior than "personally knowing the deceased" (Swanson & Colman, 2013; Abrutyn & Mueller, 2014). Moreover, this emotional and suicide contagion has sustained and cumulative effects: after controlling for a series of risk factors, exposure to same-age individuals' suicide attempts still predicts adolescents' suicidal ideation and behavior two years later (Abrutyn & Mueller, 2014); adolescents with multiple exposures to relatives' and friends' suicidal behaviors show higher suicide risk (Liu, Wang, et al., 2020). Similar results have been found in studies on virtual suicide exposure (Bridge et al., 2020). Therefore, research on this population should not only focus on the negative impacts of suicide bereavement but also pay special attention to multiple suicide exposure risks in their offline social networks and online social media, and emphasize analyzing the interaction between suicide exposure and factors such as cognitive and emotional regulation abilities, developmental characteristics, interpersonal patterns, and digital media use.

Currently, differences in the impacts of suicide death exposure versus suicide attempt exposure on adolescents and young adults remain unclear. Although exposure to relatives' or peers' suicide deaths or attempts is associated with increased suicide risk among adolescents and young adults (Kline et al., 2022; Mitchell et al., 2019), some studies indicate that adolescents exposed to relatives' or friends' suicide attempts show higher suicide behavior risk than those exposed to suicide deaths (Liu, Wang et al., 2020; Ho et al., 2000). Peers of suicide attempters show higher levels of psychiatric symptoms and suicidal ideation than peers of suicide decedents, with higher externalizing problem risk, while peers of suicide decedents show higher internalizing problem risk (Ho et al., 2000). This suggests that young suicide-exposed individuals have differentiated psychological reactions when facing different suicide behavior outcomes, and future research needs to systematically examine the psychological processes involved.

2.3 Individuals with Mental Disorders or Suicide Risk

Individuals with mental disorders or suicide risk have higher rates of suicide exposure than those without mental disorders (Yao et al., 2022; Athey et al., 2022). Due to impairments in psychological functioning and coping styles, as well as vulnerabilities in social support systems and neurobiology, they are prone to pathological reaction patterns to suicide exposure. However, because their mental disorders and clinical symptoms vary, their reaction types and intensity also show significant individual differences.

First, suicide exposure has different effects on their clinical symptoms. Research confirms that when depressed patients encounter online suicide information, it activates their inherent negative cognitive triad about self, world, and future, exacerbating helplessness and hopelessness (Voros et al., 2022). Psychiatric inpatients who learn about fellow patients' (including unfamiliar patients') suicides experience grief and guilt reactions similar to suicide-bereaved individuals, and may also exacerbate somatization, intrusive flashbacks, dissociative episodes, increased psychological arousal, hypervigilance, and sleep disorders, or increase needs for care and medication use. Patients with prominent positive symptoms may also develop delusions, such as believing they are responsible for the suicide or have close connections with the deceased (Beyraghi et al., 2023; Seeman, 2015). Individuals with high emotional reactivity and high dissociative tendencies are more severely affected (Pouliot et al., 2011).

Second, suicide exposure has complex effects on suicide attitudes, ideation, and behavior. Some patients may intensify suicidal ideation (developing a desire to imitate the deceased) or be inspired to develop suicidal impulses and use the same method as the deceased due to real or virtual suicide exposure (Beyraghi et al., 2023; Pouliot et al., 2011; Zahl & Hawton, 2004). Some patients may feel anxious about their own suicidal thoughts and worry about imitating the suicide (Beyraghi et al., 2023; Pouliot et al., 2011). Others may reject suicide as an option, contemplate other feasible methods, or disclose their own suicide attempt experiences to close others (Zahl & Hawton, 2004). For this population, suicide exposure does not trigger single emotional contagion and suicide imitation but also triggers their cognitive reappraisal process—reweighing the pros and cons of suicidal behavior or making decisions about suicide.

Joiner (1999) explicitly stated that suicide contagion is most likely to occur in those already at high suicide risk. Adolescents who died by suicide in suicide cluster incidents were more likely to come from dysfunctional family environments, and most had histories of suicide preparation, threats, or attempts, and had been hospitalized for mental disorders or substance abuse problems (Davidson et al., 1989). Mental disorders moderate the relationship between adolescent suicide exposure and subsequent suicide attempts (Kline et al., 2022). Additional evidence comes from sexual and gender minority (SGM) individuals, who have higher rates of mental disorders and suicide risk than the general population (Lynch et al., 2020) and are more than three times as likely as heterosexuals to experience severe emotional distress due to suicide exposure (Clark et al., 2023). Approximately one-quarter of SGM individuals have been exposed to SGM peers' suicidal behaviors, which more easily generates empathy and emotional contagion, increasing their suicide ideation and behavior risk (Canetto et al., 2021; Cerel et al., 2021). This also demonstrates that suicide contagion in populations with mental disorders and suicide risk has systematic characteristics, and these high-risk individuals require additional attention after suicide incidents. Clinical intervention also needs to shift from a single individual treatment model to an ecological systems intervention model, addressing both cognitive and emotional correction for high-risk individuals and studying suicide contagion blocking mechanisms in homogeneous groups.

2.4 Occupational Suicide-Exposed Individuals

Some professionals in special occupations encounter others' suicidal behaviors in their work environment, characterized by high frequency, strong impact, and inevitability. Representative groups include first responders (including firefighters, ambulance staff, and police) and mental health practitioners (MHPs, primarily referring to counselors or therapists, psychiatrists and nurses, and social workers), most of whom experience multiple suicide exposures throughout their careers (Witczak-Błoszyk et al., 2022; Stanley et al., 2015).

One source of psychological trauma for first responders is witnessing suicide scenes. As the first to arrive at suicide scenes, firefighters suffer strong impacts from witnessing suicide deaths, particularly those of children and adolescents, but must suppress intense negative feelings due to professional role constraints (Nelson et al., 2020; McDonnell et al., 2022). Nearly half of ambulance staff also report distress from workplace suicide exposure (Witczak-Błoszyk et al., 2022). MHPs develop emotional connections with suicidal individuals through deep psychological involvement in the helping and treatment process. After a client's suicide death, MHPs experience trauma/grief reactions similar to suicide-bereaved individuals, and most consider it to have negative impacts on their personal lives (Sanford et al., 2021; Lyra et al., 2021). Occupational suicide exposure also extends to practitioners' professional competence and the stability of the helping workforce. High levels of suicide exposure are associated with high levels of burnout, low professional efficacy, and deteriorated interpersonal relationships among first responders (Witczak-Błoszyk et al., 2022; Stanley et al., 2015). MHPs face more prominent professional efficacy crises and behavioral changes after a client's suicide,容易产生自我怀疑和挫败感、对专业学习更不自信，这将影响后续的专业实践；一些 MHP 日后在与有自杀风险者工作时会更谨慎、更加担心承担法律责任，甚至拒绝与有自杀风险的人工作，或考虑转行、提前退休 (Sanford et al., 2021; Lyra et al., 2021). Additionally, occupational suicide exposure shows clear cumulative effects on practitioners' suicide risk: suicide exposure frequency positively correlates with firefighters' own suicide attempts, with firefighters exposed 12 or more times more likely to be screened as at risk for suicidal behavior (Kimbrel et al., 2016). Evidently, occupational suicide exposure impacts practitioners no less than suicide bereavement, and they also need postvention.

In summary, substantial evidence confirms that suicide exposure causes severe psychological trauma for suicide-bereaved individuals and occupational suicide-exposed individuals, exacerbates symptoms in individuals with mental disorders or suicide risk, and triggers suicide contagion among adolescents and young adults. It can be inferred that overlapping populations among these vulnerable groups have even higher probabilities of experiencing significant negative impacts. This aligns with Palmer et al.'s (2018) vulnerability model, which posits that suicide-exposed individuals who simultaneously meet criteria for geographic proximity, psychosocial proximity, and pre-existing risk status are highly vulnerable populations. However, current research has several limitations. First, sample bias: most studies focus on adolescents and young adults, with even fewer studies on groups beyond these four categories, making it impossible to determine whether other populations are also vulnerable. Second, unclear differences in negative impacts across suicide exposure types: a meta-analysis examining differential impacts of suicide attempt versus suicide death exposure found that suicide death exposure increased individual suicide death risk by 3.23-fold and suicide attempt risk by 2.91-fold, but showed no significant association with suicidal ideation; suicide attempt exposure increased individual suicide attempt risk by 3.53-fold, with no significant association with suicide death risk (Hill et al., 2020). However, the practical significance of these results remains unclear, and most studies do not distinguish suicide exposure types or only examine one type without explaining differences in negative impacts across types. Third, lack of core negative reaction measurement indicators and limited screening methods for non-bereaved suicide-exposed individuals: for suicide-bereaved individuals, potential high-risk individuals can be identified by measuring core symptoms of PTSD and PGD, but actual screening accuracy is low for non-bereaved suicide-exposed individuals.

3 Mechanisms of Negative Impacts of Suicide Exposure

Current research on mechanisms underlying negative impacts of suicide exposure primarily involves trauma/grief maintenance mechanisms for suicide-bereaved individuals and suicide contagion mechanisms following suicide exposure. However, most studies provide empirical explanations or deductive speculations based on traditional theories, with few high-quality empirical studies.

3.1 Trauma/Grief Maintenance Mechanisms in Suicide-Bereaved Individuals

The Dual Process Model of grief and the Two-track Model of Bereavement (Kustanti et al., 2024) indicate that suicide-bereaved individuals often oscillate between loss-oriented and restoration-oriented states, struggling to balance processing the loss and restoring personal functioning. The causal systems perspective on mental disorders offers a framework for understanding this difficult process. This perspective suggests that symptoms of mental disorders are often interacting and reinforcing elements within the same complex network, with causal relationships and meaningful connections among them, where symptoms themselves maintain the illness and other symptoms (McNally et al., 2015). There may be one or several core symptoms that prevent overall symptom relief. For example, experiential avoidance is considered a primary cause of trauma/grief maintenance (Nam, 2016). This suggests researchers can identify core symptoms that hinder recovery from trauma/grief to explain symptom maintenance mechanisms.

The core experiences of suicide-bereaved individuals (guilt and blame) and feelings of shame and stigma perception are key variables maintaining trauma/grief. Research confirms that guilt or self-blame and stigma perception are significantly positively correlated with PGD, PTSD, depression, and suicidal ideation (Feigelman & Cerel, 2020), and also lead to low levels of posttraumatic growth (PTG) (Pitman et al., 2017; Oexle et al., 2020). Specifically, guilt, self-blame, shame, and stigma perception cause suicide-bereaved individuals to neglect and hide their painful feelings, limit their ability to talk about the suicide incident, and increase social avoidance, which is extremely detrimental to alleviating bereavement pain (Azorina et al., 2019; McGill et al., 2023; Westerlund et al., 2020). Consequently, individuals who worry that disclosing their suicide bereavement experience will bring shame and embarrassment report more PGD and mental health problems (Feigelman et al., 2018), and those with less perceived social support are more likely to engage in suicidal behavior (Bahamón et al., 2023). Conversely, self-forgiveness, secure attachment, sense of belonging, perceived social support, and self-disclosure buffer psychological pain in suicide-bereaved individuals. Self-forgiveness, which includes accepting one's faults, letting go of self-resentment, and cultivating positive self-cognition, is a protective factor against depression and suicide and promotes adaptive coping strategies and PTG (Levi-Belz & Gilo, 2020; Gilo et al., 2022). Perceived social support and self-disclosure chain-mediate the relationship between secure attachment and PTG (Levi-Belz & Lev-Ari, 2019; Levi-Belz et al., 2021). Securely attached suicide-bereaved individuals hold positive beliefs about self and others, have higher interpersonal belonging, and are more willing to interact with others, all of which help them integrate traumatic experiences and form coherent narratives (Levi-Belz et al., 2021; Levi-Belz & Rotem, 2022; Feigelman et al., 2018).

Therefore, clinicians should actively address guilt and blame in suicide-bereaved individuals to alleviate responsibility attribution dilemmas, reduce experiential avoidance to promote integration of traumatic memories and meaning-making, decrease shame and stigma perception to facilitate help-seeking, and encourage interpersonal communication to obtain emotional support. Scholars need to continue examining the dynamic associations between these specific negative reactions and experiential avoidance in suicide-bereaved individuals to promote the transition from experiential to evidence-based clinical interventions. For example, network analysis methods can be used to construct network models among multiple variables to identify key "bridge symptoms" and predict pathways of symptom deterioration or alleviation, providing targets for suicide bereavement intervention.

3.2 Suicide Contagion Mechanisms Following Suicide Exposure

Joiner (1999) argued that spatiotemporal clustering of suicide incidents is a collection of independent suicide events among high-risk, homogeneous groups, with no imitation or contagion involved. Suicide decedents are more likely to befriend other high-risk individuals (assortative relating), and shared risk factors such as similar family environments and common life stressors are core explanations for suicide contagion. In contrast, Mueller and Abrutyn (2015) confirmed that the key to suicide contagion lies in "knowing about" others' suicidal behaviors; if peers have suicidal ideation and behavior but adolescents are unaware, suicide contagion will not occur. Scholars currently use contagion models, symbolic interactionist theory (SIT), social cognitive theory (SCT), the interpersonal theory of suicide (IPTS), and the integrated motivational-volitional model (IMV) to explain suicide contagion phenomena.

The contagion model draws from infectious disease research in public health, summarizing factors that trigger suicide contagion into five categories: (1) host susceptibility (whether individuals are born with genetic-physiological predispositions to mental disorders); (2) modes of transmission (such as direct transmission—person-to-person through direct contact with the deceased; or indirect transmission—learning about suicides through friends or media); (3) degree of virulence (such as celebrity suicides having stronger contagion than criminal suicides); (4) susceptibility to contagion (primarily referring to whether individuals already have mental disorders or psychological distress); and (5) dose dependency (the more frequent or numerous the contacts with suicide incidents, the greater the impact) (Haw et al., 2013). The contagion model assumes that others' suicidal behaviors do not have uniform or similar effects on suicide-exposed individuals, which can explain why individuals with pre-existing suicide risk and those experiencing negative life events show increased suicide risk after suicide exposure, and why suicides among higher socioeconomic status individuals easily trigger contagion (Ma-Kellams et al., 2018; Hawton et al., 2020). Although the contagion model analogizes suicide contagion to virus transmission without emphasizing human psychological complexity and agency, it inspires scholars to construct suicide contagion risk assessment models by analyzing transmission modes, virulence, susceptibility, and dose, and to develop corresponding "isolation strategies" and "immunity enhancement strategies." These strategies aim to protect vulnerable populations while avoiding excessive information restriction, reducing direct exposure among high-risk groups, and guiding relevant departments to deploy prevention resources promptly after suicide incidents.

SIT and SCT place greater emphasis on internal psychological processes and both focus on the key role of "identification" with the deceased in suicide contagion. SIT originates from sociological research on group culture and meaning-making, positing that human behavior is not mechanical but accompanied by processes of interpretation, understanding, and meaning-making. These processes are built upon symbolic systems and are easily influenced by social interaction and cultural environments (Abrutyn et al., 2020). People communicate and disseminate suicide behavior information through various symbolic systems, forming cultural scripts or meaning-making about suicide during group narrative processes (Abrutyn et al., 2020). For example, if media reports focus on depicting the deceased's emotional struggles, family difficulties, and post-suicide consequences, or construct suicide as a symbolic act of expressing extreme pain, despair, or anomie, these symbolic meanings may be processed and adopted by audiences, with some individuals identifying that the deceased achieved some form of "relief" and viewing suicide as a problem-solving method (Abrutyn et al., 2020). SIT can also jointly explain suicide contagion with social integration and regulation theory, positing that in closed communities (including online communities) with high social cohesion, symbolic transmission and cultural script formation occur faster and are more easily adopted by individuals (Hawton et al., 2020). Therefore, media professionals and clinicians should understand both mainstream cultural group narrative characteristics and sensitively grasp special symbolic systems in subcultural groups, guiding groups to avoid simplistic attribution of suicidal behavior to specific stressors or falling into romanticized or ritualized narrative patterns. They should also strive to construct positive cultural transmission paradigms—promoting cases of successfully coping with crises, positive help-seeking behaviors, and hopeful recovery prospects—to exert effective socio-psychological protective effects.

SCT focuses on cognitive processes, emphasizing that behavior, individual factors, and environmental factors interact to jointly influence individuals' social cognition and behavioral learning. Individuals initiate and maintain new behaviors not only through observational learning reinforced by outcomes but also by forming internal cognitive models through symbolic representation to recall, interpret, and even predict behavioral outcomes (Bandura, 2009). Embodied simulation and abstract inferences are two main pathways of social cognition. The former involves automatically representing others' emotions and behaviors through the mirror neuron system to understand others, while the latter involves actively constructing theory of mind (ToM) about others from observation, reasoning, and instruction to explain or predict others' mental states and behavioral patterns (Alcalá-López et al., 2019). When individuals experience suicide exposure, they may automatically activate the brain's mirror neuron system, producing unconscious "mirror reactions" that allow observers to personally experience the deceased's mental and behavioral states, or activate abstract reasoning systems, enabling individuals to make cognitive inferences and interpretations about the deceased's intentions, motivations, and suicidal behavior, and to evaluate the feasibility of suicide as a problem-solving method. Social cognitive processes are influenced by individual factors. If suicide-exposed individuals have deficits in mentalization ability, they will have difficulty distinguishing self and others' mental states (self-other distinction, SOD) (Luyten et al., 2020). They may be unable to effectively regulate embodied experiences generated by the mirror neuron system, producing pathological identification with the deceased, or project their own mental states onto the deceased, producing projective identification, leading to excessive emotional reactions or imitation of suicidal behavior (Haw et al., 2013; Gauld et al., 2019) (see Figure 1 [FIGURE:1]). Studies provide evidence for the role of identification in suicide contagion: Hong et al. (2019) found that young people who experienced increased negative emotions while watching a suicide-themed web series were more likely to identify with the suicidal protagonist and believe the series increased their own suicide risk; Till et al. (2015) used an experimental method of watching suicide films and found that individuals who identified with the protagonist and had higher baseline suicide risk perceived the protagonist as more attractive, realistic, and relevant to their own lives, and reported stronger suicidal ideation after watching the film. In summary, suicide contagion is not simple behavioral imitation but a complex process involving neural, cognitive, emotional, and social levels. Although the SCT theoretical framework is relatively abstract and empirical research on core variables such as symbolic representation, embodied simulation, mentalization, self-other distinction, identification, and empathic responses is still insufficient, it has important implications for preventing suicide contagion. Researchers can start with cognitive intervention by adjusting suicide-exposed individuals' cognitive reasoning and belief systems about suicidal behavior and enhancing their mentalization abilities related to self-other distinction to reduce risks of maladaptive identification and decrease chances of emotional and suicide contagion.

Figure 1 Suicide Contagion Mechanism Based on Social Cognitive Theory and Mentalization Ability

Additionally, some scholars explain suicide contagion using IPTS and IMV theories. Both posit that suicide exposure plays an important role in individuals' transition from suicidal ideation to action. Suicide exposure can increase the accessibility of suicidal ideation, suicide capability (reduced fear of death, increased fearlessness about death), and change attitudes toward suicide (such as viewing suicide as inevitable, unpreventable, or optional) (Ma-Kellams et al., 2018; Soberay et al., 2021; Lee et al., 2022). IPTS and IMV also view suicide-related mental imagery as a factor in the ideation-to-action transition. Suicide exposure can trigger individuals to develop approach-oriented mental imagery about suicide, such as intrusive images causing mental dyscontrol, cognitive flashbacks of suicide as a solution, images of unfulfilled ideals, and imagination of suicide processes and outcomes, thereby activating and intensifying trapped experiences in high-distress individuals and aggravating thwarted belongingness or perceived burdensomeness (Nilsson et al., 2023). Individuals with mental disorders or suicide risk process suicide exposure information more deeply, projecting themselves into the deceased's story情境 through imaginative involvement. This process also strengthens suicidal ideation, even romanticizing suicide and reducing fear of death perception, accelerating the transition from ideation to action (Liu, Huang, et al., 2020). This again demonstrates that suicide contagion results from the interaction between individual vulnerability and environmental factors, requiring multi-dimensional defense networks formed through cognitive intervention, social support, and environmental regulation.

The above theoretical explanations of suicide contagion mechanisms have cross-population and cross-situational applicability, capable of explaining suicide contagion phenomena in different populations and exposure types, and providing important conceptual frameworks and practical foundations for understanding suicide contagion processes and postvention. Future researchers can deepen theoretical verification from multiple aspects: for the contagion model, examine individual susceptibility factors, differences in harm between direct and indirect exposure, virulence of different suicide incidents, and dose dependency issues; for SIT, use natural language processing techniques to analyze meaning-making processes and transmission trajectories of suicide-related symbols in subcultural groups; for SCT, find proxy indicators for core variables such as cognitive reasoning, embodied simulation, and mentalization, compare differences between vulnerable and non-vulnerable groups, or use neuroimaging techniques to monitor associations between mirror neuron system response characteristics and psychological reactions in suicide-exposed individuals. Additionally, collecting psychological reaction processes and narrative materials from exposed individuals through qualitative research can provide bases for integrating various theoretical mechanisms and constructing a more comprehensive theoretical system of suicide contagion mechanisms.

4 Postvention for Suicide Exposure

Shneidman first coined the term "postvention," emphasizing the importance of supporting and intervening with suicide-bereaved individuals and viewing postvention as a direct form of preventing future suicide (cited in Bell & Westoby, 2022). As defined by Andriessen, Krysinska, and Hill et al. (2019), postvention is "activities developed for suicide-bereaved individuals by or with suicide-bereaved individuals, aimed at promoting recovery after suicide and preventing adverse outcomes including suicidal behavior." In recent years, expanding postvention to include all individuals affected by suicide exposure has become a basic consensus. Cook et al. (2015) pointed out that postvention objects should be expanded, providing a more comprehensive definition of postvention as "organized responses after suicide incidents that promote healing from grief and pain, alleviate other negative impacts on suicide-exposed individuals, and prevent suicide among high-risk groups after exposure in a comprehensive, balanced, and effective manner." However, current postvention practice still focuses on suicide-bereaved individuals, with postvention for numerous suicide-exposed individuals difficult to implement, insufficient to alleviate the wide-ranging negative impacts triggered by suicide incidents.

4.1 Postvention for Suicide-Bereaved Individuals

Current intervention methods for suicide-bereaved individuals mainly include individual intervention, peer support groups, group intervention, community intervention, and online resource use, with slightly more detailed discussion of peer support groups, group intervention, and community intervention.

Individual intervention refers to counseling and psychotherapy. Jordan (2020) noted that psychological intervention for suicide-bereaved individuals should focus on alleviating trauma, integrating loss, and reconciling with the suicide experience as core goals, including restoring safety and control, repairing cognitive and belief systems, constructing psychological buffering space, enhancing social regulation abilities, repairing connections with the deceased, reconstructing narratives of the deceased's life, and regaining life meaning. Therapists need to provide stable supportive relationships and positive psychoeducation to help suicide-bereaved individuals rationally understand suicide causes and accept their own psychological pain, thereby promoting adaptive coping. Drawing on cognitive grief therapy for other bereaved individuals to provide 16-week structured treatment for suicide-bereaved individuals can also improve medication adherence and reduce suicidal ideation and PGD symptoms (Zisook et al., 2018). Individual intervention can specifically address trauma and grief symptoms and is very necessary for long-term suicide-bereaved individuals, who should be encouraged to actively seek help. Clinical psychologists should receive systematic specialized training in suicide bereavement treatment before providing services.

Peer support groups developed early and have been most discussed, initially initiated autonomously by suicide-bereaved individuals, usually as open rolling groups where members achieve mutual help through experience sharing, coping strategy learning, psychoeducation, and emotional support. This is an intermediate form between non-professional and professional helping. Its main advantage is that homogeneous experiences among members can effectively alleviate suicide-bereaved individuals' isolation and stigma perception (O’Connell et al., 2024). However, non-professional leaders may lack clinical training to properly handle crisis situations, potentially causing excessive focus on traumatic experiences within the group and over-activating suicide-bereaved individuals' emotions (Westerlund, 2020). Bartone et al. (2018) noted that effective peer support programs need to meet basic requirements such as accessibility, confidentiality, and professionalism, establish collaborative mechanisms with professional institutions, strictly screen and train leaders, and provide continuous supervision for leaders. Optimized peer support groups are usually led by trained suicide-bereaved individuals alone or together with MHP professionals (McIntosh, 2017; Ali & Lucock, 2020), conducted in semi-structured ways (Griffin et al., 2022). Although participants report that peer support groups help understand and cope with psychological pain and obtain emotional support and resource information, individual differences among members may weaken the universality of homogeneous support, limiting benefits for some participants (Ali & Lucock, 2020). In contrast, group interventions led by MHPs, while similar in form to peer support groups, have higher safety and more diverse intervention methods. Examples include CBT-oriented psychoeducational groups (Berardelli et al., 2020) and online groups (Wagner et al., 2022), mindfulness weekend retreats for adults (Scocco et al., 2022), weekend grief support camps for children and adolescents bereaved by parental suicide (Krysinska et al., 2024), and art group interventions (Strouse et al., 2021), all showing significant intervention effects. Group interventions are usually based on structured or semi-structured protocols that systematically explain typical reactions to suicide bereavement, grief processes, and suicide behavior mechanisms, using psychoeducation, reading and writing, art creation, physical exercises, and mindfulness training to strengthen group emotional connections, promote individual emotional expression and narrative reconstruction, thereby alleviating suicide-bereaved individuals' psychological pain. However, criteria for applicable objects for these two types of interventions are not yet clear and require future research clarification. Additionally, online support groups, memorial websites, or forums initiated autonomously by suicide-bereaved individuals, and online resources provided by non-profit organizations can serve as extensions of traditional peer support groups and group interventions. Their advantage is providing freer discussion spaces and improving mental health satisfaction for some participants (Carlon et al., 2025), but unsupervised online interactions may exacerbate rumination tendencies in some individuals (Westerlund, 2020). Suicide-bereaved individuals should use online support communities cautiously, preferably in conjunction with offline professional interventions.

Community intervention is represented by active outreach support, which involves volunteers (suicide-bereaved individuals, MHPs, first responders, etc.) providing supportive assistance at suicide scenes or conducting home/phone visits to offer practical help, resource information, and referral services to suicide-bereaved individuals (McIntosh et al., 2017). Representative programs include the Local Outreach to Suicide Survivors (LOSS) in the United States (Abbate et al., 2022), the national StandBy postvention service in Australia (Maple et al., 2019), and the Primary Care Navigator Model (Hill et al., 2022). Their core value lies in immediate response and proactive contact with suicide-bereaved individuals after incidents, establishing psychological service linkage mechanisms and implementing rapid referrals. This can overcome barriers of traditional psychological interventions such as geographic limitations, stigma, and insufficient help-seeking motivation, moving the intervention window forward. Evidence indeed shows that active outreach services can effectively shorten the time interval between suicide exposure and help-seeking for suicide-bereaved individuals (Abbate et al., 2022), with service recipients showing significantly lower suicide risk, social support deficits, and loneliness than non-recipients (Gehrmann et al., 2020). However, such interventions require inter-agency cooperation and high demands for policy support and human/material resources.

Recent reviews and meta-analyses indicate that intervention studies for suicide-bereaved individuals show obvious heterogeneity in intervention methods, participant screening, control group settings, and outcome measurement, making it difficult to integrate findings across studies (Ramamurthy et al., 2025). Some evidence supports that the above intervention methods can effectively alleviate trauma/grief symptoms, psychological pain, and suicidal ideation in suicide-bereaved individuals, with the most effective mechanism being helping them establish supportive connections and obtain understanding and belonging in empathic community environments (Andriessen, Krysinska, Hill, et al., 2019; Gehrmann et al., 2020; Abbate et al., 2022). Psychological support for suicide-bereaved individuals also shows good cost-effectiveness across socioeconomic indicators including healthcare, employment, mental health, and life expectancy (Comans et al., 2013). However, evidence for long-term efficacy of these interventions is insufficient, with participants' PTSD and PGD outcomes not significantly improved at follow-up (Andriessen, Krysinska, Hill, et al., 2019; Strouse et al., 2021). A key reason may be structural deficits in the professional service system for suicide-bereaved individuals: intervention resources provided by MHP professionals are scarce, evidence-based intervention protocols and practical training in postvention for MHPs are lacking, and many suicide-bereaved individuals report insufficient professional support due to lack of access channels (Ligier et al., 2020). Therefore, relevant experts and scholars need to accelerate research on evidence-based intervention methods, actively construct specialized service systems, develop professional training and supervision for suicide bereavement intervention, and strengthen technological innovation and digital transformation, using artificial intelligence-assisted diagnosis and treatment and mobile health intervention programs to provide scientific and accessible services for suicide-bereaved individuals.

4.2 Systematic Postvention Guidelines

To alleviate the negative impacts of suicide incidents on numerous suicide-exposed individuals, relevant departments or institutions should implement a series of intervention measures after suicide incidents to improve psychological distress among suicide-exposed individuals, prevent public mental health deterioration, and prevent suicide contagion. Some countries' and regions' professional associations or official mental health departments have issued "Suicide Postvention Guidelines" or "Suicide Cluster Response Frameworks" (collectively referred to as guidelines below) (Andriessen, Krysinska, Kõlves, et al., 2019; Palmer et al., 2018), calling for creation and maintenance of necessary resources, facilities, and service systems to effectively respond to suicide incidents and guide stakeholders to take organized and targeted intervention measures (Cook et al., 2015). Most guidelines focus on schools, residential communities, or specific workplaces (such as fire departments, psychiatric inpatient wards), with some specifically mentioning special populations such as ethnic minorities or sexual minorities (Gulliver et al., 2016; Beyraghi et al., 2023; Andriessen, Krysinska, Kõlves, et al., 2019; Ramamurthy et al., 2025), emphasizing multi-stakeholder collaboration (Hill & Robinson, 2022).

Most guidelines are developed based on crisis intervention models and expert consensus, focusing on immediate intervention in the proximal timeframe after suicide incidents. Main contents include: establishing postvention teams and emergency plans, initial emergency response (confirming information, issuing announcements, coordinating resources), safe discussion of suicide (guiding media, family members, individuals, and groups to communicate and disseminate suicide information appropriately), supporting suicide-exposed individuals, preventing suicide contagion (screening high-risk/vulnerable populations, implementing crisis intervention), and other follow-up matters (recommendations on memorial activities, restoring order, long-term psychological assistance, and future suicide prevention education programs) (Aluri et al., 2023). Among these, psychological support strategies for suicide-exposed individuals can refer to the Public Health Model, providing corresponding interventions based on the degree of impact on suicide-exposed individuals (Andriessen, Krysinska, Kõlves, et al., 2019): providing informal social support and psychoeducation to all suicide-exposed individuals (Universal Strategies), providing individual counseling, group intervention, and mutual help groups to mildly affected individuals (Selective Strategies), and referring highly distressed and/or high mental disorder risk individuals to hospital psychiatric or psychotherapy institutions (Indicated Strategies) (see Figure 2 [FIGURE:2]). In postvention, it is crucial to attend to psychological pain in suicide-exposed individuals, break suicide topic taboos, encourage discussion of feelings, and use this as an opportunity to conduct suicide prevention education (Mueller & Abrutyn, 2024). Suicide cluster response frameworks also focus on routine monitoring of suicide deaths and attempts and cluster detection for timely warning and intervention (Hill & Robinson, 2022).

Figure 2 Public Health Model for Suicide Postvention

Existing guidelines provide important guiding frameworks for postvention practice, covering comprehensive intervention systems from individual to community levels. However, only a few studies have reported on practice effects: a community in Hong Kong that implemented systematic postvention programs for five years showed significantly decreased suicide rates (three control communities showed no such trend) (Lai et al., 2020); a school in South Korea that followed guidelines to implement postvention for five months showed significant decreases in PTSD, PGD, anxiety, and depressive symptoms among students in the trauma group (Cha et al., 2018); four schools in Slovenia also reported that guidelines helped improve schools' crisis response effectiveness, enabling rapid access to local mental health resources and effective, long-term professional support for affected students and parents (Podlogar et al., 2022). This limited but consistent evidence indicates that systematic postvention has good clinical value and practical significance, and stakeholders in all sectors should learn and implement postvention guidelines.

Of course, existing postvention guidelines also have many limitations. First, limited application scope: guidelines are primarily based on geographically concentrated settings such as schools and communities, focusing on preventing "point cluster" phenomena, with limited guidance for postvention in online media and certain online communities, and less attention to intervention for virtual exposure. Second, insufficient effectiveness evidence, with no evidence-based postvention guidelines established. Ideally, longitudinal data should be used to evaluate feasibility and effectiveness, but due to practical difficulties such as ethical approval, sample recruitment, and control group monitoring, research capturing and measuring the impact of postvention on rare phenomena like suicide contagion is costly and difficult to implement. There are also no research reports on the feasibility and effectiveness of specific measures such as issuing suicide announcements, safe discussion of suicide, and memorial activities. Third, multiple barriers exist between theoretical recommendations and practice transformation, including uneven resource allocation, professional talent shortages, and cultural stigma challenges. Guidelines mainly provide programmatic recommendations with limited descriptions of relevant training programs, specific operational methods, and tools (Williams et al., 2022). Most professionals or school psychologists mentioned in guidelines report lacking knowledge and skills in postvention and having received no relevant training (Tiatia-Seath et al., 2019; O’Neill et al., 2020). Some stakeholders who have implemented postvention programs report not knowing which department is responsible or leading, feeling difficulties and inexperience in identifying high-risk suicide-exposed individuals and monitoring and guiding public opinion, and shortages of MHP professional human resources also limit sustainable postvention activities (Hill & Robinson, 2022). More critically, many organizations do not understand or accept postvention, with some officials holding stigmatizing attitudes toward suicide, refusing to conduct postvention work, and avoiding initiating any suicide-related activities (Lai et al., 2020). Fourth, cultural applicability needs verification. Existing guidelines inadequately consider applicability to different ethnic groups and socio-economic-cultural backgrounds and require adaptation and validation in Eastern cultural contexts. Future research and practice need to focus on breaking through these systematic barriers, promoting inter-departmental collaboration, localized adaptation, and technological innovation, and gradually establishing sustainable postvention service systems.

5 Research Summary and Future Directions

Existing research on suicide exposure and its negative impacts and interventions responds to public psychological concerns but still has many limitations. First, research focus is biased toward suicide-bereaved individuals, with studies on negative impacts of suicide exposure and postvention methods and effects primarily focusing on relatives and friends of the deceased. Second, classification and identification of vulnerable populations are imprecise: although suicide-bereaved individuals, adolescents and young adults, individuals with mental disorders or suicide risk are known to be vulnerable, this is limited in identifying significantly affected individuals among broadly exposed populations. Third, empirical research on negative impact mechanisms is not in-depth: exploration of trauma/grief maintenance mechanisms for suicide-bereaved individuals is mostly limited to mediation or moderation analyses among few variables, while discussions of suicide contagion mechanisms remain at the level of empirical explanations or deductive speculation from traditional theories, lacking empirical analysis and verification of intrapersonal cognitive, emotional, and behavioral impact pathways. Fourth, the postvention system has obvious shortcomings: insufficient supply of specialized services for suicide-bereaved individuals, lack of research on intervention methods and effects for non-bereaved suicide-exposed individuals, and weak evidence bases for current postvention guidelines due to methodological limitations and practical constraints. Possible future research directions are as follows.

5.1 Expand Research Objects and Update Survey Tools

Future researchers urgently need to advance high-quality empirical exploration among non-bereaved suicide-exposed individuals, focusing on emotional, cognitive, and behavioral reactions and their temporal characteristics among vulnerable populations such as adolescents and young adults, individuals with mental disorders or suicide tendencies. Simultaneously, researchers should attach great importance to the negative impacts of suicide behavior information disseminated through social media, particularly the multiple harms caused by exponential diffusion and information iteration of suicide incidents by netizens to suicide-exposed individuals.

Additionally, suicide exposure is an individual's life experience rather than a psychological trait. Many studies use a simple question to ask respondents whether they know someone who has died by suicide (only assessing presence/absence of suicide exposure), with some studies only including samples exposed to suicidal behaviors within the past year. This cannot clarify differences in negative impacts between single and multiple exposures or different exposure types. The lack of standardized survey tools makes it difficult to compare and integrate results across studies. Future research needs to design more detailed suicide exposure questionnaires that quantify characteristics of suicide exposure by collecting information on timing, type, frequency, and relationship to the deceased, enabling high-quality cohort or longitudinal studies to explore impacts of different suicide exposure situations on different populations and their similarities and differences. In quantitative research on negative impacts of suicide exposure, scholars should also change the current practice of using only traditional psychological indicators (PTSD, PGD, depression, anxiety, suicidal ideation and behavior) to assess impacts. Future research needs to add qualitative or phenomenological methods to comprehensively capture complex psychological reactions after suicide exposure, to develop negative impact scales for suicide exposure or select more specific measurement tools to assess dimensions and degrees of negative impacts, laying a solid foundation for subsequent identification and classification of at-risk populations.

5.2 Identify Vulnerable Populations and Strengthen Mechanism Research

First, emphasize classification and screening of suicide-exposed individuals. Future researchers need to conduct large-scale cross-sectional and longitudinal surveys based on comprehensive mastery of complex psychological reaction measurement indicators for suicide-exposed individuals, using latent profile analysis, taxometric analysis, or transition analysis to explore categories and classification bases for mildly versus severely affected individuals. Second, researchers can attempt to use network analysis, machine learning, and other methods to analyze predictive effects of demographic variables, psychological characteristics, and suicide exposure features on negative impacts, identifying protective and risk factors, their relational pathways, and key nodes, and selecting key variables with good predictive efficacy to build risk stratification models for suicide contagion. For online suicide exposure, researchers can also use natural language processing techniques to conduct in-depth analysis of relevant individuals' online verbal information to identify internal cognitive patterns, emotional states, and explicit behavioral tendency characteristics, thereby screening high-risk populations for suicide contagion and providing bases for subsequent personalized postvention measures.

Second, strengthen mechanism research to identify intervention targets. Other factors causing meaning-making and responsibility attribution dilemmas in suicide-bereaved individuals, such as relationship rupture with the deceased, family conflict or suicide communication taboos, and excessive family cohesion, may all hinder recovery from trauma/grief (Jordan, 2020; Chen, 2023). Future researchers can explore impacts of these variables on psychological pain in suicide-bereaved individuals. Regarding suicide contagion, on one hand, researchers can use qualitative research to interview individuals with suicidal ideation or behavior to explore processes of how suicide exposure affects their emotional reactions and suicidal ideation/behavior, identifying key variables triggering emotional or suicide contagion for theoretical integration. On the other hand, quantitative research using cohort studies, controlled trials, and cognitive neuroscience methods is needed to verify emotional and suicide contagion mechanisms based on SCT, SIT, IPTS, and IMV frameworks, examining key roles of group meaning-making, social cognition, suicide capability, and suicide mental imagery between suicide exposure and negative impacts, thereby identifying intervention targets. For example, researchers can design multi-version experimental materials on group attribution of suicidal behavior, implement reading interventions for suicide-exposed individuals, and then examine between-group differences in participants' attribution methods for others' suicidal behavior to verify impacts of group meaning-making on suicide-exposed individuals. Alternatively, questionnaire surveys can test the mechanism path of "mentalization deficits → pathological identification/projective identification → emotional contagion/suicide contagion" to assess the potential value of enhancing suicide-exposed individuals' mentalization abilities in blocking emotional and suicide contagion chains.

5.3 Strengthen Postvention Research and Build Evidence-Based Guidelines

Relevant experts and scholars should emphasize practice and effectiveness testing of suicide bereavement interventions to compensate for shortcomings in specialized intervention provision. Tang et al.'s (2025) meta-analysis found that CBT-oriented online interventions for general suicide-bereaved individuals have good effects, with better outcomes for interventions with more than 10 sessions and therapeutic feedback. Online acceptance and commitment therapy (ACT) intervention programs also show positive prospects for improving bereavement symptoms (Willi et al., 2024). Future researchers can design online intervention programs based on CBT, ACT, mindfulness, or narrative therapies to provide more accessible psychological services for suicide-bereaved individuals. Intervention programs should also highly align with the intertwined trauma and grief symptoms in suicide-bereaved individuals' despondent predicament, focusing on addressing negative cognitions and emotions such as guilt, blame, and shame, and meaning-making dilemmas, and embedding PTSD, PGD, or other outcome measurement indicators with formal effectiveness feedback as part of the intervention (She et al., 2021). For long-term suicide-bereaved individuals, therapists should also intervene in other risk factors maintaining trauma/grief symptoms, such as exploring individual treatment plans for improving family relationships or conflicts and their effectiveness, or providing psychological support for their families (such as CBT-oriented family psychoeducation) or even family therapy.

For suicide-exposed individuals in schools or communities, relevant experts and scholars should follow the three-tier framework of the public health model to develop and test differential intervention programs for different risk levels. For example, at the universal intervention level, psychoeducation content should be designed with core goals of improving suicide prevention literacy and mental health literacy, using reading interventions, online or offline courses to help suicide-exposed individuals understand suicidal behavior and their own reactions, reduce suicide stigma, and enhance knowledge and awareness of psychological helping and self-help. At the selective intervention level, group interventions or self-help programs should be designed with core goals of alleviating negative cognitions and reducing emotional contagion, helping suicide-exposed individuals confront their negative cognitive and emotional reactions, learn coping skills, and improve mentalization abilities centered on self-other distinction. At the indicated intervention level, the goal is to improve clinical symptoms and prevent suicide contagion among high-risk individuals, with relevant workers actively conducting crisis interventions such as referring high-risk individuals and coordinating family and community resources for practical support. In effectiveness research, researchers should adopt experimental or quasi-experimental methods as much as possible, corresponding intervention goals with "core outcome indicator sets" to improve result reliability and comparability. For other components of postvention guidelines, such as recommendations on issuing suicide incident announcements, safe discussion of suicide, and conducting memorial activities, research should also be conducted to understand psychological needs of suicide-exposed individuals and balance contradictions between satisfying public psychological needs and excessive exposure. In summary, evidence-based postvention guidelines should clarify which measures are appropriate and effective for which suicide-exposed individuals and for which improvement goals.

For online suicide exposure or virtual exposure, universal intervention should be dominant, with research on online psychoeducation. For example, in social media interventions, pushing psychoeducation content to online communities can help guide users to safely discuss suicide topics and promote supportive behaviors among them. The Chatsafe project developed by Robinson's team is a positive attempt in this direction (La Sala et al., 2023). Additionally, professional scholars should advise social media platforms to improve content review mechanisms, optimize recommendation algorithms and ethical standards, reduce suicide information推送 for vulnerable users, and increase推送 of mental health service resources and positive information.

5.4 Reduce Intervention and Help-Seeking Barriers and Conduct Localized Intervention Practice

Due to lack of corresponding theories, policies, and professional guidance, shortages of MHP professionals, and insufficient postvention competency, postvention practice in mainland China is very weak. Moreover, traditional Chinese "suicide stigma" and "death taboo" are also key factors hindering establishment of specialized postvention systems and help-seeking by suicide-exposed individuals. Suicide incidents cause loss of group "face," and families or schools of the deceased may choose to conceal suicide incidents due to fear of affecting family/school reputation (Zou et al., 2022), with some communities refusing any postvention practice (Lai et al., 2020). At the individual level, most suicide-bereaved individuals, particularly men, choose to hide grief and avoid mentioning suicide incidents due to family care responsibilities and grief communication taboos (Li et al., 2024; Chan & Cheung, 2022), and deliberately distance themselves from others, becoming "invisible groups" (Chan & Cheung, 2022). Those suicide-exposed individuals who resonate with the deceased or view them as similar also feel hurt or develop self-doubt due to media or others' negative evaluations and alienation of the deceased (Lai et al., 2021; Zou et al., 2022), and have concerns about help-seeking.

Therefore, the primary future task is to strengthen MHP professional training by incorporating basic knowledge and skills about suicide exposure, suicide contagion, and postvention into suicide prevention and crisis intervention courses in clinical and counseling psychology master's programs or MHP continuing education programs, to improve professionals' awareness of suicide exposure, vigilance for suicide contagion, and postvention competency. Second is to streamline postvention protocols and conduct postvention training and practice. Currently, Chinese government policy support for school mental health education is increasing, providing favorable conditions for conducting school postvention training and practice. However, postvention protocols should still be streamlined to reduce implementation difficulty and resistance, focusing mainly on issuing suicide announcements and safe discussion initiatives, implementing the three-tier intervention framework, adapting to school class culture systems, training homeroom teachers or counselors for universal intervention, training psychological teachers for selective and indicated interventions, and reminding parents to monitor psychological changes in suicide-exposed students. Third is to continuously improve suicide stigma and death taboo in Chinese culture. Relevant experts and scholars should actively seek policy support and funding, conduct extensive public suicide prevention education campaigns and gatekeeper training to help the public understand suicide phenomena and causes, clarify the multi-factorial nature, treatability, and help-seeking effectiveness of suicidal behavior, improve public suicide prevention literacy and mental health literacy, reduce prejudice and discrimination against suicide decedents and bereaved individuals, and increase public acceptance of suicide research and intervention programs. Additionally, mainstream media can be advised to encourage affected suicide-exposed individuals to seek help while following suicide reporting guidelines when covering suicide incidents.

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