Repercussions of homicide on victims ’ families : a literature review

1 Escola Nacional de Saúde Pública Sergio Arouca, Fiocruz. R. Leopoldo Bulhões 1480, Bonsucesso. 21041-210 Rio de Janeiro Brasil. daniellaharth@gmail.com 2 Departamento de Estudos sobre Violência e Saúde Jorge Careli/Claves, Escola Nacional de Saúde Pública, Fiocruz. Rio de Janeiro RJ Brasil. 3 Departamento de Medicina Integral Familiar e Comunitária, Universidade do Estado do Rio de Janeiro. Rio de Janeiro RJ Brasil. Repercussões do homicídio em famílias das vítimas: uma revisão da literatura


Introduction
Due to its irreparable character and the fact that it leads to complete denial of rights, murder appears as the violent event of more serious human and social consequences 1 and indicates the extreme limit of aggressive and destructive potential of human beings 2 .It is estimated that some 64,357 people have been homicide victims in Brazil in 2012, leading the country to stand at 11 th in the world lethal violence ranking among 133 countries analyzed 3 .Brazil ranks third in South America, behind Venezuela and Colombia 4 .The high homicide rate in Brazil (22.7 / 100,000 inhabitants), three times higher than the world average (6.9 / 100,000 inhabitants), signals the importance of research on this serious situation that affects the lives of Brazilians at four different levels 4 .
Homicides are a matter of concern not only for the daily lives lost, but also to people close to the victims who are deeply affected by the traumatic loss.It is estimated that each murder affects the lives of about 7 to 10 family members, not to mention friends, neighbors and co-workers 5 , that is, a significant number of people facing one of the most devastating faces of violence.
Studies on this issue labeled homicide victims' relatives as homicide survivors 6 .This term may sound, however, a contradiction.In fact, homicide victims do not survive.However, it is considered that every murder produces two categories of victims: those directly murdered and associated or "secondary" victims, as they are also known.These include family, friends and close people, i.e. the survivors.Unlike direct homicide victims who are easily identified and recorded by statistics, their family and friends remain unknown, with little or no support to their needs and truly outcast in many contexts 7 .
Death by homicide includes, in most cases, some specific aspects: violence used, sudden, abrupt loss of life and, in the case of murder of children and youth, premature death.This tragic combination of factors influences, in particular, family's responses to loss and may even have a negative impact on relatives' health 8 .
Violence, including homicide, appears as a social issue, but becomes a public health problem as the need to receive individual and collective health problems caused by violent events is directed to this sector 9 .This concept maintains the relevance of a study that points homicide's consequences for the victims' families.The main objective of this paper is to review literature on the subject and gather findings that contribute to a perspective more sensitive to the needs of homicide survivors.

Methodology
An integrative literature review was conducted, as it is a broad methodological approach that allows the inclusion of theoretical and empirical studies, enabling a complete overview of a particular subject.This is a valuable method in health, it can guide practice and reveal knowledge gaps to be filled by future studies 10,11 .
Regarding the survey of scientific studies, a search was done in 2015 in the following databases: Scopus, PubMed and Lilacs.It was found that a significant literature was not located in such bases, thus search was performed through Google Scholar as a complementary tool.A search key was built from both the terms of the respective bases' controlled terms and free terms in order to increase search sensitivity.Keywords used were terms such as "homicide", "family", "impact", "effects", "resonance", "homicide survivors", "secondary victims", "indirect victims" and their English and Spanish equivalents.Search included papers, books, book chapters, dissertations and textbooks in Portuguese, English and Spanish in the 1990-June 2015 period, and a language filter was applied for Portuguese, English and Spanish.
The key used returned 1,684 references, of which 38 were included in the review.Documents were selected by reading titles, abstracts and full texts (Figure 1).Quantitative, qualitative and empirical studies that addressed the impact of death by homicide on the victims' families were included in the review.Repeated documents and documents whose content did not address directly topics related to the purposes of the study, such as studies of parricide, femicide, suicide following homicide and genocide were excluded from the review, as were studies that were addressing violent deaths in general, without distinguishing them from each other.
Thirty-eight studies were selected and were compatible with the criteria and the purpose of the present study, 27 in English (71.1%), 10 in Portuguese (26.3%) and one in Spanish (2.6%).Regarding the format of documents, 32 were papers published in scientific journals (84.2%), two books (5.3%), two dissertations (5.3%), one book chapter (2.6%) and one textbook (2.6%).Most studies were conducted in the United States, totaling 24 works, 9 were conducted in Brazil and one each in Colombia, United Kingdom, Netherlands, Portugal and Canada.Documents were read in full and analyzed with qualitative reading based on content review references in the thematic mode 12 .A raw data encoding was performed from the careful exploration of the material, and results were processed and interpreted through thematic units.From this review, the central themes that best characterized what emerged in literature on the situation of homicide victims' relatives were: impact on health, the family system in the post-homicide period, re-victimization factors and post-homicide facilitating aspects.Chart 1 shows the distribution of references according to the selected themes.

Impacts on the health of homicide survivors
Psychology and psychiatry have produced most studies on the situation of individuals who have lost a loved one by homicide.Many of these studies have sought to understand and measure, from different approaches, the mental and physical impact of deaths by homicide in the lives of families, focusing mainly on traumatic reactions, from a disease model associated with the development of posttraumatic stress disorder (PTSD) and depression 7,8,[13][14][15][16][17][18][19][20][21]27 .
According to Soares et al. 22 , quoting Prigerson (1999), PTSD is a disorder triggered in response to an unexpected, irreversible and traumatic event generally identified by health and psychology professionals.Historically, PTSD has been studied in people who had directly experienced situations of violence (war soldiers, rape  victims, persons affected by human and natural disasters, among others).However, it is currently argued that even people who did not directly lived the violent event can experience symptoms of this disorder.This is the case of those affected by the violent loss of a close family member or friend 22 .A recent study 13 conducted with 47 participants who have lost a loved one by homicide in a US city showed a close relationship between homicide and onset of psychological problems.In this study, more than half of the participants evidenced criteria compatible with mental disorders.
The occurrence of post-traumatic stress disorder was also analyzed by Murphy et al. 16 in a longitudinal study on parents of young children who have suffered violent deaths.Parents were divided into three groups according to the type of violent death (suicide, homicide and accidents) and monitored for five years.Findings of this study reinforce the relationship between PTSD symptoms and loss of a loved one by homicide, even after a couple of years.The "homicide" group had the highest stress level and the lowest level of acceptance of death.Furthermore, Rheingold et al. 19 evaluated the consequences on the mental health of young Americans aged 12 to 17 years survivors of a homicide.It was found that teenagers who have lost someone close by that kind of death show more frequently symptoms that characterize PTSD and depression and even alcohol and other drugs abuse.
In a national study, Vieira et al. 23 also noted an increased use of alcohol, tobacco and even drugs by family members in an attempt to min-imize pain and suffering caused by the violent loss.This strategy, however, has proven to be very harmful to the extent that it affects the health and increases tension in the household.
Studies on PTSD prevalence in homicide victims' relatives are not common in the Brazilian context, only one study 22 developed in Rio de Janeiro was located.This study examined the impact of losses by violent deaths, including homicide, in the lives of those close to the victims.Regarding deaths by homicide, PTSD symptoms were noted in many of the participants.The study also found that the type of violent death is relevant, because loss by homicide tends to cause moderately intense reactions.
Authors 22 also point out that the effects of these violent deaths can extrapolate kinship and friendship ties and affect the lives of people who did not even know the victim, mainly through the news channeled in the media.Soares et al. 22 suggest that, in Brazil, given the high level of violence in civil society, media reports and even police violence, there may be a higher incidence of PTSD symptoms in people who have not experienced violence either directly or indirectly through family and friends.
In addition to psychological effects, various emotional and behavioral reactions are shown in literature, such as feeling emptiness, weakness, despair, loneliness, loss of interest in life, anger, hatred, guilt, isolation, anxiety, fear, sadness and anguish 24,25 .
Dalbosco 24 found in his study that mothers of young homicide victims often show an apparent force, when in fact they conceal from the rest of the family their deep psychological distress.
In addition to the emotional shock, various health problems were observed in relatives of homicide victims.Literature indicates symptoms such as hypertension, diabetes, weight loss, obesity, anorexia, insomnia, memory loss, stress, phobias, thyroid disorders, gastric and cardiac problems and even simple physiological changes (such as tachycardia) 23,25,26 .Therefore, such serious health consequences severely affect the quality of life of those close to the victims.

Family system in the post-homicide period
In addition to the health issues that affect family members, the deleterious effects of homicide in the maintenance of family relationships also stand out.The family environment becomes a reason of discomfort and distress, since daily life brings out homicide memories.The anniversary dates of violent events and holidays can be particularly painful moments 22 .
Violent loss can impact the dynamics of family relations, contributing to the removal and weakening of family ties 25,28,29 .A study by Bussinger and Novo 25 highlights the experience of homicide victims mothers who, after the event, began to feel strange among people who have always been close and intimate, leaving them isolated and with a feeling of loneliness.A decreased work performance and lack of interest in leisure time was also observed.
Financial and economic problems can also occur as a result of violent death, especially if the victim has been an important family income provider.As suggested by Soares et al. 22 , even spending on bureaucracy, removal, burial and rituals affect the budget of poor families and can often cause internal strife in the family.These financial issues may force the family to restructure, leading to a redistribution of family roles.
Children and adolescents are also affected and may evidence particular responses to loss.Clements and Burgess 27 conducted a study with 13 children between 9 and 11 years old.Data indicated that children used to display a sense of fear founded on the idea that other family members and even they themselves could be targets of the homicide perpetrator.They also described that they felt invisible amid the familiar chaos that occurs after the homicide and find it hard to keep school routine.
Hertz et al. 7 mention a study conducted by Freeman (1998), in which children and adolescents (between 7 and 19 years old), siblings of homicide victims were heard.It was found that they avoided sharing with adult family members their suffering in an attempt to spare them additional concern.
National studies 23,24 have found that adolescents tend to be more nervous and restless before the loss by homicide situation, with a behavior that varies between fear and courage, experienced in an exacerbated way before borderline situations.Dalbosco 24 says that teenage family members deal with suffering with an impulse to act and take action, resulting in violent behaviors driven by the desire for revenge, quest for justice and suffering relief.Denderen et al. 15 studied the families of homicide victims in the Netherlands and found that young people showed significantly more desire for retaliation against the homicide perpetrator than adults and the elderly.Based on Ehlers and Clark (2000), authors 15 argue that the desire for revenge can block the grieving process and hinder the acceptance of death, keeping them focused on the reasons for the loss and punishment deserved by the murderer.This personal approach contributes to the development of a climate of constant tension in the household.

Re-victimization factors in the family path
Factors such as violence, unpredictability and intentionality of death by homicide are the complicating factors of the grieving process 30 .In addition, factors such as homicide's social stigma, lack of a social support network and the relationship with the press and justice are known to intensify the emotional burden, increase the risk of developing PTSD and produce a situation of re-victimization of homicide secondary victims 8 .
Miller 31 noted that some homicide victim characteristics could exacerbate the suffering experienced by relatives and contribute to a complicated grief.As to these factors, the author highlighted the involvement with drugs, prostitution, domestic violence or other criminal activities and being part of groups marginalized by reasons of race or social class.
The social stigma encompassing death by homicide, especially in those cases where the victim carried a "risk behavior", is capable of producing in relatives a sense of isolation from others and deprives their right to live their mourning of the loss.Death by homicide in this context is understood as deserved and family suffering is overlooked because it is not worthy 8,27 .Thus, wellknown features of the victim's former life can exert strong influence on the community take in relation to this death, which results, especially, in weak social support offered to the victim's family 31 .
Moreover, Clements and Burgess 27 warrant that people's distancing may be unintentional.For example, where homicide occurred in situations of extreme violence and cruelty, people can have a profound inability to get to know what to say and how to approach the victim's family.Domingues and Dessen 29 highlight the community as an indispensable source of comfort to the family through its network of social support (school and community leaders, neighbors, health care system, media and church, among others).However, when this network fails to promote support, it ultimately weakens the already very vulnerable family system.
The literature analyzed also gives special attention to the justice criminal system as an important factor of re-victimization in the family's grieving process 8,24,30,[32][33][34][35][36] .Family complain about the lack of empathy and compassion demonstrated by police and other justice professionals, the lack of information about the process and dissatisfaction with the sentence 33,36 .Asaro 8 says that, because it is a long and exhaustive process, the investigation and prosecution of homicide can generate anger, frustration and emotional stress in relatives.
The adversarial relationship between justice and the family of a homicide victim is described by Bussinger and Novo 25 from the viewpoint of impunity.In a study on social representations of justice by Brazilian mothers of murdered children, the author 25 pointed to a strong distrust vis-à-vis the legal justice system.In the specific case of this study, all mothers had managed to prove in court the suitability of their children, who shared the fact that they were killed by police in little clarified circumstances.The author establishes a relationship between feelings of distress and humiliation, constantly experienced by these mothers with regard to the judiciary and of incomprehension before death as driving factors of the idea of "an eye for an eye, a tooth for a tooth" justice, that is, the "law of retaliation", revenge and sentences' equivalence.
Dalbosco 24 believes that the legal system's non-performance of its expected functions just gives way to personal revenge, which becomes an alternative.In addition, justice's low effectiveness lead families to find in the "divine" the possibility of an inscribed comfort, especially the idea of "God's righteousness", which, as per popular saying, "is slow but does not fail".Bussinger and Novo 25 believes that, while mothers distance themselves from justice in terms of concrete actions, they get closer to an abstract realm marked by a belief in justice's "divine action".
In addition, Baliko and Tuck 30 state that feelings of anger and dissatisfaction described by families because of the legal system's inefficiency can hinder the family's process of "giving a meaning" to death.While hearing homicide survivors in the UK, Malone 34 found that lack of information and insensitive communication are two important sources of complaint against the criminal justice system.The author 34 explains that the experience of these people is crossed by the investigation and justice agencies since the news of the death, the victim's identification and, finally, the questions raised in the crime investigation process.This entire process feeds families and friends of victims with high expectations about the homicide trial, in which it is believed that, when identified, the perpetrator will receive a long prison sentence and that this will bring some sense of closure, that is, closing on the lived experience of loss and a sense that justice has been done.However, since it identifies the author, the conclusion of the case can result in the most intense and overwhelming sense of anger and suffering, and it is exactly at this point that the sources of support tend to withdraw themselves, leaving the victim's family and friends more helpless.
Much in the same way as justice, the media is portrayed as a source of stress to relatives.Alarcão et al. 37 believe that relationship between death and publicity trails two paths: media can be an ally of homicide survivors in search for justice and, from another perspective, can invade privacy.Interest in audience levels makes the press give the loss a public dimension, which can easily produce death dehumanization and trivialize families' suffering.The lack of sensitivity that permeates most sensationalist materials overshadows press' role to inform and gives way to its tendency to turn tragic deaths into news.Families may also feel overly violated and exposed by media speculation.The way the victim is represented by the press may be distorted, as may be the circumstances leading to the murder.As a result, families feel they lost control of their own truth about the victim 33 .
Asaro 8 describes that relatives are often so fragile and vulnerable that they do not realize that they have the right to refuse press intervention.However, with or without authorization, family members may have to deal with the face of their loved one printed in the media when the event is an important fact for the community or the country.This media procedure plays an important role in stirring families' suffering.
Parappully et al. 38 found that some homicide survivors can achieve a positive transformation in the face of traumatic loss.So they listed a number of factors they believe are linked to overcoming the loss, such as, for example, personal characteristics of determination, leadership, positive attitude, compassion and easy expression of feelings; self-care practices, such as making pleasurable activities; attachment to spirituality; positive overcoming of previous traumas; support from family and friends, as well as the community through support groups and psychotherapeutic treatment.
Armour 33 also emphasizes the role of sectors such as the media and the criminal justice system, primarily responsible for negatively influencing the way the family experiences post-homicide (as mentioned in previous topic), but, on taking a sensible and cohesive approach to embrace indirect murder victims, can stir more positive responses to loss.
Clinging to spirituality becomes important in studies on the topic when presented as one of the main strategies used by victims' families to cope with loss 28,37,38 .Alarcão et al. 37 believe that murder arouses victims relatives' intense feelings of incomprehension, injustice and revolt, which may often only be appeased in the spiritual realm, in which belief of a better world prevails, since the physical world is full of violence, disrespect, pain and suffering.
The way individuals experience death of a close person by homicide differs given the historical and contemporary complex human interactions based on socio-cultural influences.
From this concept, Sharpe and Boyas 39 highlight the issue of North American black population that is historically marked by slavery, oppression, discrimination and a number of socio-economic challenges, which are, in part, reproduced to this today.These authors state that, even with the overrepresentation of blacks in homicide-related death rates in the United States, little emphasis has been given to the experience of this population when faced with this kind of death, since, in general, Caucasians are the most contemplated by the investigations on this theme.
This discovery led authors 39 to develop a study in order to understand how the American black population deals with the loss of relatives by homicide.Findings point to a loss by murder coping pattern marked by spiritual attachment and the endeavor to give loss some meaning.There was also a significant relationship of solidarity among relatives while, at the same time, one could highlight the need to cover up feelings and emotions concerning the victim and the homicide event.It is worth noting that such behavioral patterns revealed by the study are associated by authors to historical and current contexts experienced by this population.
The mourning of a loved one by homicide is reported as usually experienced with a lot of intensity, more lasting and complex than the mourning for non-violent death, which indicates, in many cases, the need to seek assistance to try to minimize this situation 40 .In spite of this, only a small number of people end up being benefited by specialized arrangements to provide care to secondary victims of homicide 13 .
Whereas homicide generates a strong impact on the biopsychosocial realm of those indirectly affected 26 , some works 7,21,[40][41][42][43][44][45][46][47] have discussed and presented subsidies and intervention models for the reception, monitoring and management of therapy that have shown positive results in response to the consequences of this traumatic loss, and they are: crisis intervention, drug therapy, group support, family therapy, individual therapy and even restorative justice.Tuck et al. 42 mention Spungen (1998) when she states that group and family therapy can be especially useful in this circumstance, because people often experience stress in the family system and other social support networks.As for restorative justice, Tuck et al. 42 refer to a study by Umbreit and Vos  (2000) which concluded that the mediated dialogue between the homicide victim's family and the perpetrator may lead the family to experience a sense of relief and lightness immediately after the meeting, although some questions about the homicide remain.
National activities 24,29,37,48 emphasize the incipient offer of specialized facilities to receive and monitor this audience, considering the health, justice and financial needs.They also emphasize the lack of priority by government institutions in relation to the population affected by criminal acts.Schilling 48 affirms that treatment for the indirect victims of violence, especially fatal crimes victims' families, is a huge challenge, as it requires taking into account a broader understanding of victimization caused by violence, that is, the understanding that the violent event generates repercussions in a group of very large people, producing indirect and diffuse effects.Discussion about death by murder leads to a reflection on the concept of the right to life, which Schilling 48 justified from the design of the Universal Human Rights, in the Declaration of the Rights of Man (1978) and the Universal Declaration of Human Rights (UN, 1948) who claim to every human being the right to life, liberty and personal safety.

Final considerations
As pointed out by Soares et al. 22 , research is not conducted in a cognitive vacuum; it does not start from scratch.There is a legacy of other studies, theorists, thinkers, writers and ordinary people that we need to address.From this statement, this study sought to conduct a literature review, presenting state of the art studies on homicide victims' families.This is the first ever review on the subject in Portuguese and, since it gathers a significant range of national and international studies, it can serve as an important source of information for the development of future research.Anyway, the main objective of this study is to stir a debate on the situation of homicide victims' families.
In the field of Brazilian studies on homicide, numbers and charts have been emphasized as the situation of victims' families remains, in many cases, left in the dark.Gradually, national studies are beginning to emerge, although they are still far from representing a significant number of productions.
Despite efforts to locate works produced in developing countries, whose structural characteristics of the society are close, at least in part, to the Brazilian context, only one Colombian paper has been identified.It is understood that international research can and should be used as a way to fill some of the persisting gaps in the Brazilian academic scenario, although one must be careful to analyze them critically by considering their original context.
The analysis of the selected works shows that homicide violence transcends the victim it directly produces, because it can profoundly affect the quality of life of those in their surroundings.In this scenario, the family figure is highlighted by observing that relatives are those who suffer most directly the consequences of this traumatic loss.While victim's suffering ends with homicide, it is just the beginning of a long, painful journey for families 7 .
Impacts on physical and mental health of family members are strongly outlined in literature, pointing to the need for greater involvement of the health sector, particularly in the context of public health.As pointed out by Walsh and Mc-Goldrick 49 , deaths, such as homicide, which disproportionately affects the poorest regions can traumatize an entire community.
Special attention must be given to re-victimization factors that cross the families' grieving process.While awaiting support and care, many families end up bumping into situations of neglect, invisibility and professional unpreparedness.Re-victimization situations are even more common when the murder victim evidenced transgressing behaviors, which has a direct impact on the family.Thus, the analysis of works made it possible to glimpse the risk of perpetuating concepts embedded in the social imaginary, especially those that disqualify the value of life lost before the family's legitimate suffering.
Finally, we wish to emphasize the need for an integrative look at these families and the development of strategies to receive them considering their multiple demands.We also stress the prioritization of training professionals that directly or indirectly deal with these families in their work institutions.Here, police, justice professionals, social workers and health professionals stand out, and even education professionals, since, as shown in literature, children and adolescents suffer the consequences of violent loss with significant impairments in their social and school life.

Collaborations
DH Costa participated in the stages of search and analysis of articles, article writing and critical review.K Njaine and M Schenker participated in the writing of the article, critical review and approval of the version to be published.

Figure 1 .
Figure 1.Flow of studies selected for integrative review.

Chart 1 .
References distribution by theme.