Indirect homicide victims: impacts, support received, and coping strategies Vítimas indiretas dos homicídios: impactos; apoio recebido e estratégias de superação

Brazil has recorded a high percentage of homicides and deaths due to legal intervention. This article is part of a qualitative multiple case study about indirect victims who lost relatives to homicide perpetraded by security agents and police officers in Rio de Janeiro. Data were collected in four individual interviews with family members of people killed by police officers and three family members of police officers who were victims of homicide, and then subjected to thematic analysis. The testimonies revealed the major impacts of the loss of a family member on the indirect victim’s health, such as intense mental suffering and the negative impacts on human occupations such as work, leisure, health care, and sleep. Institutional support is limited in the face of the traumatic experience, whereas activist groups and entities tied to human rights advocacy are of great help in overcoming the pain of loss, especially for those who have lost their family members to the police. Further research is needed about the gaps between public facilities and policies and the needs of indirect victims.


Introduction
Violence is a complex social phenomenon that varies over time and directly affects human life and health systems, since it demands resources from hospitals, emergency rooms, and outpatient clinics, in addition to harming people's quality of life, causing damage to the physical and mental health of direct and indirect victims, and influencing the rate of potential years of life lost.
Among the expressions of violence, homicide is one of the most brutal, as it denies the basic right to life.It is defined as the destruction of human life by a person who intended to kill or injure another (Souza;Pinto;Ribeiro, 2020).
Brazil has recorded high homicide rates.In 2018, there were a total of 57,956 homicide deaths, which represents 27.8 deaths per 100,000 inhabitants (Santiago;Nunes;Macena, 2021).Although there has been a significant reduction in homicide deaths in the country since 2017 (with great inter-and intra-regional disparities), there has been an increase in the average annual percentage variations in deaths due to legal intervention in almost all regions, from 2000 to 2019 (Santiago Nunes;Macena, 2021).Deaths cause by State agents are considered homicides in this article.
Many studies focus on homicide rates and the profile of the groups that are the agents and victims of these aggressions; however, research on the indirect victims of these daily tragedies in the country is less common.Indirect victims are the people, most often family members, related to the person who was killed.These people often experience serious psychological and physical harm (Hertz Prothrow-Stith;Chery, 2005) that needs to be made visible.
This article presents an excerpt from a broader comprehensive study entitled "Narrativas das vítimas indiretas: A voz de familiares de civis mortos por policiais e de policiais assassinados" (Narratives of indirect victims: The voice of family members of civilians killed by police officers and of murdered police officers), which focuses on the experiences of these people's family members, taking the city of Rio de Janeiro as the empirical field.The aim was to identify and describe the impact of the traumatic event on the lives of the indirect victims.However,
given the scope of the topic and the need for further theoretical and analytical development of some of the issues addressed in the mother study, in this article, we decided focus on the types of support received by the indirect victims after the loss of a family member and the strategies they adopted to overcome their pain and get on with their lives.
Thus, the general objective of this article is to identify and describe the impacts on the health and occupations of indirect victims after homicide, and thus analyze the support received by the victims' families from governmental (related to health, social assistance, justice, and public security) and non-governmental institutions; we also sought to understand what strategies were adopted by indirect victims to overcome the traumatic experience.

Material and methods
This is a qualitative case study, with an intentional sample, carried out in the city of Rio de Janeiro, historically marked by frequent conflicts between the police and the population, as well as between the police and criminal groups.
Individual interviews were carried out with four family members of people who were killed by police officers and three family members of police officers who were victims of homicides, with the criterion that the death had occurred at least two years before.This condition aimed to ensure distance from the violent event and, consequently, to reduce the emergence of more intense emotions in the interviewees.The interviews took place in the second half of 2019 and were interrupted in March 2020 due to the COVID-19 pandemic.All of the people interviewed were over 18.
The family members of homicide victims were accessed using the snowball technique, which is a useful method for researching groups that are difficult to access or study, or when there is no precision about their number.This method consists of a non-probabilistic sample that uses reference networks and referrals, useful for studying sensitive, private issues that therefore require the knowledge of people belonging to the target group or are recognized by them as informants for the study (Bockorni;Gomes, 2021;Vinuto, 2014).
The first step was to look for indications of people known to be participants/creators/organizers of associations that support police officer who were victims of violence and of social movements seeking justice for the deaths of family members by state security agents.Initially, these people were interviewed and referred to others who had gone through the same experience of loss, and so on in chains of reference.However, given the subject and the violent process experienced by these family members, it was difficult to get them to participate in the study.
The people who were invited claimed fear of retaliation, disbelief in institutions and the State, discouragement, and weariness at the painful and tiring process of seeking justice, and that they had already given interviews for other academic research.
Based on these arguments, the search for other informants was widened: health service professionals who cared for people with these experiences and filmmakers who had made films with these people's testimonies.Even so, some people who were referred refused to take part in the research, especially the family members of murdered police officers.
In qualitative research, data saturation is often used as a criterion for closing the sample, that is, "when no new elements are found and the addition of new information ceases to be necessary, since it does not alter the comprehension of the researched phenomenon" (Nascimento et al., 2018, p. 244;our translation). However, Fontanella et al. (2011) point out that there are difficulties in objectively verifying and explaining the saturation process, and state that, in non-probabilistic samples, the definition of saturation is based on the researcher's empirical experience, guided by theoretical knowledge about the object of study.
The researcher considers that there is empirical saturation when they see that they already have the data needed to answer their research questions; and that there is theoretical saturation when the field no longer provides new elements that help to deepen the theorizing (Fontanella et al., 2011).We believe that both criteria were met in this study.
The interviews were conducted by a trained researcher, digitally recorded, and transcribed, and they lasted an average of 90 minutes.Only one participant did not allow the recording, and the interview was recorded later.Most of the interviews took place in a closed room, in privacy, and at the location requested by the interviewees, to ensure the confidentiality of the conversation.The interview covered the following topics: the interviewee's own life trajectory; the conditions that enabled the violent death to occur; the affective, psychological, social, and financial impacts of the death for the interviewee; the support received from institutions/ social networks; and the strategies used to overcome the traumatic experience.These last two are the focus of this article.
The material collected was subjected to content analysis, thematic modality, as recommended by Gomes (2015).This approach consists of the discovery of the "nuclei of meaning that make up the communication and whose presence or frequency of appearance can mean something for the chosen analytical objective" (Gomes, 2015, p. 92, our translation).The data went through the following phases of analysis: (1) pre-analysis: corresponds to the floating reading; (2) exploration of the material, with successive readings for coding the interviews, considering the meanings and recurrences of the statements; (3) treatment of the results, inference, and interpretation: moment in which the categorization and description of the data occurs (Gomes, 2015).
Each participant received a code containing a fictitious name followed by an indication of belonging to one of the groups studied (G1: group of family members of people killed by police officers; G2: group of family members of police officers killed).
The research was submitted to the research ethics committee of the Sergio Arouca National School of Public Health (ENSP), Oswaldo Cruz Foundation (Fiocruz), and approved under opinion n. 3.443.421.
In order to take care of possible risks to participants, contacts of health services or reference professionals were identified and provided in case participants experienced any discomfort or psychological stress during the interview.

Results and discussion
Seven people were interviewed, six women and one man; four are indirect victims of police action, that is, they have had their children killed/injured by security agents, and the other three interviewees were family members of police officers killed because they were police officers.They all live in the municipality of Rio de Janeiro, the same city where the violence was perpetrated against their family members.
Chart 1 shows information such as fictitious names, age, gender, ethnicity, place of residence, degree of kinship with the person who was killed, and the year of death.The ages of the indirect victims range from 41 to 71 years and those of their dead family members range from 2 to 51 years; half of them self-declare as black; only one person lives in the southern zone of Rio de Janeiro, whereas the others live in peripheral and working-class communities or neighborhoods.The data are presented according to whether they belong to group 1 or group 2. Whereas some of the people interviewed reported a worsening of preexisting conditions, others reported that, after a few months, they were diagnosed with hypertension, diabetes, or had health problems such as aneurysm and facial paralysis.Similar reports were described by Costa et al. (2017) and Costa, Njaine, and Schenker (2017).Despite not being able to establish a direct relationship between the homicide of the family member and the onset/aggravation of chronic diseases, the statements suggest a worsening in their general health status.

Chart 1 -Sociodemographic characteristics of the research participants
Chart 1 -Continuation.
The thematic analysis of the interviews was organized into three categories: (1) violence and the impacts on the health and occupations of indirect victims; (2) support received from governmental and non-governmental institutions; and (3) strategies adopted by indirect victims to overcome the traumatic experience.

Violence and the impacts on the health and occupations of indirect victims
All interviewees, whether indirect victims of police killings or of killed police officers, reported deterioration or worsening in their general health status after the homicides, with similar symptoms among the female participants and the only male interviewee.
In group 1, two interviewees reported that pre-existing health conditions worsened after the death of family members.Although the interviewees reported the impact of the violence they experienced on their health, they stressed that this impact extended to other people, such as neighbors, friends and, above all, other close family members.For every fatal victim, three to seven people are estimated to suffer intensely from the loss (Soares;Miranda;Borges, 2006;Souza;Pinto;Ribeiro, 2020).These people also had their health badly affected, as we can see in the following statements: Common to all the interviews was the statement of intense mental suffering accompanied by depressive symptoms, such as insomnia, lack of appetite, suicidal ideation, as well as aggressive behavior, compulsion for food or shopping, and startle at stimuli that resemble gunshots.The following statement exemplifies some of these characteristics: The first year after my son died I thought about dying every day, every day, every day.When I got home and didn't hear the 'manhê' that he used to say […], the despair was immense.I prayed, I was at work and I prayed that the time to go home wouldn't come.If I could, I'd stay there.[…] I felt like dying every day.(Telma, G1) Symptoms of depression and anxiety are frequently cited in the literature by people who have lost a family member in a violent way (Connolly;Gordon, 2014), with many developing symptoms related to post-traumatic stress disorder (PTSD) or having the condition altogether, with the incidence of this rate being approximately 23% (Hertz;Prothrow-Stith;Chery, 2005).
The same symptoms and health conditions were reported by the interviewees who had their family police officer killed, especially with regard to mental suffering.Two interviewees said they had depressive symptoms or depression, and one said she had panic disorder, which had a negative impact even on her work: This withdrawn behavior, characterized by difficulty socializing and considered an alienation from social relationships that reduces the support network, is reported in studies as an outcome of the violence suffered by that family nucleus (Connolly;Gordon, 2014), which directly affects the social participation of the indirect victim in their daily relationships.
These narratives indicate that the burden of suffering experienced by the indirect victims, in addition to causing illness, has led to a disruption or weakening in the occupations performed by these people.Occupations are understood as daily activities carried out individually or collectively that give meaning and purpose to life (Gomes;Teixeira;Ribeiro, 2020).Examples of occupations include self-care activities, instrumental activities of daily living, rest, sleep, education, work, leisure, and social participation.
The most diverse statements of these indirect victims point to this restriction and weakening of their various occupations, such as: not being able to sleep properly; having difficulty interacting with people, as well as working and studying; limiting leisure activities; and neglecting self-care.
One aspect that contributes to explaining the burden of illness that culminates so abruptly in occupations is that the family members' grief is often not recognized and legitimized by public opinion.This is most clearly seen among the interviewees in group 1, whose relatives were killed by public security agents.In these cases, due to the excessive delay in a judicial resolution of the case, mourning becomes a never-ending process that changes family ties with great impact on these people (Araújo;Sousa;Silva, 2022).This process of prolonged mourning, which causes enormous suffering, can also be observed in the people who have had their police family members murdered.
Indirect victims can often experience isolation due to feelings of powerlessness, lack of security, and sadness, which directly affects their engagement and motivation to carry out their daily tasks.According to Hammel (2020), giving people the opportunity to engage in old or new occupations in their social support networks should be seen as a basic human right, even though they often experience social helplessness, a condition that occurs both due to the lack of information about the judicial process and the lack of support from institutional facilities that could help them (Costa et al., 2017;Souza;Pinto;Ribeiro, 2020).

Governmental and non-governmental support received by the victims' families
Based on previous studies that described social helplessness as a recurrent condition among indirect victims (Araújo;Souza;Silva, 2022;Costa et al., 2017), we sought to investigate whether there was support from government institutions for these family members.Examples of government institutions include health, social assistance, justice, and public security agencies, which, to a greater or lesser extent, are involved in events of this nature.
It can be observed in the statements of the two groups studied that the State, here understood as government institutions, provided little support to indirect victims.This little or no institutional support is offset by strong support from informal or non-governmental social support networks, as emphasized by the group who had their family member killed or injured by police officers, especially with regard to the support provided by activist movements of mothers who are indirect victims of violence and groups that claim for human rights.
The social support network can integrate family ties, friends, and people from the community, and includes positive aspects that provide support in times of crisis and often mitigate factors that cause stress (Costa, 2009).The higher the level of social support, the greater the possibility of a person developing adaptive strategies to deal with adverse situations in everyday life (Costa, 2009;Pizzinato et al., 2018).
The support mentioned by the interviewees include: the mutual exchanges of mothers who organize collectively in activist groups; gestures of solidarity from the community itself to the indirect victims, expressed by donating utensils or testifying about the crime at the police station; and by other family members taking in the mothers.
Three interviewees reported that the support of other mothers who were indirect victims of violence and some political organizations, represented here by the activism of social movements, especially those engaged in these movements, were an important source of support and care: Araújo, Souza, and Silva (2022) report that there are several groups of mothers in Brazil who are demanding justice; however, in this study, it can be seen that the groups, in addition to being organized for activism, function as a space for welcoming, to share a pain that can only be experienced by another mother.This mutual help and exchange allow them to take up new occupations and thus give their lives a new meaning.
Gestures of solidarity from the family and community with the situation were mentioned by three interviewees.This support is seen as something very significant for the mothers, because these attitudes made many cases go to court, due to the testimony of neighbors who were witnesses or because the community itself helped with other resources to care for the family.
We talk about everything [referring to the nonbiological grandmother].With her, we never had any secrets.Neither me nor my children.We've always talked to her about everything, any kind of problem, anything.So, I talk to her.Every day that I come home from work, she lives next to the emergency care unit [UPA], in those apartments over there.(Telma,G1) At least two other participants also reported having received support and care from their families to console them in the face of the difficulties experienced as a result of their bereavement, although it is important to mention that the way in which each family provides support varies greatly.Family reorganization after loss, in certain circumstances, allows values such as solidarity and bonding to emerge in the emotional repertoire of many of these indirect victims (Domingues;Dessen;Queiroz, 2015).This happened in some cases, according to the statement: My support, first of all, God, my family.My whole family was very supportive, they looked after me; they still do, to this day.The first support came from my family, especially my sister.(Arlete, G1) Arlete was the only interviewee in group 1 who mentioned the work of the police station in her son's case in a positive light: There was an investigation that, in relation to the other cases I had access to, was quick.Some cases never made it out of the police station.Ten months later, the first hearing of my son's case took place.They had no other option, there were several witnesses: 10 residents.What's more, the precinct chief did a good job.The policemen's weapons were seized that same day, they went to testify at the homicide department [DH].The police officer who killed my son, in his first statement to the DH, denied that he had fired any shots.But the bullet was lodged in my son's body, a ballistics test was carried out.It's a good thing this officer was using a corporation gun, because they don't usually do that, they use unregistered guns.The examination revealed the police officer who shot him.(Arlete, G1) In group 2, only one interviewee reported having received religious support, which came from a close person: A friend threw me in a car and took me to Universal [Church].I went for a year.She didn't miss a day.Every Sunday, Monday, and Tuesday.And there I got back on my feet.I was even baptized.That's what cured my depression.(Verônica, G2) The other people interviewed, although they claimed to have a religion, did not mention any support of this nature.
The indirect victims in group 2, like those in group 1, also received little institutional support, with family support being the main support mentioned.The support that family members of killed police officers receive appears to be more limited than that provided to victims in group 1, since they are able to rely on activists, politicians, family members, and the community.
I had no assistance whatsoever.And then I started getting together with some police mothers.[…] And the Secretariat doesn't open up either, it doesn't accept our service.'No, the police don't need that, they don't want that, that's a handout, that's a disgrace.'A disgrace is to stay on the bed, as we've seen the police do.They don't let you.(Zianete,G2) This last statement shows that the perpetuation of stigma towards indirect victims is continuously lived out by these family members, which undermines the provision of formal and informal social support, given that many of these victims end up not receiving support of any kind (Souza;Pinto;Ribeiro, 2020).
The Unified Social Support System and the Unified Health System were not mentioned directly in the interviews.Health care by a professional psychologist was mentioned briefly in a few interviews and without any further information about where the care was provided and how it began.A study by Costa, Njaine, and Souza (2020) mentions that health and social support professionals are often not very active when it comes to assisting victims of violence; many of these professionals work in precarious facilities, with limited material and human resources, and experience a sense of powerlessness when dealing with this issue and public.Many of them have experienced violence of this and other kinds and therefore feel fragile when dealing with the cases they see, in addition to the lack of training on the subject in the facilities.Another important point highlighted in this study is that, in their own professional work, there is a perpetuation of the stigma of being black or brown, poor, living in peripheral communities, whose dead family members are symbolically associated with criminality, in relation to deaths by homicide, even though different professionals have different experiences and approaches when confronted with these cases (Costa;Njaine;Souza, 2020).

Strategies adopted by indirect victims to overcome the traumatic experience
Faced with the traumatic experience and the limited institutional support, we investigated the possible strategies adopted by family members to cope with the suffering they went through.It was observed that the support of other mothers and social movements struggling for justice proved to be an important support at the time of the loss.Continuing in political activism and the struggle for justice emerged from the statements as one of the main strategies adopted by the victims to deal with the loss.This occurred in both groups, but it was predominant among family members who had their children killed by police officers.
According to Araújo, Souza, and Silva (2022), activism can be interpreted as a search for moral reparation in the face of public opinion, since these indirect victims are often labeled as "mothers of criminals." The struggle for justice, against impunity or, as many have mentioned, the "need to give a voice" to the murdered family member, to not to let them be forgotten, it emerges as an effort not to erase family histories.Despite the suffering from always reliving the pain and trauma of the loss, these activities fuel them with the liberating and therapeutic strength and courage to keep fighting for justice, (Vianna;Farias, 2011), not just for their case, but for that of all the other mothers who have had their children killed.The following statement exemplifies this: Being in the struggle today, for me, is a cure.It's in these spaces that I can […] shout his name, show what happened to him.It's as if I'm keeping him alive, and that's so important.Keeping that memory, because I'll never forget, but I want people not to forget either.It's the moment when I put this pain out there, I scream, I hug other mothers and family members.I found healing in the struggle.(Arlete, G1) The engagement in political activism for some participants was and continues to be so significant that it generated opportunity and motivation for one of them to attend college: My future I only aim at the conviction of the defendants and, in addition to the conviction of the defendants, my college education to help other mothers.In a different way.Like, today, as a mother, I see how difficult it is to have a lawyer.(Débora, G1) Social support can be divided into three major spheres: emotional, which is based on relationships of trust and sharing feelings; instrumental, which includes help with tasks and cases of illness; and informational, which consists of advice and guidance (Pizzinato et al., 2018).The social support network set up among indirect victims who have had their children killed by security agents is organized in a movement in which, at the same time that they engage in activism and provide support to fragile mothers or fathers, they seek to contribute to the collective organization, in a continuous cycle that generates new meaning to the daily lives of these people.
This engaged care from one indirect victim to another ends up constituting a co-occupation, in other words, a practice shared by several people, with active participation in an interactive and reciprocal relationship.
A second aspect, although less mentioned in the statements, was the investment in individual occupations, centered on self-care, health management, and leisure activities to overcome pain and health problems.Among the activities mentioned are going to the gym, taking walks, or doing leisure activities, and getting involved in religious activities.
And I go to the gym every day too […] I exercise, sometimes I sit on the floor and stay there until it's 1 o'clock, there are times when I realize it and I've been there for 2 hours.I go every day, every day.I only don't go on Saturdays and Sundays, but I go every day.Sometimes I go there and only do two exercises, but I like that there are lots of people.There are some girls who like to talk to me.Sometimes they don't even talk to me, because they know I'm not okay.But I like to go every day, it's also done me good.(Telma, G1) Among the women who had their police family members killed, one interviewee reported that she had tried to set up an organization that would bring together the families of police officers who had survived violence, so that it could function as an organization that these mothers could rely on.The words of this mother, whose daughter was brutally murdered, carry a great significance, as they elucidate the fragility of the State in protecting its own personnel (Duarte, 2019).When a homicide occurs, the State often neglects the victim's family members.The following statement exemplifies a case in which the police husband was shot (shortly before the police son-in-law was lethally wounded in a confrontation) and received psychological assistance, but no other family members were included:

So, we created an association
He had psychological treatment.He still has it to this day.I don't have any.Like, they focused on him, they forgot that he has a family.And I, in turn, didn't say anything.He went to the psychiatrist, the psychologist.He still goes to this day.(Josélia, G2) The report above reinforces the invisibility of indirect victims of violence who are not even recognized as victims, and do not receive any kind of support from institutions (Kamimura, 2009).The other people interviewed in group 2 reported that religious activities, physical exercise, and the mutual support of their families were important activities in their daily lives in order to get up and overcome the trauma.

Final considerations
This study focused on the impact of homicide on indirect victims, analyzing the support they received in the face of fatality, and the strategies they used to overcome the traumatic event.All the participants interviewed reported worsening of their general health, marked by intense mental suffering, which impacted negatively on daily activities related to work, leisure, health care, sleep, etc.
One support mentioned by people who had children killed by security agents was that of activist groups or human rights organizations.This activism, in which many were directly or indirectly involved, enabled them to rearrange new occupations in terms of social participation, since they began to share activities with other people who had experienced the same trauma, involved in similar activities, and with similar experiences, which can be interpreted as a collective strategy to overcome the pain of losing a family member.Other forms of support and strategies were mentioned; however, the State is largely absent in providing support to these family members.This indicates the importance of future studies seeking to better understand this "gap" between State agencies and policies and indirect victims, in order to adopt or improve public programs and policies.
Notably, few studies have sought to analyze from a comprehensive point of view the strategies adopted to try to overcome the loss and pain, and to get on with life in different groups (family members of people killed by police officers and family members who had their police family members killed), which is an important contribution of this study.In addition, the results reinforce the need to implement policies that protect citizens and families, which promote equity and inclusion for those who have historically been the most vulnerable, excluded, and discriminated against.Policies that result in benefits for society as a whole, that go beyond the police-oriented view with which the issue is restrictively and traditionally dealt with.
At the time, those who supported me a lot were Cebraspo [Brazilian Center for Solidarity with the Peoples], which are still present to this day.[…] Then, through them, I got to know the newspaper Nova Democracia, I got to know the network against violence, I got to know the struggle of the organizations, Projeto Legal, I got to know the Justiça Global, I got to know... who else?The Amnesty Internacional, I met Reaja, from Bahia, the As Mães de Maio.I got to know other movements.(Débora, G1) […] Several mothers who took me in […] today I'm part of their group, the Mães de Manguinhos and family members of victims.[…].Whenever I can take part in a demonstration, I go, I'm there.It's not often that I go, because of work […].(Telma, G1) was completely disoriented.And this house I had in the Navy condominium, which I lent to her, I had to sell to pay off card debts, purchase debts I had made.I bought, bought, bought.I reached almost 90kg.I ate, ate, ate, ate desperately.I ate, I cried, I didn't go to work, I missed work.
It wasn't possible, because the police are very closed.They don't open up.I don't know.I honestly can't say what the police officers' problem is.They suffer in silence.I think they're ashamed to say they're being helped, and they think they're superheroes, right, but when that "superhero" gets shot, crippled, the State doesn't care anymore.They're nothing to the State, they're not superheroes, they're nothing.(Zianete, G2)