Bereaved from sudden, violent deaths are at higher risk of post disaster diagnoses such as complicated grief and PTSD, compared to non-violent bereaved (e.g., Kaltman & Bonanno, 2003; Nakajima, Ito, Shirai, & Konishi, 2012; Norris, 2007; Rheingold, Zinzow, Hawkins, Saunders, & Kilpatrick, 2012). Risk factors for complicated grief are traumatic deaths (e.g. homicide, suicide, disaster, or accident), emotional closeness to the deceased, lack of preparedness, age and gender (Lobb et al., 2010; Nakajima et al., 2012), and the risk excels when young people die (Hardison, Neimeyer, & Lichstein, 2005; Ringler & Hayden, 2000). Although it is well documented that bereaved after violent and sudden deaths are at risk for complicated reactions, more knowledge is needed on how complicated grief is associated with functioning and well-being for bereaved friends.

The event.
On July 22^nd, 2011, a Norwegian right-wing extremist executed two sequential terror attacks. The killer first detonated a car bomb outside the Government building in Oslo, killing eight people. Then he drove to Utøya, a small island where 500 to 600 people were gathered for the Worker’s Youth League’s (AUF – the youth division of the Norwegian Labour Party) annual summer camp. In total 69 people were killed at Utøya, mainly young people (the youngest were only 14 years old), and many were badly injured. The terrorist events are the deadliest attack on Norway since World War II, and represent a national tragedy that has affected the entire Norwegian society.

The importance of friendships.
Having relationships with and being attached to others is important for human beings, and young people, especially, invest a lot of energy in being included, and being part of a group (Coleman, 2011). During adolescence and through young adulthood there is a shift with decreasing parental support and increasing support from friends (Margolese, Markiewicz, & Doyle, 2005). The importance of friend relationships during adolescence and young adulthood would predict that losing a close friend at this age could be a life-changing experience (Balk, Zaengle, & Corr, 2011; Ringler & Hayden, 2000). Experiencing a loss could lead to growth and maturity, but may also interfere with normal developmental tasks and impede function (Doka, 2000; Neimeyer, Laurie, Mehta, Hardison, & Currier, 2008). Young girls have a closer relationship with their friends than boys do, with higher levels of both intimacy and peer support (Coleman, 2011; De Goede, Branje, & Meeus, 2009; Malone, 2012; Markiewicz, Lawford, Doyle, & Haggart, 2006), predicting stronger grief reactions in girls.

Perceived closeness to victims has previously been found to be positively associated with stronger reactions following disasters (Dyregrov, Frykholm, Lilled, Broberg, & Holmberg, 2003). The intensity of the grief reactions may then be better predicted by the emotional relation one had to the deceased (Pfefferbaum et al., 2000; Rheingold et al., 2012; Servaty-Seib & Pistole, 2006-2007). Previous studies have also found that for some the loss of a friend can result in more severe grief reactions than the loss of an extended family member (Holland & Neimeyer, 2011; Pfefferbaum et al., 2000; Servaty-Seib & Pistole, 2006–2007). However, a friend’s grief does not receive the same attention and recognition (Rickgarn, 1987; Ringler & Hayden, 2000; Sklar & Hartley, 1990).

Additional stressors related to the loss.
Several studies have explored the impact of mass killings (Neria et al., 2007; Norris, 2007; Nurmi, 2012). Specific incidents such as the shootings at Virginia Tech University (Vicary & Fraley, 2010), the 9/11 attacks (Ahern, Galea, Resnick, & Vlahov, 2004; DiGrande, Neria, Brackbill, Pulliam, & Galea, 2011), the Oklahoma bombing (Pfefferbaum, 2000) and the Boston Marathon bombing (Comer et al., 2014) have received special attention. The modern 24-hour news cycle, combined with the use of cell phones, internet and social media, opens for dramatic, repeated coverage both during and after the commission of crimes (Nakajima et al., 2012; Turvey, 2012). This intense, often prolonged, media coverage can cause additional stress and increase symptom severity, with almost constant reminders (Ahern et al., 2004; Holman, Garfin, & Silver, 2014). A year after the Utøya killings (April 2012) the killer was put on trial and sentenced to 21 years of preventive detention, which is the maximum length of imprisonment given in Norway. In addition, if the prosecuting authorities still believe that the killer poses a danger after the longest time runs out, they may raise new legal proceedings to get the outer frame extended by five years at a time. The trial continued for more than two months, with extensive (for long periods live) media coverage. Throughout the first year, the event was mentioned in the news every day, usually as the major news item. The Norwegian Health Authorities mounted a proactive and systematic community help approach for the survivors’ and the bereaved families. Seminars were arranged for Norwegian teachers and school-owners to mount a proper response for students who had been directly affected by the terror-attack as survivors or bereaved. Help, preferably over time, is associated with positive adjustment to the loss (Ringler & Hayden, 2000), but bereaved friends were not included in this approach.

We use the term ‘complicated grief’ as an overarching term for complications in bereavement, among which prolonged grief is the most common (see Maercker & Lalor, 2012 for a presentation and discussion of the concepts). Normal and complicated grief are part of a continuum, rather than being categorically different (Holland, Neimeyer, Boelen, & Prigerson, 2008). Ongoing maturation and development may, in addition to shifts in symptomatology with increasing age, add to the complexity of understanding and studying normal and complicated reactions for adolescents and young adults (Kaplow, Layne, Pynoos, Cohen, & Lieberman, 2012).

Both clinical experience and research have identified problems related to the interplay between trauma and grief, and if a person is present and witness to a death, or the traumatic circumstances surrounding the death easily gives rise to inner images of what happened, it may be very difficult to think of memories of that person without the «traumatic» circumstances invading their thoughts (Neria & Litz, 2004). Bereavement after the unexpected loss of a loved one is associated with elevated risk for an onset of PTSD, panic disorder, depressive episodes, and multiple psychiatric disorders like mood and anxiety disorders (Keyes et al., 2014). The nature of young girls’ relationships could also imply that they will be especially at risk for complicated reactions (Coleman, 2011; Malone, 2012).

Purpose and main objectives of the study.
The death of an adolescent affects many friends, classmates and peers every year, but few studies have focused on how youths are affected by losing a close friend, and how we can support and help them. This study is part of a larger project, which aims to increase awareness of bereaved parents, siblings and friends’ situation after the killings at Utøya 22^nd of July 2011, and focuses solely on the bereaved after these deaths. Results from the studies on bereaved parents and siblings will be presented in other articles, whereas only results from the group of friends are presented in this article. The study is non-experimental, and in order to get an overview of the unexplored field of friends as bereaved, an exploratory focus for analyses was chosen rather than a hypothesis-testing one. Focus is on possible associations and relations between grief and trauma reactions, functioning, received and wanted help, and media exposure. The research questions are:

1. To what degree are friends struggling with grief and trauma reactions, and how can we explain the symptom severity?
2. What help have the bereaved friends received?
3. How does symptom severity and received help affect psychosocial functioning for bereaved friends?
4. Are there gender differences in regard to symptom severity, help measures and psychosocial functioning for bereaved friends?

Method

Participants and procedure.
Bereaved friends of the eligible 67 of the 69 persons (two were foreign citizens and excluded) who were killed on Utøya were included in the study. For each deceased, we assumed that there were at least 4–6 close friends or boyfriend/girlfriends, which meant that several hundred young people lost a close friend. Delays due to funding and approving meant that recruitment could not start until February 2013. Names of family members were obtained using public records of the deceased after the Utøya terrorist attacks and linked to the National Population Register, and in addition to participating in the study themselves, family members were asked to recruit four to six of the deceased’s friends to the study. Friends representing 30 of the 67 deceased (45%) filled out questionnaires. Based on previous research experience with populations bereaved by potentially traumatizing deaths, a careful and respectful approach was emphasized (Dyregrov, 2004; Dyregrov et al., 2011). The project was approved by the Regional Committees for Medical and Health Research Ethics (REK) in Norway.

The sample of friends consisted of 76 young adults (22% (n = 17) men and 78% (n = 59) women) who lost a close friend or a boyfriend/girlfriend at Utøya. Although age varied between 15 and 41 years (mean = 20.72, SD = 4.96), participants were defined as young adults since 92% of the sample was between the age of 17–29 (see also Herberman Mash, Fullerton, & Ursano, 2013). The age range was wide because friends of both the youths and the few adults who were killed on Utøya were included. Of the women 64% (n = 38) lost a female friend, 32% (n = 19) lost a male friend, and 3% (n = 2) lost a boyfriend, while of the men 77% (n = 13) lost a male friend, 18% (n = 3) lost a female friend, and 6% (n = 1) lost a girlfriend.

Measures.
Informants were given a 10-page questionnaire. The first part was developed at our research center and consisted of questions mapping socio-demographic (e.g. age and gender) and loss-related questions (whom they had lost). The friends were also asked to report any absence from school or work, the duration of absence, if their grades or work performance had deteriorated or improved since the loss, and if school or work tasks felt more demanding than before the loss. Help measures included questions on experienced need for professional help, if they had received help or not, and from whom, and how the contact with the helpers was established. They were also asked in open-ended questions if they had any advice to professionals on what help bereaved should receive, if they had any negative experiences with the received help, or if there were barriers for help seeking. In addition the friends were measured on how many hours they watched the news (< 2 h, 2–4 h and > 4 h), if they found the media coverage or trial to have been stressful, and if they tried to protect themselves from the media coverage.

The Inventory of Complicated Grief (ICG-19) was used to measure maladaptive symptoms of loss and to predict long-term dysfunction (Prigerson et al., 1995). The instrument consists of 19 items, with a five-point scale (scored 0-1-2-3-4) ranging from «Never» to «Always». A cut-off point of 25 was used to distinguish participants with normal grief from those with more complicated reactions (Prigerson et al., 1995). Cronbach’s alpha was .90.

The Impact of Event Scale (IES-22 Revised) consists of 22 items with a five-point scale (scored (0-1-2-3-4) ranging from «Not at all» to «Extremely», and was used to measure the subjective response to the specific traumatic event (Weiss & Marmar, 1997). The measure included three subscales: intrusion (i.e. re-experiencing symptoms; intrusive feelings, thoughts and images); avoidance (i.e. numbness, avoidance of feelings and situations), and hyperarousal (i.e. irritability and hypervigilance). A cut-off of 34 on the total score is indicative of a PTSD diagnosis (Morina, Ehring, & Priebe, 2013). Cronbach’s alpha for the total score was .93.

The General Health Questionnaire (GHQ 12) was used to measure the bereaved’s current mental health and level of general psychological distress and inability to carry out normal functions (Goldberg & Williams, 1988). The instrument consists of 12 items, each rated on a four-point scale (scored 0-0-1-1). A cut-off of 3 indicates psychological distress (Makowska, Merecz, Moscicka, & Kolasa, 2002). Cronbach’s alpha was .84. In this study, we also included two questions on suicide ideation from GHQ 28 (item 25 and 28).

The Work and Social Adjustment Scale (WSAS) was used to measure functional impairment attributable to the loss (Mundt, Marks, Shear, & Greist, 2002). This is a five-item instrument, with a scale (scored 0–8) ranging from «Not at all» to «Very severely». According to Mundt et al. (2002) a WSAS score above 20 suggests moderately severe or worse functional impairment, while scores between 10 and 20 are associated with significant functional impairment but less severe clinical symptomatology, and scores below 10 appear to be associated with subclinical populations. Cronbach’s alpha was .85.

Data analysis.
Data were analyzed using SPSS, version 21. Predictor variables (e.g. demographic variables, media exposure, symptom levels and need for help) were analyzed with regard to outcome variables (e.g. functional impairment at school or work). Descriptive analyses were conducted to assess the symptom level of the bereaved friends and to determine how many who had scores indicating complicated reactions, on measures reflecting function in school or work, on received help, and on additional stressors like media exposure. Correlations and t-tests were then used to assess the possible links between trauma, grief, functional impairment, general psychological distress, and felt need for help, in addition to possible gender differences. Mixed linear modelling analyses were used to obtain mean scores and p-values while adjusting for potential cluster effects for subjects that knew the same victim. In order to obtain sum- and cut-off scores on the symptom measures for all informants, missing values for the instruments were imputed using multiple imputations (Rubin, 1996; Schafer & Graham, 2002). Values on other variables that could predict a score on the specific variable were used to compute new values, before calculating the sum- and cut-off scores on the symptom measures.

Results

The friends reported high levels on all symptom measures (Table 1). As many as 83% (n = 63) scored above the cut-off, implying a risk for complicated grief reactions (ICG-19), and the most common reactions were longing, and feelings of not being able to accept the death. For trauma reactions (IES-22 R), 68% (n = 52) scored above the cut-off, and most common were feelings of unreality and problems with intrusive reminders. For psychological distress (GHQ), as many as 71% scored above the cut-off, and the most common symptoms were feeling depressed and lying awake worrying. On suicide ideation, 26% (n = 20) answered that they often or sometimes thought of the possibility of ending their life, and 29% (n = 22) answered that they often or sometimes found that the idea of ending their life kept coming into their mind.

As for functional impairment attributable to the loss (WSAS), 25% (n = 19) scored above 20, and 36% (n = 27) scored between 10 and 20. The most frequent problems were with regard to ability to study or work (item 1) and social activities (item 3). About half of the friends (53%, n = 40) also reported that they had been away from school or work because of the loss (varying from a few days’ absence to 100% sick leave). Furthermore, 37% (n = 28) reported that their grades or work performance had deteriorated since the loss, and 68% (n = 50) reported that to some degree schoolwork or work tasks felt more demanding than before, females reporting this more than males (80% compared to 29% respectively). Open-ended questions showed that many still wished for more help from school, mainly regarding adaptations, e.g. extended deadlines, 1½ years after the loss.

Although symptom severity seemed to decrease with age, there were no significant correlations between age and symptom severity. Yet there were clear gender differences on all symptom measures (Table 1), where females scored higher than males. For the mean scores, these differences were significant (p < .05) for complicated grief reactions, trauma reactions and psychological distress, but not for functional impairment. For complicated grief reactions as many as 92% (n = 54) of the females, compared to 53% (n = 9) of the males, scored above the cut-off, while on trauma reactions 76% (n = 45) of the females compared to 47% (n = 8) of the males scored above the cut-off. On psychological distress 80% (n = 47) of the females, compared to 41% (n = 7) of the males, scored above the cut-off.

In the first week after the terror attack as many as 62% (n = 47) watched news of the event more than four hours per day. This declined after a while, but there was a peak during the presentation of the friend’s death at the trial, when 34% (n = 26) watched more than four hours a day. Friends found the media coverage more stressful than the trial to «a large extent» or «a fairly large extent» (71% (n = 54) and 59% (n = 45) respectively). Yet as many as 65% (n = 49) reported that they tried to shield themselves from the media coverage. Independent samples t-tests indicated gender differences on additional stress from media coverage (t(74) = 2.52, p = .014) and the trial (t(74) = 3.40, p = .001), where 76% (n = 45) of the females, compared to 53% (n = 9) of the males, found the media coverage stressful, and 66% (n = 39) of the females, compared to 35% (n = 6) of the males, found the trial stressful to «a large extent» or «a fairly large extent».

Many of the friends (68%, n = 52) felt that they needed help from public welfare services to some extent after the loss, but only about half of these received any help (Table 2).

Most of them also had to make contact themselves with the support services, and few had been contacted and offered support. Some had negative experiences with the help (e.g. poor communication with helpers, or helpers who did not acknowledge their needs for help). On the issue of barriers to help-seeking behavior, many of the friends answered in open-ended questions that they were «only friends», or that they felt others needed help more than them. Bivariate correlations (Pearson’s r) showed a strong positive correlation between experienced need for help and level of symptoms (Table 3), and more need of help was associated with increased levels of trauma reactions, complicated grief symptoms, psychological distress and functional impairment (r’s varying between .39 and .58, p < .001).

There were also strong positive correlations between absence from school or work, and need for help (r = –.55, p < .001), indicating that those with the strongest need for help were most absent. No significant correlations were, however, found between these variables and actual received help. Independent samples t-tests were conducted to explore gender differences on need for help. Significant gender differences (t(74) = 2.99, p = .004) were found, and frequencies showed that 43% (n = 26) of the females, compared to only 12% (n = 2) of the males, felt the need for help to “a large extent” or a «fairly large extent».

Discussion

The main findings in this study are that the bereaved friends, and especially the females, score high on both grief and trauma reactions, and on general psychological distress. This is associated with functional impairment and affects school or work tasks. The combination of the Utøya terror incident itself with its combination of a tragic loss surrounded by very traumatic circumstances, the intense and continued media exposure and the lack of recognition of friend’s grief are a possible explanation of the high level of symptomatology in friends.

Bereavement following violent losses (accidents, homicide or suicide) increases the risk for complicated grief, thereby causing greater distress (e.g., Currier, Holland, & Neimeyer, 2006; Hardison et al., 2005; Lobb et al., 2010). Other studies that have explored reactions to mass killings also find high scores on complicated grief and trauma reactions. After the 9/11 attacks, 43% of the bereaved (both family members and friends) screened positive for complicated grief (Neria et al. (2007), while after the shootings at Virginia Tech University students who knew one of the victims scored especially high on PTSD symptoms (Vicary & Fraley, 2010). Pfefferbaum et al. (2000), however, did not find that bereaved students after the Oklahoma bombing had higher trauma reactions than non-bereaved (although this possibly could be explained by the relationships not being so close).

In addition to age and gender, several risk factors for complicated grief reactions are present for this sample, e.g. the way the young people were killed and the age of the victims (Hardison et al., 2005; Lobb et al., 2010; Nakajima et al., 2012). The females in our sample were especially in the risk zone for severe problems in all domains, except functionality, compared to the males. Young girls tend to be more affected by stress, more dependent on others for support, have more intimate relationships with friend, and are more sensitive to others’ expectations, which may imply different risks for males and females. Males may be at risk if they keep their problems to themselves, while females may be at risk if they are too dependent on external help (Coleman, 2011; Malone, 2012). Women’s inclination towards worrying and rumination compared to men, may play a part in explaining the gender difference. This is a sample of young adults, and there is clearly a need to better understand how friends’ reactions interact or relate to intensity of relationships formed at this age, according to their ability to regulate emotions, the type and circumstances of the death, previous exposure to trauma and loss, and the developmental tasks involved in entering adulthood (Kaplow & Layne, 2014). Young people could be overrating their reactions to negative phenomena, however since there were no significant correlations between age and symptom severity this implies that friends have strong reactions independent of their age.

Previously it has been found that the loss of a friend can lead to more traumatic grief than the loss of a non-close family member (Holland & Neimeyer, 2011; Pfefferbaum et al., 2000; Ringler & Hayden, 2000; Servaty-Seib & Pistole, 2006–2007), but when comparing the scores of friends with those of close family members (bereaved parents and siblings) in our study, we found as high, and sometimes higher, scores in friends (Dyregrov, Dyregrov, & Kristensen, 2014). Among friends, 83% were in the risk zone for complicated grief, compared to 82% of the parents and 75% of the siblings. On trauma reactions implying risk for problems comparable to a PTSD diagnosis, 68% of the friends scored above the cut-off, compared to 61% of the parents and 72% of the siblings. On general psychological distress, 71% of friends scored above the cut-off, compared to 88% of the parents and 75% of the siblings. In particular, friends had reactions like longing and not being able to accept the loss, and had high levels of intrusive thoughts and avoidance symptoms. Many reported feelings of unreality and experienced traumatic reminders. In addition, they reported feelings of depression and worry, and had relatively high scores on suicidal ideation.

Mass killings and deaths by deliberate and violent murder is often handled as a crime against the «state», turning the attention to the law system, media coverage, and society’s attempts to construct meaning following the tragedy (Armour, 2003). Victims are then left more alone with their grief, anger and other feelings after the loss. Media may reduce uncertainty about what happened, but the intense media coverage, where the event is kept active and alive, can also add to friends’ symptom levels and affect wellbeing (Ahern et al., 2004; Holman et al., 2014). Many answered that they tried to limit exposure to the media coverage, but their questionnaire scores reflected a high intake of news, especially immediately after the incident. The media exposure with its almost constant reminders of the trauma may have made it more difficult to process the loss, as it may be difficult to grieve over your friend without being reminded of how he or she was killed. Also, constantly having your thoughts oriented towards the lost person may add to friends’ grief.

Friends were not offered proactive follow-up and they were precluded from taking part in interventions and rituals, such as viewing the deceased, receiving information about the death, and visiting the site of the death, which may help the bereaved to grasp the reality of the loss, and facilitate acceptance, especially after traumatic and violent losses (Kristensen, Weiseth, & Heir, 2012). According to Prigerson and Maciejewski (2008) acceptance of the loss seems to correspond with a decline in grief-related distress. While the immediate family was likely to receive information from the police and authorities (Lereim et al., 2012), and had apt possibility to view their dead family member, friends did not have access to these helping measures. They had fewer opportunities to make the loss real by seeing the dead body, or by being told the facts about the killing by police and the autopsy personnel.

Over 60% of the friends in our study had severe or moderately severe functional impairment, especially reporting problems with ability to study or work and participating in social activities. Schools that had students affected by the terror-attack as survivors or bereaved after the Utøya killings were offered training to raise their awareness and knowledge about reactions and needs of survivors and bereaved family members. Unfortunately this assistance addressed only the survivors and bereaved siblings (Lereim et al., 2012), and did not take into account that friends could require similar attention. If in need of help, they often had to make contact on their own initiative, which is usually unlikely in this age group. The high symptomatology may therefore also reflect little utilization of help. Only about half of the friends had received help from professionals after the loss, despite the fact that many desired help (especially females). Many reported that they felt that school or work tasks were more demanding than before the loss. The fact that 39% reported lower grades correspond well with other Norwegian studies, e.g. the study of Bugge (1997), who found that 40% of grieving students reported lower grades in the first years after the loss. Many reported absence from school or work, and those who had the highest need for help were most likely to be absent from school or work. Some of the friends did receive some help from teachers and school counsellors, but many still wished for more help 1½ years after the loss. Dyregrov, Bie Wikander, and Vigerust (1999) found, in a study of classmates and good friends following the accidental death of an adolescent, that Norwegian students received good help and support from the school, but that friends from outside the deceased’s class largely went unnoticed.

Previous research has shown that longer duration of help could be associated with a more positive present adjustment, but the duration of help received is often shorter than what bereaved adolescents want and need (Ringler & Hayden, 2000). If schools provide help, they are often more likely to do this immediately after a death, and students experiencing long-term effects of grief may be overlooked, as students without overt symptoms can be (Hedman, 2012; Pfefferbaum et al., 2000). Although teachers are expected to help grieving students, many feel that they are not trained to handle a student’s death, and additional professional development in the area of crisis response training are often needed (Dyregrov, Dyregrov, & Idsoe, 2013; Hart & Garza, 2012).

A clear strength of this article is that it adds to our knowledge about an under-studied grieving population – close friends. A terror event resulting in extensive mass killings was unprecedented in Norway. However, as terror has become more frequent in Western countries, we considered it important to learn from the incident. Broadening the perspective from the family to friends can make us better prepared for future events. Another strength of the study that may increase the generalizability of the findings is the homogeneity of the sample, which we consider representative, within the context. Nonetheless, we have no possibilities to compare the sample to the rest of the population. However, the homogeneous background of the group may decrease the generalizability to studies of bereavement due to homicide or murder, with more deprived and heterogeneous population groups. Another limitation to the study is the age range of the sample. We have chosen to define the sample as young adults since the larger proportion of the sample were between the age of 17 and 29. This article reflects the friends’ situation at one time point, and does not show the natural progression of reactions over time. In addition, we have not measured, and therefore cannot control for, variables, such as previous traumatic events or losses.

Conclusion

Although depicted as «forgotten grievers» (Rickgarn, 1987; Ringler & Hayden, 2000; Sklar & Hartley, 1990), friends are heavily affected by their loss of a close relationship. This study shows that bereaved friends evidenced severe reactions to the loss of their friend, a loss even comparable to those of close family members. A lack of recognition for friends’ grief is one possible explanation for the high symptom severity. The tendency not to acknowledge friends’ grief was also reflected in how friends viewed themselves as bereaved. It is worrying to see that many of them felt that they could not seek help because of their role of being «only a friend». It is important to understand that the intensity of young people’s grief reactions can partly be predicted by the emotional relationship they had to the deceased (e.g., Servaty-Seib & Pistole, 2006–2007). This calls for a broader perspective on who is affected when someone dies, and that follow-up measures should be broadened to include more than just the closest family. Finally, given the lack of a clear theoretical model for understanding the links between the violent death of a friend and the psychological problems outlined in the article, this as an area in need of further research.

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