Article

Angels of Courage: The Experiences of Mothers Who Have Been Bereaved by Suicide

OMEGA—Journal of Death and Dying 0(0) 1–27 ! The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0030222817725180 journals.sagepub.com/home/ome

Chris Shields1, Kate Russo1, and Michele Kavanagh1

Abstract Despite the increasing number of people being bereaved by suicide, little is understood concerning the experiences of those bereaved by suicide as they struggle to make sense of a loved one’s death. The current study explored the experiences of four mothers who had been bereaved by suicide and the role of support groups in the meaning-making process following bereavement by suicide. Participants were interviewed and transcribed interviews were then analysed from an interpretative phenomenological perspective. Four main themes were identified: Continuing role of the mother; A never-ending quest; Finding sanctuary; and Rising up from the ashes. These themes relate to a range of emotions following bereavement by suicide, the meaning-making process, the social context and the role of the support group. Clinical implications are discussed in relation to these findings. Keywords suicide, bereavement, mothers, grief, loss

It has been suggested that suicide is a complicated and difficult type of bereavement to experience (Clark & Goldney, 1995). Clark (2001) has suggested that over 1 million people worldwide die by suicide each year. In Ireland, the suicide

1

Queen’s University Belfast, Belfast, Northern Ireland, UK

Corresponding Author: Chris Shields, Queen’s University Belfast, Belfast, Northern Ireland, UK. Email: [email protected]

2

OMEGA—Journal of Death and Dying 0(0)

rate has grown from a relatively low rate in the 1960s to rates convergent with European rates in the 1990s, doubling in the past 20 years (Begley & Quayle, 2007). Recent statistics reported by the Northern Ireland Statistics & Research Agency (2012) indicate that in 2011, 289 individuals died by suicide in Northern Ireland. Using Shneidman’s (1969) estimation of six individuals affected by each suicide, this means that 1,734 people were bereaved by suicide in Northern Ireland in 2011 alone. Clark (2001) has suggested Shneidman’s (1969) estimate is conservative, and it is probable that the actual proportion of the population affected by suicide is higher (Cerel, Padgett, Conwell, & Reed, 2009). Those bereaved by suicide must deal with a set of unique problems associated with death by suicide (Cerel, Jordan, & Duberstein, 2008). These problems may include a prolonged search for the reason for the suicide, a distorted sense of responsibility for the death, feelings of being blamed for the death and elevated feelings of anger directed at the person who has died by suicide, as well as social stigmatization (Cerel et al., 2009; Jordan, 2001). Alongside these difficulties, there may be an increased propensity for family members to also attempt suicide (Runeson & Asberg, 2003) and an additional risk of developing psychiatric disorders such as post-traumatic stress disorder and depression (Cerel et al., 2009). At a time when those bereaved by suicide are faced with dealing with some of those issues outlined earlier, research would suggest that the traditional avenues of support, such as family and wider social support, can be lacking (Begley & Quayle, 2007; Cerel et al., 2009; Feigelman & Feigelman, 2008). Cerel et al. (2008) state that social support after bereavement is a crucial factor in determining bereavement outcome following any manner of death and that factors that interfere with the ability of a social group to provide support to the bereaved can have a direct bearing on their mourning trajectory. The authors go on to suggest that the most deleterious impact of suicide on social networks is the distortion of communicational processes that may occur after the death. At a time, then, when support may be most needed, parents of those who have died by suicide may be faced with a disintegration of support networks. Grad, Clark, Dyregrov, and Andriessen (2004) refer to this process as social helplessness, reflecting the social network’s difficulty in responding to and supporting those bereaved by suicide in a manner that is beneficial to the bereaved. While the initial experience of those bereaved by suicide appears to be one of the compassion from those around them, this seems to diminish over time. As a result, Grad et al. (2004) suggest that later, when those bereaved by suicide start to reorganize their life again, they need to rebuild an entirely new social life. This process of the disintegration and reconstruction of a social life in the aftermath of a suicide may be paralleled by a process of biographical disintegration in which parents who have lost a son to suicide struggle to reconstruct their own lives and identity in the light of a suicide (Owens, Lambert, Lloyd, & Donovan, 2008). Owens et al. (2007) state that the ultimate task for parents

Shields et al.

3

bereaved by suicide is to construct a version of events that enables them to both make sense of the past and to contemplate the future. The parent bereaved by suicide may find it impossible to disentangle the events leading to their son’s suicide from the impact that the suicide has had on their own lives. Owens et al. (2007) suggest that the parent who has been bereaved by suicide is not only trying to understand ‘‘why did this happen to him?’’ but also ‘‘why did this happen to me?’’ Parents are, then, according to the authors not only trying to make sense of their son’s death but also their own loss and the destruction of their life’s work as a parent. The process of meaning making, then, after the loss of a child to suicide is crucial in enabling parents to go on living (Owens et al., 2007). According to Park and Folkman (1997), meaning within the coping process has been assessed in terms of answering the question of why an event occurred, examining ways in which life has changed because of the event, and stating the degree to which one has found meaning in the event. It would seem that these factors would be related to the biographical reconstruction by the parent of a child who has died by suicide as discussed earlier. Park and Folkman (1997) stress the role of reappraisal and the importance of achieving congruence between an individual’s global meaning and the appraised meaning of a particular event. Park and Folkman (1997) suggest that the main role of searching for meaning is to reduce the incongruence between the appraised meaning of an event and the individual’s global meaning in terms of beliefs and goals. According to Park and Folkman’s (1997) model, the meaning-making process is considered successful when people achieve reconciliation by changing either the appraised meaning of the event to reconcile it with their global meaning or their beliefs and goals to accommodate the event (Park & Folkman, 1997). Indeed, research would suggest that if the bereaved are able to find meaning within the death, then this can impact on posttraumatic growth and healing (Kalischuk & Hayes, 2003; Smith, Joseph, & Das Nair, 2011). However, not all meaning-making outcomes are positive and people may fail to achieve integration between their beliefs and goals and a traumatic event. Neimeyer, Baldwin, and Gillies (2006) discuss the relation between continuing bonds coping, meaning construction, and complicated grief symptoms. Neimeyer et al. (2006) claim that recent theorists suggest that retaining a bond with a deceased attachment figure may have an adaptive function. The authors suggest that a reorganization of the bond can be achieved by strategies such as retaining a psychological, rather than physical, closeness to the deceased, or having a sense of their comforting presence in times of stress. However, the continuing bond can be either constructive or obstructive. Indeed, Neimeyer et al. (2006) found that continuing bonds could be related to traumatic and separation distress, but that this was moderated by the ability to find meaning of the death.

4

OMEGA—Journal of Death and Dying 0(0)

For those bereaved by suicide, this process of meaning making may take place within a difficult social context (Cerel et al., 2009). When a parent bereaved by suicide is faced with a lack of support, both within the family (Feigelman & Feigelman, 2008) and within the wider community (Grad et al., 2004) support groups may help to fill the void. It has been suggested that those bereaved by suicide often join support groups in an attempt to seek comfort and support after a loss and to counteract the personally depreciating aspects of suicide stigmatization (Feigelman & Feigelman, 2008). Several mechanisms have been identified through which support groups may be beneficial to those who attend. Gitterman and Shulman (2005, p. 289) suggest that a ‘‘healing force’’ is released when people discover that they are not alone in their feelings. It has also been suggested that providing those bereaved by suicide with an opportunity to tell their story in an accepting atmosphere is important (Feigelman & Feigelman, 2008). It is also thought that support groups allow group members to help each other and thus improve their self-esteem in the process (Feigelman & Feigelman, 2008). Park and Folkman (1997) also suggest that the more resources, including support, that people have, the more able they are to cope with stress. The role of suicide support groups, then, involving people who have gone through similar experiences and who are willing to provide social support and are not blaming, may play a crucial role in individuals’ ability to make sense of their loss and biographically reconstruct their lives in a helpful way.

Rationale Given the research mentioned previously, there are a number of factors which contribute to the need for the proposed article. Suicide is an area that can affect a relatively large number of people not only in Ireland but worldwide. Following a suicide those bereaved are left to face a complex process of finding meaning within the death. The process of making meaning can be constructive and lead to healing and posttraumatic growth (Kalischuk & Hayes, 2003; Smith et al., 2011), or if those bereaved are unable to find meaning within the death, may lead to complicated grief symptoms (Neimeyer et al., 2006). Despite the importance of the meaning-making process for those bereaved by suicide, Begley and Quayle (2007) suggest that few studies have reported on how those bereaved by suicide describe their experiences in the aftermath of a family suicide. Suicide support groups may provide much needed support for those bereaved by suicide and may provide a context for a meaning-making process for those affected by suicide. Indeed, suicide support groups are widely used by those bereaved by suicide (Cerel et al., 2009). Despite this, there is little research examining the efficacy of support groups for those bereaved by suicide, and Begley and Quayle (2007) suggest that the meaning-making process within the context of support groups is underinvestigated.

Shields et al.

5

Hjelmeland and Knizek (2010) suggest that within the suicidology literature, there has been an almost exclusive use of quantitative methodology focusing on explanations. The authors argue that this focus on quantitative methods has led research concerning suicide into a dead end and recommend a focus on understanding, rather than explaining, using qualitative methods. Hjelmeland and Knizek (2010) suggest that qualitative research allows the researcher to look at relationships between important factors in a way which is not possible using quantitative methods. The authors go on to suggest that in focusing on understanding rather than explaining, hermeneutics, the theory of interpretation is essential. This is one of the key elements of interpretative phenomenological analysis (IPA). The current study aims to examine the experiences of mothers who have been bereaved by suicide and to explore how mothers bereaved by suicide make sense of the event within the context of support groups. Although other research has employed IPA to investigate aspects of the experience of those bereaved by suicide (Begley & Quayle, 2007; Smith et al., 2011), the current study adds to these by examining the experiences of mothers and the meaning-making process following suicide and locating the support group within that process. The study included four participants recruited from a suicide support group which is run in Derry, in Northern Ireland, an area of high suicide.

Method Interpretative IPA was used to explore the experiences of mothers bereaved by suicide because of its commitment to how people make sense of their major life experiences (Smith, Flowers, & Larkin, 2009). IPA allows the researcher to ‘‘go back to the experiences themselves’’ (Smith et al., 2009, p. 1) and enter the world of each participant to gain a rich and detailed understanding of their experience rather than attempting to discuss experience in relation to predefined, abstract categories. The phenomenological approach allows for rich in-depth insights into the experiences of participants, allowing new insights to be gained. This is especially suitable as there is limited research focusing on the lived experience of those who have been bereaved by suicide. IPA recognizes that the accounts provided by participants will reflect their attempt to make sense of their experience, and the researcher can only access this experience based on the account that the participant supplies. This account is then interpreted by the researcher in order to understand that experience (Smith et al., 2009). This interpretation can then be positioned in relation to the wider social, cultural, and even theoretical context (Larkin, Watts, & Clifton, 2006). Within the area of suicide bereavement, the benefits of such an approach are clear. Parents bereaved by suicide may be faced with a complex process of reconstructing their life without their loved one in it and may be faced with a series of problems unique to bereavement by suicide. How parents make sense of

6

OMEGA—Journal of Death and Dying 0(0)

these experiences and how they interpret their experiences can be of crucial importance in allowing parents to go on living (Owens et al., 2007).

Participants Participants were a purposive, self-selected sample of four mothers of young people who have died by suicide and who attended a suicide support group (see Table 1). Participants’ ages ranged from 45 to 60 years of age, and all participants had lost a son to suicide. Two of the participants’ sons had died by hanging and two by drowning. Participants responded to information provided by the primary researcher by contacting him using the details provided on the information sheet. Participants were excluded from the study if they had been bereaved by suicide within the previous 18 months. Hawton, Houston, Malmberg, and Simkin (2003) contacted participants between 7 and 37 months after a bereavement, with a mean of 20 months. However, 26.5% of participants reported that they would have preferred to have been contacted sooner. It would seem, then, that 18 months may provide participants with an appropriate amount of time to start making meaning of their experiences. In order to ensure a homogenous sample, fathers were excluded from the study. Given that an in-depth analysis of participants’ data is required, including an analysis of the language used, those who had limited English and might not have been able to communicate their experiences in rich detail were also excluded from the study.

Data Collection The primary researcher conducted in-depth interviews with participants, which lasted between 1 and 1.5 hr. Interviews were digitally recorded and transcribed verbatim. The interviews were conducted at a convenient venue and were semistructured in format. Questions were based on existing literature and clinical practice and were designed to illicit information concerning participants’ experiences of the aftermath of the suicide, social support, and the role of the

Table 1. Descriptive Details of Study Participants. Participant Sue Jill Jenny Marie

Age 55–60 50–55 45–50 45–50

Time since suicide

Method of suicide

11 8 4 3

Hanging Hanging Drowning Drowning

Years Years Years Years

Shields et al.

7

support group. Questions were designed to be free from technical jargon and leading content.

Procedure A member of the research team is involved in running a suicide support group and introduced the proposed study to the members of the group. The support group facilitator had no further role in the research process and was not aware of the participants. Recruitment was carried out by the primary researcher who was not associated with the support group. Those interested in participating in the study were invited to stay behind after a group session to discuss the study with the researcher and to view the information sheet and ask any questions. Participants were then provided with the researcher’s contact details and asked to contact him if they would like to take part in the study. Those who did contact the researcher were then asked to complete a consent form. Once participants had given consent, individual interviews were arranged. Participants were then asked for oral consent at the end of the interview for use of the material discussed.

Data Analysis Analysis of the data collected during interviews was in accordance with guidelines on IPA supplied by Smith et al. (2009). Initially transcribed data were read and reread, so that the researcher could become immersed in the data. Any immediate, powerful observations of the transcript were noted. Next, the semantic content and language use were examined on an exploratory level and anything of interest in the data was noted. During this stage of analysis, a comprehensive set of notes and comments on the data was gathered staying as close to the participant’s explicit meaning as possible (Smith et al., 2009). Alongside this, more interpretative noting was conducted. In the next stage of analysis, emergent themes were developed by examining the connections and patterns between the initial notes on the data (Smith et al., 2009) and the researcher then searched for connections across the emergent themes. When analysis of the first participant was completed, ideas which emerged from the analysis of the first case were bracketed off, as far as possible to limit the impact that they may have on analysis of subsequent participants (Smith et al., 2009). When analysis of all cases was completed, possible patterns across participants were examined.

Quality and Rigor Throughout the research process, the primary researcher kept a reflective diary which included notes related to themes identified, any powerful observations which left an impression from the interviews, and interpretations of participants’

8

OMEGA—Journal of Death and Dying 0(0)

information. Given the interpretative nature of IPA, the first transcript was analyzed by two members of the research team and discussed to ensure that the themes generated emerged from the data. An audit trail was also kept indicating the various stages of analysis and links between the participants’ data and quotations and subsequent themes. When the final themes had been identified, these were discussed with other members of the research team to ensure that the process of moving from the initial data to the final themes was open and transparent. To contribute to the transparency of the study, it is important that the reader understand the background of the primary researcher so as to have an awareness of the possible influences on the interpretation process (Smith et al., 2011). The primary researcher had previous experience of being bereaved by suicide with his nephew dying by suicide approximately 11 years previous. None of the participants in the current study asked the researcher about his experience of suicide. The reflective diary was used to record any potential influence of this personal history on the data analysis process, and this was also discussed during supervision.

Results In exploring the experiences of mothers who had been bereaved by suicide and examining how these mothers make sense of the event within the context of support groups, four themes were identified which reflect the experience of the participants. These themes are outlined in Table 2 and described the participants’ process of trying the make sense of the loss of their sons by suicide, feelings associated with this loss, the social context in which this process occurs and the role of the support group in helping participants to find meaning.

Theme 1: Continuing Role of Mother Mothers who have lost a child to suicide continue on in the role of mother, even though their child had died. This process involved protecting their children from any blame associated with the act of suicide by minimizing the role of the son in the suicide. This was accomplished by directing the blame inward onto themselves or directing it outward onto services, alcohol, medication, or other people. Table 2. Master Themes and Their Subthemes. Master theme Continuing role of mother A never-ending quest Finding sanctuary Rising up from the ashes

Arising from Finding a place for blame, idealization of the son, keeping a bond with the son, and keeping the memory alive Journeying, searching for answers, and understanding Being a lynchpin, finding a place to belong disintegration and loss of self, finding hope, and rebuilding self

Shields et al.

9

Finding a Place for the Blame Through internalizing the blame, mothers were left feeling guilty for not being able to identify any signs leading to the suicide and questioning their ability as a mother. By externalizing the blame, mothers were often left feeling anger toward services or other people who they felt should have done more to help their son. Sue described the guilt she felt having internalized the blame associated with her son’s suicide: At the start I was riddled with guilt. As I say why did I not (pause) how did I not notice and all. I was riddled with guilt and blaming myself.

Although this protected her son from blame, it left her with a burden of guilt and questioning her role in the suicide. Marie also protected her son from any blame associated with taking his own life but through a process of externalizing the blame on to the medical staff responsible for his care and the medication that he was taking: I just feel as though it was neglect. You know I feel as though it was the medication he was on that caused all that agitation. Because that wasn’t there before he went into hospital.

This served a function of protecting both the son and the mother from the blame associated with suicide but could leave a feeling of intense anger toward others. While the process of internalizing or externalizing the blame may leave the mothers with feelings of intense guilt or anger, this may be preferable to tainting their view of their son with feelings of anger toward him.

Idealization of the Son Dealing with the blame surrounding a suicide and protecting the son was coupled with a process of idealizing the son in a way that was free from blame, shame, or embarrassment. It also highlighted the unique relationship between mother and son. Jill and Jenny described their sons in a way that highlighted the positive aspects of their relationship. This allowed these mothers to protect their relationship with their son and helped with the process of continuing a bond, even after death. Me and him were just perfect together and he was come the perfect son again. (Jill) And he was beautiful (pause) you had to have seen him. Because he had turned, had got braces. He’d grown, you know from that weedy boy that I had first described. He had got tall, broad, his teeth were like a film star’s. He was lovely. (Jenny)

10

OMEGA—Journal of Death and Dying 0(0)

This overemphasize of the positive aspects of their son was, in some cases, coupled with the minimization of any negative aspects. Despite describing her son as a ‘‘perfect son,’’ Jill went on to provide information that would contradict that view. However, this information was used to emphasize the struggles that her son had to endure and did not detract from the view of her son as perfect. Constable Smith . . . was telling me that they picked Sam off the bridge after 12 that night . . . Constable Smith said he knew Sam. He had been giving him a hard time singing (IRA songs) apparently. (p. 3, line 63)

Keeping a Bond With the Son Although preserving a blameless, idealized view of their son, mothers who have been bereaved by suicide also tried to find ways of continuing the bond with their son. Despite the fact that the son was no longer physically present, there was a struggle to maintain a relationship with them on a psychological or spiritual level. This was accomplished by viewing the son as continuing to provide support in times of need and searching for signs that the son was still in some way present. For example, Jill described finding a sign that her son was still present in such a way. I was running around screaming and crying. I says ‘‘You better do something. Let me know if you’re here. Are you here?’’ Anyway, to cut a long story short, I was downstairs and I ran upstairs. And I sat on the side of the bed to try and talk to him again. And say that’s Sam’s picture there and that’s a wee ashtray (pause) there was a white feather. Now it couldn’t have been anything because the wee bottles of perfumes were all perfect. And I says ‘‘Thank you very much now son, now I know you’re here with me.’’

Keeping the Memory Alive Coupled with the process of continuing a bond with the son is the idea of keeping his memory alive. Jenny described ways in which she keeps her son’s memory alive. I always put my clothes in his wardrobe. And I be all ‘‘Jack what do you think?’’ I talk to him. My next door neighbours they laugh. I be out on the line and I would be ‘‘Jack this and Jack that.’’ And in the car I talk to him all the time. I have a big relationship with Jack.

As Jenny described, the process of ensuring that her son’s presence is never forgotten helps her to keep hold of a relationship with her son despite the fact

Shields et al.

11

that he is no longer physically present. Not only does this keep her son’s memory alive, but it may also help her cope with the loss by maintaining a relationship with this idealized son. This may play a particularly important role for mothers given some of the limitations associated with social support outside of the support group.

Theme 2: A Never-Ending Quest Participants engaged in a quest to find some meaning within the suicide and to try to understand why this event happened. This process involved trying to find an explanation for the suicide that would allow participants to live on in some way. This process, for these participants, was aided by the support group.

Search for Answers and Understanding The death of a son by suicide left the participants of the current study facing a wide range of questions concerning the reasons for this event. Jill described her attempt to try and find a reason for her son’s death and her search to make sense of an event which she could never understand. There is a sense that answers were needed to allow participants to move forward and rebuild their lives, however the answers never came. It was question after question. I was awful about questions. I wanted answers. I wanted help with answers. Tell me why my son died.

The search for answers was not simply limited to why the suicide had occurred but was related to many other aspects of the suicide, including the choice of method. Whether those who had completed suicide had drowned or had died by hanging, the participants were left asking questions to which the answers were no longer available. Jill described a process of reliving her son’s last moments to try to get understand his decision to end his life: I would ask people questions, doctors (pause) ‘‘Was he trying to take that rope off? Was he trying to get it off again?’’ You know there are so many questions with hanging where if they take a load of drink and tablets they lie and sleep and there’s no pain. With hanging themselves (pause) even the water is quick isn’t it? Hanging’s not quick.

This process of reliving his last moments included trying to understand his decision concerning the method. For Jill, the method chosen left so many unanswered questions and involved more pain than other methods. The search for answers was paralleled by a search for a deeper level of understanding concerning the loss of their child. There was a sense that developing an understanding of the suicide and finding a meaning within it would aid

12

OMEGA—Journal of Death and Dying 0(0)

participants in the healing process. For example, Marie described her ways of trying to make sense of the suicide: I’ve been reading about it and talking to other people. Like I read a lot of books about it (pause) you know after it happened. To try and understand why.’’

There seemed to be a realization that the answers that participants were searching for were not available and that the only person who knew those answers was the person who had completed the suicide. Sue illustrated how the search for answers and understanding led some participants to seek the services of mediums in an attempt to answer some of their questions: ‘‘I run to them mediums for years trying to get answer and spent a fortune on phone calls trying to get them, trying to get answers. But no answers.

Indeed, even while searching for answers and understanding, there was also recognition by mothers of the futility of this process and a feeling that what they were searching for was unobtainable. You know (pause) why. It’ll be eleven years now on Christmas day and I could still ask why. You’ll never know.’’ (Sue)

Despite acknowledging that they may never fully understand their son’s suicide, participants often arrived at an explanation that they could accept and which helped them to move forward. And I don’t know what happened that night, but maybe he’s in a better place. I sometimes wonder would my son have had a terrible life. Would he have suffered? I don’t have to worry about him anymore. And maybe now my son is at peace and rest. (Jenny)

Journeying Following their son’s death by suicide, participants embarked on a journey toward making sense of the suicide. Even though participants may never reach the end of their journey, it was a journey that they had to take and in which they had no choice. But it’s a long auld road I’m travelling. Everyday has its challenges and I just have to continue on, you know. But it’s a long old road. (Jenny)

The journey toward finding meaning took these participants into the support group, and this appeared to help participants in their quest. The journey is one

Shields et al.

13

of letting go and moving on. Jill described the anguish of this journey and the role of the support group as being a place where those bereaved by suicide could share their burden and their pain. You don’t want to be better. You think if you get better you’d be forgetting your son. I thought I had to live with pain for the rest of my life. But you learn through the group that you don’t have to live with their pain. We let go of their pain. We still carry the pain of their loss, but mentally it helps you being in the group.

The journey of the participants in the current study involved finding ways of keeping hold of some relationship with their son while being able to let go of their pain. This was a journey racked with guilt at the thought of forgetting their son, while acknowledging that the pain was a heavy burden. The support group helped the participants to negotiate this journey and live with the uncertainty that the journey involved.

Theme 3: Finding Sanctuary Participants felt the need to remain strong for their family despite their own emotional upheaval caused by the loss of their child. This was complicated by a context in which social support for participants was ever changing and appeared to fade as time passed, and participants were left feeling alone and isolated. Support which was available tended to be practical in nature with little emotional support provided for participants. Participants struggled to find a place in which their emotions could be expressed in a safe, nonjudgmental environment in which they could be themselves without worrying about the impact on others. The support group which the participants attended seemed to fill this void.

Being a Lynchpin Mothers in the current study perceived that they were at the center of the grieving family and that others were taking their strength from her. There was also the perception that, in always being strong for others, participants’ own needs were not met. Following the death by suicide of her son, Jenny described the need to remain strong and the fear of what might happened if she did not: But I knew very very quickly that if I went down this big hole that I was going down, that everybody was going to come down the hole on top of me. And I had to be strong. I thought then, I have to be strong. Which maybe wasn’t good for me.

14

OMEGA—Journal of Death and Dying 0(0)

The need to be strong for others meant that, even in their own homes, participants felt that they could not allow their true feelings and emotions to show. This had an important impact on the nature of the support that they received from family and friends. For example, Sue described not being able to discuss her pain with her family: I couldn’t talk to my family because I was too close to them. I didn’t want them to see how much I was hurting. I was trying to be strong for them, but it was killing me inside. I was trying to be strong for them is the only way I could put it, but I was dying inside.

The pain and hurt experienced by participants was so powerful that it felt uncontainable and as if it could kill them. Because of a perceived need to remain strong for the family and to not burden them with their own pain, participants felt the need to carry this intolerable pain alone. Even while trying to maintain an image of strength externally, mothers were struggling inside. The need to not show their pain and hurt to their family placed participants in a context in which they were somewhat reliant on neighbors and the wider community for support. Sue described the changing nature of this support, which was very good in the immediate aftermath of the suicide but which changed over time: Ah the neighbours were very good at the time. They were really really good. They were brilliant right enough. But, then, you know it fades. People don’t like to come too long then, because they think that they’re being nosey or they’re in the road.

In the immediate aftermath of the suicide, family, friends, and neighbors were able to take on a practical role which involved helping around the house or making dinners and cups of tea or prayer. When people where comfortable in their role, then support could be very powerful. For example, Jenny described the impact of the support she felt from the wider community: I remember going into a wee church one night. I was praying and I’ll never forget it. These people were coming in behind us, and they knew us. And I just felt like being lifted or something. And I just turned around, and everybody was praying and had their hands out to me and my husband.

Members of the wider community wanted to provide some form of support for the mothers in the current study. When they did not know what they could do to provide this support, prayer provided a means of supporting those bereaved by suicide on a spiritual level. This could be experienced as powerful. However,

Shields et al.

15

even if prayer was on going, over time, face-to-face support faded when friends and neighbors became unsure of their role. For example, Jill described some of her experiences related to problematic encounters with others: I don’t think people know what to do with you. You could be walking down the street and you do get to notice people crossing to the other side of the road. I thought it was just me losing my marbles you know. You know the support group facilitator would say that some people don’t know what to say to you. Because time has gone by.

The awkwardness of others concerning mothers bereaved by suicide was difficult for participants to understand. This was normalized within the support group by others offering possible explanations for people’s behavior. However, the fading support placed participants in a context in which they felt alone and isolated. They felt that nobody understood their loss. Even when others did try to provide support and empathy, they struggled with what to say: Because other people don’t (pause) a lot of them don’t understand. They say, ‘‘Oh my son’s in Australia and I never hear from him.’’ And I think, that’s not the same. But that angers me when people say things like that. ‘‘I know how you’re feeling because my son or my daughter is away and they don’t visit me and that’’ (pause) but it’s totally different. (Marie)

Changes concerning the social support for mothers in the current study were not only impacted by awkwardness of the wider community but also by mothers’ perceptions of themselves: I thought then that nobody would want me to be teaching their children. This was all in my head. Why would you want me to teach your child if my child took their life? This was all, all these negative thoughts were going through my head. The letters and the cards and the gifts and the flowers that I got from parents were unbelievable. (Jenny)

Participants felt that, following the suicide, members of the wider community would view them negatively and blame them for the event. This could have an impact on their role within the community and the perception that those bereaved by suicide had of themselves.

Finding a Place to Belong Participants lived within a context in which they felt isolated and alone, in which they felt the need to wear a mask and not show their true emotions to those closest to them and in which they felt the need to be strong for others, regardless of their own needs. Within such a context, participants needed their own place of

16

OMEGA—Journal of Death and Dying 0(0)

sanctuary where they could express their feelings openly and feel accepted and understood. The support group with others who had been bereaved by suicide provided such a place: It’s nice meeting people who have lost people too. They sort of, they know how difficult it can be and how you have to sort of put on a face and go out. (Marie)

The support group provided a place in which participants could take off their masks and talk about their loved one and their emotions in an open and honest way. Participants reported feeling safe and contained within the context of the group. It helped that others had gone through similar experiences and could therefore understand in a way in which others who had not been bereaved by suicide could not: I wanted to be with people who felt the way I felt. Because I didn’t think (pause) nobody knows. Unless you’ve lost somebody by suicide, you do not understand the pain. (Jill)

Given the importance of having others understand the pain that mothers in the current study were experiencing and the perception that this could only be understood by others bereaved by suicide, the importance of attending a support group specifically for suicide bereavement is apparent. Attending a support group with others who had been bereaved by suicide and in which others understood their pain and had gone through similar experiences provided participants with a place where they felt that they belonged: It’s like your own wee world sort of thing, you know (pause) and I suppose you feel safe in it and you just feel comfortable that you can share and talk it over. (Sue)

Within the support group, participants of the current study were able to focus on their own needs without worrying about protecting others or being the strong one or guiding others through their awkwardness. There was however a sense that the support group was best utilized at a particular time following the death of a loved one, perhaps when the rawness of the emotions and the shock had started to dissipate. Marie incorporated this into advice that she would give to those thinking about attending a group: Well I think I would say don’t go to soon . . . all you’re thinking about is your person and then somebody will say I lost my son five years ago. And you feel as though, well you’re used to it and I’m not. But I think they should think about it.

Attending a support group involves not only discussing your own loss and experiences but also listening to the stories of others pain and loss.

Shields et al.

17

For some, particularly in the immediate aftermath of a suicide, this may be intolerable.

Theme 4: Rising From the Ashes The final theme of ‘‘Rising from the Ashes’’ refers to a process in which participants move from a stage of personal disintegration and loss of self to finding hope and rebuilding themselves. Again, the role of the support group appeared to be crucial for this process.

Disintegration and Loss of Self In the initial aftermath of a suicide, participants reported a real sense of disintegration, which had an almost physical feeling. For example, Jill described a sense of an emotional death following a suicide: You’re brain dead and your heart is ripped out of you. You know, my heart was ripped out. And then years later my partner left us. Not that it hurt, because I was dead anyway.

Similarly, Marie described a sense of loss and the feeling of losing part of herself when her son died: It’s just a dreadful sense of loss. Like part of me has gone and part of the family has gone.

The sense of loss for mothers within the current study was so intense that it felt that a physical part of them had been lost. It was as if their hearts, the thing that kept them living, had been ripped out. The impact of the suicide was so great within the lives of these mothers that other problematic events which happened in the aftermath had no real impact in comparison.

Finding Hope The process of moving from this sense of loss to one of hope was one in which the support group seemed to play an important role. By being able to interact with others at different stages in the grief process, participants were able to get a sense that things would not always be as they currently were: I suppose you could say it was a feeling of hope. That I was going to get a bit better. I was a physical wreck (pause) there was nothing of me left. But the group (pause) there was something just in the group. I suppose it’s hope. It must be hope that I was going to feel better. (Sue)

18

OMEGA—Journal of Death and Dying 0(0)

The hope felt by participants within the group reflected a letting go of the blame and anger that they had felt concerning the death of their child. Sue described how attending the group helped her to negotiate a path through feelings of blame and guilt that she had been experiencing: Well, the group helped me to deal with those things. I’m not asking myself the questions now that I was asking myself. And I know that it was my son’s decision. I know his mind wasn’t right like, but I don’t blame anybody anymore. And I don’t feel as guilty as I did. Definitely the group helped me to get rid of the guilt. Because I was beating myself up about that.

The group helped Sue to realize that her son’s suicide was not her responsibility. Her son was not perfect after all and had made the decision. This realization seemed to help answer some of her questions and allow her to move on, leaving the guilt behind. The feeling of disintegration followed by finding hope and rebuilding the self is well explained by Jenny: This girl bought me an angel of courage. And I had her on top of my filing cabinet. And I’d say, right, whenever I’m feeling weak here, I look up and say ‘‘angel of courage, sort me out.’’ The angel of courage smashed on the floor. And I was in bits. And I picked it all up and left it on top of the filing cabinet. Two days later this wee fella came in and said, ‘‘What about your angel?’’ And I says, ‘‘I know, I broke it.’’ And he says, ‘‘Sure I stuck it back together.’’ And I went over and looked at it. And it’s my most precious thing. It’s the angel of courage who has been smashed, she’s all stuck together and her hand is missing. There’s something missing. She’s nearly all, but there’s something missing.’’

Jenny described her ‘‘angel of courage’’ which had been smashed and pieced back together, as a metaphor for herself. In being pieced back together, the angel had become the most precious thing ever. It had been pieced back together but was not whole—there was a part missing. This part will always be missing and the angel of courage, and thus, Jenny, would never be the same again: I just, you know, I’ll never be the same person again. But I’m different and I’m more (pause) I don’t know, I’m more tolerant.’’

The idea of rebuilding the self, but in a way that was different from the person that existed before was also echoed by Jill: A lot of stuff has changed in the outlook of my life. I do more. I get involved. I want to help people. Like in the WAVE centre I’d do a bit of listening ear maybe.

Shields et al.

19

The experience of losing their sons to suicide had changed the mothers in the current study. Although they had all experienced pain and hurt, they had also changed in a positive way, becoming more tolerant of others, listening to others problems, and wanting to help in some way. It seems that mothers in the current study wanted to provide others with some of the support that they had needed, and found in the support group, during their journey of being bereaved by suicide.

Discussion The current article has identified four main themes related to the bereavement process of mothers who have lost a son to suicide. These themes relate to the continuing role of the mother, the quest to find answers and understanding, finding sanctuary and a place to belong, and moving from a sense of disintegration and loss toward hope and the rebuilding of the self. Within these themes are a range of emotions related to losing a child to suicide, a struggle to find ways of maintaining a bond with the deceased and a search for a plausible explanation. This all occurs within a problematic social context in which a support group can serve an invaluable role.

The Emotions of Mothers Bereaved by Suicide The results of the current article indicate that participants are left with a range of complex emotions following the death of a child by suicide. These emotions appeared to revolve around the issue of blame, with mothers either internalizing or externalizing the blame. In an attempt to protect their child from blame and responsibility concerning suicide, those mothers who blamed themselves for not seeing the signs were left with feelings of intense guilt. Dunn and Morrish-Vidners (1987) suggest that self-blame was usually accompanied by feelings of guilt. Those mothers who protected their child by placing the blame with others including medical services were left with feelings of intense anger. Dunn and Morrish-Vidners (1987) also suggest that this process serves an important function for the bereaved in allowing them to gain a sense of control, absolves their own guilt, and displaces anger toward the deceased onto others. Indeed, participants within the current study did not report feelings of anger toward the deceased, perhaps reflecting this process of displacement. Findings of the current study relate to guilt and blame are in keeping with research suggesting that those bereaved by suicide show higher levels of guilt, blame, and responsibility for the death than those bereaved by other forms of death (Clark, 2001; Jordan, 2001; Sveen & Walby, 2008).

Continuing Bonds The process of protecting their child from blame helped participants maintain an idealized version of their child with whom they were able to keep a bond, even

20

OMEGA—Journal of Death and Dying 0(0)

after their child had died. This continuing bond included talking to their child and feeling their presence in times of stress and need. Research concerning the continuing bond with a loved one following their death now recognizes this as having an adaptive function through the maintenance of a psychological rather than a physical bond (Neimeyer et al., 2006). As suggested by participants in the current study, this continuing bond can be maintained by the bereaved cultivating a sense of the deceased’s presence in times of need (Neimeyer et al., 2006). However, the role of continuing bonds is not always positive, and it has been suggested that such bonds can also have an obstructive role on adapting to the loss (Stroebe & Schut, 2005). Indeed, within the current study, participants reported the need to not forget their son, and the feeling that moving on with their life would be a betrayal of their son’s memory. However, this was helped by the ability to find meaning within the death in practical and spiritual terms (Neimeyer et al., 2006) and participants reported feeling the presence of their loved one and turning to them for support in times of need. Neimeyer et al. (2006) suggest that those who remained closely bonded to their loved ones but were able to integrate the loss into a meaningful system of personal meaning were at less risk of complicated grief symptomology.

The Role of Making Meaning Previous research has suggested that those bereaved by suicide struggle to make meaning of the event (Dunn & Morrish-Vidners, 1987; Fielden, 2003; Jordan, 2001; Jordan & McIntosh, 2011; Kalischuk & Hayes, 2003; Neimeyer et al., 2006; Sands & Tennant, 2010; Smith et al., 2009). Owens et al. (2007) suggest that this process of making meaning is of crucial importance as it enables parents to go on living in a world that no longer contains their child. Owens et al. (2007) outline a process of biographical disintegration in which parents are struggling to make sense of not only their child’s death but also their own loss and the destruction of their life’s work as a parent. The theme of disintegration was echoed by the participants in the current study who described not only the loss of a child but also a loss of part of themselves and struggled to find meaning within this. Park and Folkman (1997) suggest that the main role of finding meaning in death is to reduce the incongruence between the appraised meaning of an event and the individual’s global meaning in terms of beliefs and goals. According to Park and Folkman (1997), the meaning-making process is considered successful when people achieve reconciliation either by changing the appraised meaning of the event to reconcile it with their global meaning or by changing their beliefs and goals to accommodate the event. Within the current study, there was evidence of participants changing the appraised meaning of the event to reconcile it with their global meaning. Participants struggled to find an explanation of

Shields et al.

21

their child’s suicide that allowed them to move forward. These explanations were related to aspects of their children’s lives which were outside of their control. These included their children’s physical health, mental health, or the role of others within their child’s life. Whatever the explanation it allowed participants to move forward and biographically reconstruct their lives in a meaningful way (Owens et al., 2008). Participants reported that the suicide had an enormous impact on their lives. Although the impact was mostly negative, participants did report to find some sort of a benefit in the event. Participants reported being more open to listening to others, more in tune with others vulnerability and engaging in charity work in an attempt to help others. This is in keeping with the findings of Neimeyer et al. (2006) who identified the ability to find a ‘‘silver lining’’ (p. 733) in the death as serving an important adaptive function.

Difficulties With Social Support Participants engaged in the process of making meaning of the event and searching for answers and understanding within a complex social environment. Participants described social support as being available in the immediate aftermath but limited to practical aspects and support appeared to fade over time. This is similar to findings by Begley and Quayle (2007) who report that immediately following suicide, the bereaved had felt supported by their communities, but that this support dwindled following the funeral. After this point, the bereaved felt abandoned and found that others acted with unease around them (Begley & Quayle, 2007). Participants described others as being awkward and behaving inappropriately toward them. This was coupled with a feeling among participants of a need to wear a mask and to not show their real feelings and vulnerability to others. The impact of suicide on social support had been outlined in the literature and Dunn and Morrish-Vidners (1987) refer to a process of ‘‘normlessness’’ (p. 200). The authors suggest that because there are no norms concerning how people should act toward those bereaved by suicide, the ‘‘normative void’’ (Dunn & Morrish-Vidners, 1987, p. 200) gets filled with awkward behavior on both sides. Maple, Edwards, Plummer, and Minichiello (2010) reported that those bereaved by suicide felt compelled not to discuss their experiences publicly and there was an internal conflict between wanting to talk but feeling the need for permission, which was rarely given. The propensity for participants in the current study to wear a mask and not discuss their true emotions is echoed by Smith et al. (2011) who suggest that participants adopted a public guise which masked their true emotions and gave the impression of functioning. This public guise allowed the bereaved to choose when and to whom they revealed their true emotions but also protected others from these raw emotions (Smith et al., 2011). Participants were able to drop their

22

OMEGA—Journal of Death and Dying 0(0)

masks when with others who had been bereaved by suicide and felt that only those who had been bereaved by suicide could really understand their experience. Within the current article, the support group provided a place in which participants could drop their masks and show their emotions to others who had also been bereaved by suicide. Indeed, for the participants of the current study, the support group played an integral part in the meaning-making process concerning the suicide.

The Role of the Support Group The support group aided the meaning-making process by providing participants with a place in which they could remove the mask that they had to wear in front of others who had not been bereaved by suicide and share their stories in a nonjudgmental supportive environment. Within this environment, participants could cry openly and discuss the most distressing aspects of their loss without reservation. Indeed, Feigelman and Feigelman (2008) suggest that this is an important element of support groups, and Baddeley and Singer (2009) suggest that being able to share the bereavement narrative with others plays a crucial role in aiding the bereaved to reconstruct their identify and make meaning. Participants reported that it was important that other members of the group had also been bereaved by suicide, since they felt that nobody who had not been through the same experience could understand their loss. This belief was strengthened by the perceived reaction of others in the community who seemed unable to provide emotional support. The support group, then, provided a normative experience for participants within a wider social context in which there was ‘‘normlessness’’ (Dunn & Morrish-Vidners, 1987). Participants also reported that it helped having members of the group at different stages of the bereavement process, so that they could seek advice and find hope from those who were further along the journey. Participants reported finding hope within the support group that things would not always be as difficult that they currently were. These findings add further support to research by Gitterman and Schulman (2005) who suggested that a ‘‘healing force’’ (p. 289) is released when people realize they are not alone in their distress. Indeed, participants reported that being with others who had been through the same experiences was an important element of the support group. The current study adds to the very limited body of qualitative research examining the experiences of mothers who have been bereaved by suicide by expanding on themes found in other studies and placing the support group within the meaning-making process for those bereaved by suicide. A number of qualitative studies have explored the importance of posttraumatic growth and healing following suicide (Kalischuk & Hayes, 2003; Smith et al., 2011). The current study also found that those who are bereaved by suicide can find hope and move forward with their lives and suggests that interacting with others

Shields et al.

23

who have also been bereaved by suicide within the context of a support group may aid this process. This allows the bereaved to identify the fact that others have been able to move on and provides hope that they will also be able to move forward. The current study also adds support to the findings of Begley and Quayle (2007) who suggest that those bereaved by suicide struggle to make sense of the suicide within the context of social uneasiness but are able to find a sense of purposefulness. However, the current study adds to these findings by including the struggle of mothers to remain strong for the family and the impact of this on social support. The current study also highlights the role of the continuing bond with the deceased and the place of the support group within the bereavement process. Although a number of quantitative studies have explored the bereavement process following suicide, the purpose of these studies is often to compare the bereavement process following suicide with other forms of bereavement. The current study provides an in-depth account of the experiences of participants following suicide and adds to the literature which suggests that the problematic feelings following suicide may be influenced by the ability to find meaning concerning the event and by the social context. It may prove interesting to compare aspects of social support and the feelings related to suicide, indicated as important for participants in the current study who attended a support groups, with those bereaved by suicide, but who have not attended a support group.

Clinical Implications The findings of the current study have several important implications related to clinical practice and services for those who have been bereaved by suicide. The current study helps to shed some light on those bereaved by suicide by exploring, in depth, the bereavement process and ways in which mothers bereaved by suicide make meaning of the event through searching for a plausible explanation and discussing their experiences with others who can listen and understand. The social context can have a negative impact on the process of meaning making, with the bereaved feeling the need to adapt a public mask and, therefore, the role of support groups within this process may be crucial. An understanding of these factors by those involved in services for those bereaved by suicide should provide valuable insight into the range of emotions and difficulties faced by this population and help those providing services to do so with empathy and understanding. Given the ‘‘normlessness’’ (Dunn & Morrish-Vidners, 1987, p. 175) faced by both those bereaved by suicide and members of the wider community, which is evident within the current article, further psychoeducational literature concerning the bereavement process following suicide and the role of social support could be made available for those in services, the bereaved, and members of the wider community.

24

OMEGA—Journal of Death and Dying 0(0)

Findings from the current study suggest that support groups may play an important role in the bereavement process of mothers bereaved by suicide and that it may be beneficial to offer the opportunity to participate in a support group to those bereaved by suicide. Within these groups, there should be space for members to express their emotions and discuss their stories openly. It would appear that these groups may function most effectively when they contain members who are at different stages in the bereavement process, so that those who are further along the bereavement process can offer hope to others. However, a caveat to this would be that, according to participants in the current study, it may be best to attend a support group after the shock and rawness of the initial impact of the loss have been worked through as participants could be overwhelmed by the powerful feelings of others. It may also be important for those involved in running such support groups to be adequately trained concerning the bereavement process following suicide, so that the needs of the participants who choose to attend can be met.

Limitations The current study allowed for the in-depth exploration the experiences of four mothers who had been bereaved by suicide in great depth. The small sample size and the fact that participants were limited to mothers mean that decisions concerning the generalizability of these findings should be made with caution. However, it should also be noted that qualitative research is less concerned with statistical generalizability than with theoretical generalizability in which findings are linked with the existing literature (Hjelmeland & Knizek, 2010). Due to the purposive sampling strategy used in the current study in which participants contacted the researcher if they wanted to take part, participants who did take part may have already negotiated many of the difficulties concerning the bereavement process and may have been qualitatively different from those who did not contact the researcher. Given that participants were sampled from a support group, those who came forward may have been particularly positively inclined toward the group. Davison, Pennebaker, and Dickerson (2000) have reported that those who attend support groups are more likely to be affected by issues which are embarrassing and socially stigmatizing and tend to be alienated from their usual support network. This may mean that those who attend support groups are more likely to have experienced their social support as problematic in comparison to those who do not attend support groups. The implication of this is that participants in the current study may have been more inclined to struggle with issues related to social support and thus view the support group as beneficial and necessary. However, it should be noted that the aim of the current study was to examine experiences of those who attend support groups and the role of the support group in the meaning-making process for these participants. However, future research could focus on other individuals

Shields et al.

25

who have been bereaved by suicide, such as fathers and could compare the bereavement process of those who have attended support groups, with those who have not.

Conclusion The bereavement process following suicide is a complex one which involved a range of problematic emotions, a search for meaning within the death of a loved one and a complicated social context in which both those who have been bereaved and members of the community are unsure of their actions (Dunn & Morrish-Vidners, 1987). Within this context, support groups for those bereaved by suicide may provide opportunities to discuss their experiences openly and honestly without worrying about masking their true emotions, being strong for others or being judged. Such support groups can help participants make meaning of their experiences and move forward in their lives. Indeed, participants in the current study reported that they felt more in tune with others vulnerability and were more willing to listen to others and engaged in charity work in an attempt to help others, and the support group may have played a role in this change. The challenge for services involved in the care for those bereaved by suicide is to further investigate the possible role of such support groups and to help provide those bereaved by suicide with normative experiences and opportunities to explore their experiences openly and honestly. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References Baddeley, J. L., & Singer, J. A. (2009). A social interactional model of bereavement narrative disclosure. Review of General Psychology, 13, 202–218. Begley, M., & Quayle, E. (2007). The lived experience of adults bereaved by suicide: A phenomenological study. Crisis, 28, 26–34. Cerel, J., Jordan, J. R., & Duberstein, P. R. (2008). The impact of suicide on the family. Crisis: Journal of Crisis Intervention & Suicide, 29(1), 38–44. Cerel, J., Padgett, J. H., Conwell, Y., & Reed, G. A. (2009). A call for research: The need to better understand the impact of support groups for suicide survivors. Suicide & Life-Threatening Behavior, 39(3), 269–281. Clark, S. (2001). Bereavement after suicide—How far have we come and where do we go from here? Crisis, 22, 102–108.

26

OMEGA—Journal of Death and Dying 0(0)

Clark, S. E., & Goldney, R. D. (1995). Grief reactions and recovery in a support group for people bereaved by suicide. Crisis, 16, 27–33. Davison, K. P., Pennebaker, J. W., & Dickerson, K. P. (2000). Who talks? The social psychology of illness support groups. American Psychologist, 55, 205–217. Dunn, R. G., & Morrish-Vidners, D. (1987). The psychological and social experience of suicide survivors. Omega, 18, 175–215. Feigelman, B., & Feigelman, W. (2008). Surviving after suicide loss: The healing potential of suicide support groups. Illness, Crisis & Loss, 16, 285–304. Fielden, J. M. (2003). Grief as a transformative experience: Weaving through different lifeworlds after a loved one has completed suicide. International Journal of Mental Health Nursing, 12(1), 74–85. Gitterman, A., & Shulman, L. (2005). Mutual aid groups, vulnerable and resilient populations, and the life cycle. New York, NY: Columbia University Press. Grad, O. T., Clark, S., Dyregrov, K., & Andriessen, K. (2004). What helps and what hinders the process of surviving the suicide of somebody close? Crisis, 25, 134–139. Hawton, K., Houston, K., Malmberg, A., & Simkin, S. (2003). Psychological autopsy interviews in suicide research: The reactions of informants. Archives of Suicide Research, 7, 73–82. Hjelmeland, H., & Knizek, B. L. (2010). Why we need qualitative research in suicidology. Suicide and Life-Threatening Behavior, 40(1), 74–80. Jordan, J. R. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide & Life-Threatening Behavior, 31(1), 91–102. Jordan, J. R., & McIntosh, J. L. (2011). Is suicide bereavement different? A framework for rethinking the question. In J. R. Jordan & J. L. McIntosh (Eds.), Grief after suicide: Understanding the consequences and caring for the survivors (pp. 19–43). New York, NY: Routledge. Kalischuk, R., & Hayes, V. (2003). Grieving, mourning, and healing following youth suicide: A focus on health and well being in families. Omega-Journal of Death and Dying, 48(1), 45–67. Larkin, M., Watts, S., & Clifton, E. (2006). Giving voice and making sense in interpretative phenomenological analysis. Qualitative Research in Psychology, 3, 102–120. Maple, M., Edwards, H., Plummer, D., & Minichiello, V. (2010). Silenced voices: Hearing the stories of parents bereaved through the suicide death of a young adult child. Health & Social Care in the Community, 18(3), 241–248. Neimeyer, R. A., Baldwin, S. A., & Gillies, J. (2006). Continuing bonds and reconstructing meaning: mitigating complications in bereavement. Death Studies, 30, 715–738. Northern Ireland Statistics & Research Agency. (2012). The Registrar general’s quarterly report. Belfast, Northern Ireland: Northern Ireland Statistics and Research Agency. Owens, C., Lambert, H., Lloyd, K., & Donovan, J. (2008). Tales of biographical disintegration: How parents make sense of their sons’ suicides. Sociology of Health & Illness, 30(2), 237–254. Park, C., & Folkman, S. (1997). The role of meaning in the context of stress and coping. General Review of Psychology, 2, 115–144. Runeson, B., & Asberg, M. (2003). Family history of suicide among suicide victims. American Journal of Psychiatry, 160, 1525–1526. Sands, D., & Tennant, M. (2010). Transformative learning in the context of suicide bereavement. Adult Education Quarterly, 60, 99–121.

Shields et al.

27

Shneidman, E. (1969). Prologue. In E. S. Shneidman (Ed.), On the nature of suicide (pp. 1–30). San Francisco, CA: Jossey-Bass. Smith, A., Joseph, S., & Das Nair, R. (2011). An interpretative phenomenological analysis of posttraumatic growth in adults bereaved by suicide. Journal of Loss & Trauma, 16(5), 413–430. Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method and research. London, England: Sage. Stroebe, M., & Schut, H. (2005). To continue or relinquish bonds: A review of consequences for the bereaved. Death Studies, 29, 477–494. Sveen, C. A., & Walby, F. A. (2008). Suicide survivors’ mental health and grief reactions: A systematic review of controlled studies. Suicide & Life-Threatening Behavior, 38(1), 13–29.

Author Biographies Chris Shields is a clinical psychologist working in the area of adult mental health in Northern Ireland. Chris’ research within the area of suicide was influenced by the death of his nephew by suicide and the impact that this had on the family and wider social circle. Chris is a father of two young boys and a keen runner. Kate Russo is an assistant course director on the Doctorate of Clinical Psychology programme at Queen’s University Belfast. She is also an independent consultant clinical psychologist, specializing in the self-management of chronic and life-limited medical conditions. She has a particular interest is using phenomenological research to improve people’s lives. She is also an author and eclipse chaser. Michele Kavanagh is a consultant clinical psychologist who specializes in the area of self-harm with young people and families within the social care system. She is also a trainer on the Clinical Psychology Training Programme for Northern Ireland based at Queen’s University Belfast where she has responsibilities for personal and professional development.