UNIVERSITY OF CALGARY
Exploring the Impact of Suicide Attempts on the Bereavement Journey of Those Who
Have Experienced a Loss due to Suicide
by
Kimberly Everingham
A THESIS
SUBMITTED TO THE FACULTY OF GRADUATE STUDIES IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF
SOCIAL WORK
DEPARTMENT OF SOCIAL WORK
CALGARY, ALBERTA
JULY, 2011
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This research study used descriptive phenomenological methodology to explore the impact of previous suicide attempts on the bereavement journey for those who have lost a loved one to suicide. Given the prevalence of suicide and suicide related behaviours in our communities, understanding how suicide impacts support systems is important in order to provide appropriate and necessary support to those support systems. The participants in this study presented mental illness, suicide attempts, treatment, and relationships with their loved ones as key influencing factors on their grief journey. This thesis provides a basis for professionals to understand the significance of suicide attempts for support systems so that the support systems can be themselves supported.
ii Acknowledgements
Words can not begin to express my deepest gratitude to Dr. Margaret Williams for her support, guidance, and wisdom. Without her, I am not sure I would have moved past the desire to write a thesis and into the actual doing part. Her encouragement and challenges helped me persevere. Thank-you.
I want to thank my family. Michael, you have been supportive and encouraging throughout this whole adventure. Olivia and Quinn, you have spent your whole life knowing I need time to write my thesis, now it is done. Now I do not have to think about my thesis when we are playing in the park. Without the support of my mother-in-law,
Marj, who was always happy to look after the kids so I could work, study, and brood about finishing this thesis would have taken years longer to write.
Thanks to my parents, Bill and Beryl, for their loving support.
I also want to thank Pat Kostouros who has helped me through so many things over the years, and this thesis is just another to add to the list. Thank-you for being my sounding board and such a good friend.
Finally, thanks to all of my friends and colleagues who have supported, encouraged, and challenged me. Your support has not gone unnoticed.
iii Dedication
! This thesis would not have been possible without the four participants, Margaret,
Jude, Matthew, and Hope. Thank you for your trust and courage to share your experiences.
This thesis is written in memory of my loving grandparents, Roy and Ann
Pottinger.
iv TABLE OF CONTENTS
Abstract ...... ii
Acknowledgements ...... iii
Dedication ...... iv
Table of Contents ...... v
List of Figures ...... ix
Chapter One: Personal Journey ...... 1
Chapter Two: Literature Review ...... 4
Prominent Theories in Grief Work ...... 4
Common Themes in Suicide Bereavement ...... 7
Stigma ...... 9
Trauma ...... 13
Intense feelings ...... 14
Suicide attempts ...... 18
Uniqueness Disputed ...... 21
Conclusion ...... 24
Chapter Three: Methodology ...... 27
Choosing a methodology ...... 27
Modified descriptive phenomenological methodology ...... 31
Phenomenological reduction ...... 32
Chapter Four: The Research Design ...... 38
Sampling ...... 38
Trustworthiness ...... 41
v Credibility ...... 41
Transferability ...... 43
Dependability ...... 43
Confirmability ...... 44
Bracketing ...... 44
Transcribing data ...... 47
Analysis ...... 47
Chapter Five: Introduction of Participants ...... 50
Margaret ...... 50
Jude ...... 52
Hope ...... 52
Matthew ...... 54
Chapter Six: Findings ...... 56
Figure 6.1: Map of Meaning Units and Constituents ...... 56
Mental Illness ...... 57
Comprehension of mental illness ...... 58
Stigma ...... 60
Isolation ...... 62
Mental health of participant ...... 63
Suicide Attempts ...... 65
Stigma ...... 65
Isolation ...... 67
Disbelief of suicide ...... 69
Shocked but not surprised ...... 69
vi Hopefulness ...... 70
Hyper-vigilance and fear ...... 71
Treatment ...... 73
Hopefulness ...... 73
Confidentiality ...... 76
Professional as the expert ...... 78
Frustration and helplessness ...... 80
Relationship with Loved One ...... 83
Failure to connect ...... 83
Hopefulness ...... 86
Loss of voice ...... 88
Chapter Seven: Discussion of Findings ...... 90
Study’s Highlights ...... 90
Study’s Findings ...... 93
Mental illness ...... 94
Suicide attempts ...... 97
Treatment ...... 101
Relationship with loved one ...... 105
Figure 7.1: Cyclical Nature of a Relationship with Suicide Ideation ...... 107
Additional findings ...... 108
Strengths of Study ...... 110
Limitations of Study ...... 111
Chapter Eight: Conclusion ...... 113
Practice Implications ...... 113
vii Research Implications ...... 116
Personal Journey ...... 117
References ...... 119
Figures ...... 128
Figure 6.1: Map of Meaning Units and Constituents ...... 128
Figure 7.1: Cyclical Nature of a Relationship with Suicide Ideation ...... 129
Appendix 1: Recruitment Notice ...... 130
Appendix 2: Questions for Participants ...... 131
viii List of Figures
Figure 6.1: Map of Meaning Units and Constituents
Figure 7.1: Cyclical Nature of a Relationship with Suicide Ideation
ix 1
Chapter One: Personal Journey
The idea for this thesis began eight years ago when I was working directly with those bereaved by suicide. I knew that in order to address my curiosity about the connection between suicide attempts and the grief journey for those bereaved by suicide,
I would need to embark on a research project that allowed for in-depth exploration. I thought I understood the significance of the topic when the research began, but through the interview process, I was reminded of the few opportunities those who have experienced a suicide death have to talk about how suicide has impacted their lives. My journey of researching and writing this thesis has made the importance of talking about suicide, mental health, and grief abundantly clear to me. Years after the death of their loved ones, some of the participants spoke about how they have no one they can share their grief with and that they did not understand suicide and mental illness. I am grateful and honoured they decided to share their experience with me.
I liken the journey of learning and understanding descriptive phenomenological research, the methodology use in the study, to moving to another culture and learning another language. It was both overwhelming and frustrating with brief moments of celebration when I thought I understood a concept. I chose phenomenological research because this methodology was the best fit for the research and my belief systems. At no point during this research, either interviewing, analyzing data or writing, did I feel confident that I completely understood the phenomenological research process. I believe years of practice, like years of living in the foreign culture, might help me have a better grasp of the methodology and feel more confident of the process. 2
I also experienced a parallel journey around my own understanding of suicide attempts and suicide bereavement. For years I have struggled with the question of
“why?”. When my mom was 11 years old, her dad killed himself, leaving behind three amazing young girls and my incredible grandmother to live on their farm in rural
Manitoba. Not only has his death always confused and saddened me, the fact that we rarely talk about him and his death saddens me more. To hear participants express the stigma they had experienced around the suicide attempts and knowing that research identifies stigma as being a unique component of suicide bereavement, I can only wonder how much of a role stigma has played in how our family looks at his death.
I have also come to understand the gift that my mom’s dad, Jim, gave me in taking his own life. Each participant in the study spoke about how the death of their loved one changed how they engage the world. Two of the participants created foundations to talk about mental health and suicide to communities and two of the participants provide counselling and support to others. Through the past four years of writing this thesis, I have come to understand Jim gave me two invaluable gifts from his death. I am aware that my passion in understanding suicide and suicide bereavement is a direct result of him taking his own life. Secondly, his death allowed for my grandmother to marry a man whom I consider to be one of the best grandfathers anyone could ask for. Together he and my grandmother taught me about unconditional love and acceptance. For these gifts, I thank Jim.
Although the participants struggled to identify a clear link between the suicide attempt and their grief journey at the time of death, they did speak about the feelings 3 connected to the cycle I believe to be present. For me, this research has simply raised other research questions and deeper wonderings about suicide attempts and suicide bereavement. It also leaves me believing that it is difficult to determine when the grief starts for people. For the participants interviewed, treatment or support for themselves was not offered at the time of the suicide attempts but treatment was offered after the death of their loved one. Socially we seem to have a clear understanding grief is present only if there is a death. This idea needs to be changed to include grief over the other losses, such as loss of relationship or loss of hope that might occur following a suicide attempt.
Finally, at some point during all the interviews, the pain and grief for the participants around the loss of their loved one was palpable. This pain and grief is also present within my family, yet it is not discussed or acknowledged. Regardless of how long ago their loss was, the participants of this research study attested that aspects of grief stay with them. I feel honored to be given glimpses of the participants’ grief journey and to play a role in having their experience heard and told. I hope others whose lives have been touched by suicide will have moments of understanding and comfort through the voices of the participants when they read the study. I can only hope I have given justice to the participants and their stories. 4
Chapter Two: Literature Review
Prominent Theories in Grief Work
Grief is a natural part of the human experience. We experience grief as a result of loss, change, and death. Before delving in the research connected exclusively to suicide and suicide bereavement, it is important to present several theories of grief. These theories can help practitioners and those bereaved in understanding the grief journey and provide a framework on how to move through or make sense of grief. Grief work as we know it today evolved from the development of the stage theory by Elizabeth Kübler-
Ross (1969) depicting five stages of dying: denial, anger, bargaining, depression, and acceptance. Data for the stages resulted from research with people who were dying and, whether appropriately or not, were transferred to use with people who were grieving.
Kübler-Ross provided the first theory to structure and shed light on the taboo issue of grief (Copp, 1998) and became a starting point for other researchers to follow.
Since Kübler-Ross’s five stages of grief, there have been other theories developed to help us understand the grieving process. In this literature review, I will briefly present theories by Worden, Neimeyer, Doka, and Stroebe and Schut. These models are not the only grief theories available to help practitioners work with grief and aid the bereaved in understanding their grief experience but they are the predominant theories used today.
William Worden (2009) developed the four tasks of grieving. This framework provided a structure allowing the bereaved to understand grief work by outlining an active way to move through grief. The four tasks of grieving are: 1) to accept the reality of the loss; 2) to process the pain of the grief; 3) to adjust to a world without the 5 deceased; and 4) to find an enduring connection with the deceased in the midst of embarking on a new life. Worden (2009) identified the fluidity of these tasks of grief where the “tasks can be revisited and worked through again and again over time. Various tasks can also be worked on at the same time (italics in the original)” (p. 53). Worden’s tasks differed from other theories presented at the time because they “stress individuality, autonomy and choice in grief” (Goldsworthy, 2005, p. 172).
Robert Neimeyer moved away from the task and stages idea of grief work arguing
“meaning re-construction in response to a loss is the central process in grieving” (Neimeyer, 1999, p. 66): therefore a part of grief work is to make meaning of the death. He differentiated between the bereavement experience of a traumatic loss and
‘normal’ loss indicating meaning making of the death as an essential part of the bereavement journey (Neimeyer, 2000). Neimeyer (2000) believes grief therapy “...must attend to the profound challenges to clients’ (inter)personal (brackets in the original) systems of meaning brought about by tragic loss and facilitate the survivors’ own struggle to find significance both in the death and in their ongoing lives” (p. 555) Neimeyer’s work also challenges the idea that a specific grief theory fits for all grief experiences because everyone’s grief journey is unique to them based on their own experiences.
Using a narrative approach to counselling, Neimeyer encourages the bereaved to reconstruct the grief experience to make meaning out of their loss. Research completed by Neimeyer, Baldwin, and Gilles (2006) which used narrative strategies to promote meaning making indicated that this model of practice “can mitigate bereavement complications for high-risk mourners...” (p. 733). For some individuals, the narrative 6 approach to therapy may be very helpful in their grief journey.
Doka and Martin (2010) also presented the idea that everyone experiences, expresses, and adapts grief in a different way, challenging the gender stereotypes around how men and women grieve. Their findings identify people as fitting on a spectrum of being intuitive grievers or instrumental grievers. Intuitive grievers “experience and express grief in an affective way...” (p. 4) whereas instrumental grievers experience grief
“physically, as in a restlessness or a cognition” (p. 4). Doka and Martin’s thesis is important because it debunks the social belief that men are instrumental grievers and women are intuitive grievers. They found most people, men and women, grieve in a blended version of these patterns.
Another theory is the dual processing model introduced by Stroebe and Schut
(1999). This theory identifies how the bereaved cope with primary and secondary stressors that exist within the grief experience. Different stressors are coped with in different ways but understanding the movement back and forth between the stressors may help people understand their own grief journey. Stroebe and Schut (1999) suggest primary stressors, considered loss-orientated coping, is when grief work, intrusion of grief, breaking bonds/ties and relocation, and denial/avoidance of restoration changes occur. Secondary stressors, or restoration-orientated coping, is when the bereaved are attending to life changes, engaging in new activities, experiencing a distraction from the grief, and new roles, identities and relationships are developed. In the dual processing model, the bereaved move back and forth between loss-orientated and restoration- orientated coping. Over time, the bereaved do not oscillate between the two orientations 7 as often and find they are able to maintain a predominantly restorative orientation.
These theories provide a basic understanding of grief. Neimeyer differentiated between grief as a result of traumatic loss and grief as a result of normal loss. The focus of this thesis is around suicide grief, which many researchers consider to be a traumatic loss. The remainder of this literature review will explore the common themes in suicide bereavement and the research connected to suicide loss.
Common Themes in Suicide Bereavement
The World Health Organization considers death by suicide to be an epidemic claiming the lives of hundreds of people daily and impacting the lives of thousands of people for years after the suicide of their loved ones (www.who.int, 2007). The impact felt by a suicide death ripples through communities, leaving many people to mourn in the wake of their traumatic loss, yet a conspiracy of silence surrounds suicide. In Canada in
2003, over 3500 people died by suicide (Centre for Suicide Prevention, n.d.(a)) and in
Alberta in 2003, 440 people took their own life (Centre for Suicide Prevention, n.d.(b)).
With this high prevalence of suicide in our communities, as social workers, it is imperative that we understand the impact of suicide on families, friends, and social systems.
Edwin Shneidman, founder of the American Association of Suicidology, has been paraphrased by Barrett and Scott (1990) as proposing, “that in the case of suicide, the largest public health problem is neither the prevention of suicide nor the management of suicide attempts, but the alleviation of the effects of stress on the survivors whose lives are forever altered” (pp. 1-2). Barrett and Scott (1990) continued to explain: “[t]he risk to 8 health derives from the fact that the bereaved survivors, who far outnumber the individuals who have completed suicide, suffer from some severe consequences in the aftermath of someone else's self-destruction” (p. 2).
There are differing estimates of the number of people who are intimately bereaved by suicide. Lukas and Sieden (1987) suggested that for every one person who dies by suicide, eight to ten people are intimately bereaved by that death. Using a moderate estimate of six people connected to every suicide death, McIntosh (1996) suggested one out of every 68 Americans have lost someone due to suicide. Researcher John R. Jordan
(2008) believes this number “grossly underestimate the true number of survivors” (p.
680). Given this estimation of those impacted by suicide death, understanding the complexity of suicide bereavement is imperative in order to confront the stigma, stress, and misunderstanding connected to a suicide. Suicide is a community issue experienced by many people whose lives are changed by the traumatic death.
The term survivor is used widely to refer to individuals who have lost someone due to suicide. Not all people bereaved by suicide agree with the use of the word survivor arguing that this term implies someone who has survived a suicide attempt, and there is an active movement among those bereaved by suicide to change this terminology to wording that implies a person who has suffered a suicide loss. In current research, the use of the word survivor is a way to create a collective understanding of the experiences of those impacted by suicide.
Grief is a unique experience for everyone. Over the past 30 years attempts to understand the process of grief for those bereaved by suicide has increased. Most of the 9 research has concluded that there are thematic differences in the grief experienced by those bereaved by suicide versus those bereaved by other modes of death (Bailley, Kral &
Dunham, 1999; Barrett & Scott, 1990; Begley & Quayle, 2007; Dunn & Morrish-
Vidners, 1987; Jordan, 2001; Jordan, 2008; Knieper, 1999; McMenamy, Jordan &
Mitchell, 2008; Mitchell, Kim, Prigerson & Mortimer-Stephens, 2004; Reed, 1998;
Séguin, Lesage & Kiely, 1995; Silverman, Range & Overholser, 1994). The research indicates commonalities of suicide bereavement are highlighted by social stigma, trauma, and intense feelings of guilt, shame, embarrassment, rejection, and isolation. In some cases, support systems or caregivers had knowledge of suicidal ideation or a suicide attempt on the part of the deceased prior to the death. These unique aspects of suicide bereavement can create a complex grief process differing from other forms of bereavement.
This research study looks to explore the impact of suicide attempts on the grief journey of those bereaved by suicide. The dearth of research on this area of suicide and suicide bereavement limits the work we do with those impacted by a suicide loss.
Understanding suicide bereavement may assist in comprehending the impact of suicide attempts on support systems.
Stigma. “Stigma is conceptualized as a set of prejudicial attitudes, stereotypes, discriminatory behaviours, and biased social structures endorsed by a sizeable group about a discredited subgroup” (Mak & Cheung, 2008, p. 532). Suicide bereavement research identifies stigma as woven throughout the grief journey of those bereaved by suicide. Stigma plays a key role in how people bereaved by suicide may or may not 10 access support and influences how they make meaning of the death (Dunn & Morrish-
Vidners, 1987). Research has repeatedly identified stigma as unique to the bereavement journey of a survivor (Allen, Calhoun, Cann & Tedeschi, 1993; Bailey et al., 1999;
Barrett & Scott, 1990; Begley & Quayle, 2007; Cvinar, 2005; Feigelman, Gorman &
Jordan, 2009; Grad, Clark, Dyregrov & Andriessen, 2004; Jordan, 2001; Jordan, 2008;
Silverman et al., 1994). Those bereaved by suicide experience stigma from legal systems, religious belief systems, social support systems, and within themselves through their own belief systems.
The legal system can marginalize the grief experienced by families because of the legal system’s immediate involvement in the death. The death is often identified as a crime scene until the suicide is confirmed, keeping families at bay as the investigation is completed. A qualitative study exploring the effect of coroners' procedures on 16 individuals bereaved by suicide found that the power differentials of the legal system impacted the participant’s grief process. In some cases, the bereaved were re-traumatized because of exposure to graphic evidence and delayed inquests that prolonged the resolution of the death. “The inquest adversely affected resolution of grief in two main ways: by exacerbating common grief reactions associated with bereavement by suicide such as shame, guilt and anger; and, by interfering with necessary grief work, most notably, the task of arriving at a meaningful and acceptable account of the death” (Biddle,
2003, p. 1033).
Religious beliefs also support the stigma associated with suicide and suicide bereavement. Issues around morality are debated and although there are religions that 11 honor suicide as an act that will bring the individual closer to their God, most western religious practices interpret suicide as morally wrong. For some bereaved, religion creates a barrier to understanding the suicide and also contributes to their questioning of faith or understanding of God (Auger, 2000).
Social views about mental illness also play a role in perpetuating stigma. People who are actively suicidal are often hospitalized in an effort to provide support and explore options other than taking their life. Once hospitalized, the label of mental illness creates another layer of stigma. Those individuals who are labeled with a mental illness face a potentially debilitating stigma and continue to be marginalized (Corrigan, Watson
& Ottati, 2003; Corrigan, 2004). Stigma is again perpetuated when an individual identifies with the social view of mental illness and believes the stigma is true for themselves (Corrigan et al., 2003).
Furthering the stigma connected to mental illness is the lack of services for support systems within the medical community. Western culture focuses on the individual, excluding the impact of suicide on the family or community. The health care system emphasizes care for the suicidal individual due to their imminent risk of harm, but little support is provided to families or friends to help them understand the complexity of suicide and suicidal ideation. The absence of support creates a gap in services between someone who is feeling suicidal and their loved ones. Family and friends may experience fear of further suicidal attempts, negative effects on their social networks, and their own mental health concerns due to their loved one's feelings or behavior (Kjellin & Östman,
2005), yet they are rarely provided with an opportunity to explore how they are feeling 12 and what impact the suicidal behavior has had on their relationship.
Dunn and Morrish-Vinders (1987) identifed “normlessness”, meaning the lack of direction by society on how to respond to a suicide death. The normlessness further perpetuates stigmatization because the death and grief are not spoken about. Normal grief experiences can create feelings of uneasiness and leave individuals questioning acceptable responses within themselves and towards the bereaved. As Auger (2000) wrote, “...when death touches our lives in personal ways, we engage in a conspiracy of silence, not wanting others to feel too sorry for us.... We wear a mask of coping because in our culture dependence on others and appearing weak are negative signs” (p. 22). The silence surrounding suicide grief perpetuates isolation for those bereaved by suicide at a time when the bereaved are struggling to respond to the intense grief connected to their loss.
Death, as a natural part of life, is suppressed within our communities. Rando
(1984) defined the American culture as “death-denying” because “[m]any Americans will go to practically any extreme to avoid accepting death for what it is – a cessation of life, a natural part of the life cycle” (pp. 6-7). I would suggest the death-denying attitude is also true for Canadian culture where it is not uncommon for deaths to occur in nursing homes or hospitals, separate from the dying person’s family and friends. Death is pushed to the outskirts of society meaning that the aftermath of death, grief, is also denied. If
“acceptable” death creates fear and avoidance within our culture, it is safe to assume that suicide, which is plagued with moral questions and confusion, also suffers from social stigma. 13
Finally, feelings of blame and lack of support are factors that may promote the development of a complicated grief response. Some individuals bereaved by suicide are at higher risk for developing complicated grief (McMenamy et al., 2008) which creates another level of stigma due to the label of mental illness given to those “stuck” in their grief and the need for further support. Statistics also identify those who are bereaved by suicide to be at higher risk to feel suicidal themselves, compounding feelings of stigmatization and initiating the cycle of stigma again (Bailley et al., 1999; Rando, 1993).
Overcoming stigma is an integral part of suicide bereavement. Those bereaved by suicide are continually faced with stigma that layers their grief process. For some bereaved by suicide the stigma leaves them disenfranchised in their grief. The more suicide is discussed and the stigma is challenged, the healthier the healing process will be for those who have experienced a death by suicide.
Trauma. Suicide is a traumatic loss. “As with other violent deaths, suicide survivors often experience trauma symptoms of horror about the manner of death, along with signs of intrusive reliving and avoidance behaviors that are typical of post-traumatic stress disorder (PTSD)” (Jordan, 2008, p. 682). Regardless if the bereaved was the first to find the body or was present at the time of the death, trauma is compounded.
Understanding the traumatic nature of suicide is part of the grieving process. Some individuals bereaved by suicide talk about how they continue to re-live the final hours of their loved one's life over in their mind, attempting to understand how they were feeling, how they prepared to kill themselves, and what the final seconds before death was like for them. The bereaved re-live the trauma of the suicide while trying to reach an 14 understanding of the death within their own framework of grief (Jordan, 2008).
Suicide death also challenges an individual's belief systems around death and dying. Western society is often privileged to be able to equate death with age; the belief that people die when they are old or ill and have lived a full life. Suicide disputes social understanding of death by creating a moral question around the value of life. Not only do those who have experienced a suicide death have to cope with the physical, emotional, and spiritual trauma of the death, they are faced with the challenge of making meaning of fundamental beliefs that they held to be true around death. For some bereaved, the suicide has opened the door of possibility for them to take their own life in the wake of the feelings of hopelessness and helplessness from their grief (Silverman et al., 1994).
Suicide, an act they may have believed to be incomprehensible, is now an option for them to escape the pain of bereavement.
Intense feelings. “Normal” grief is a complex emotion because it encompasses many feelings such as denial, anger, depression, emptiness, and searching (Kübler-Ross,
1969). Those bereaved by suicide experience all the emotions connected to normal grief along with other emotions that magnify the intensity of their grief journey. A study that measured the grief experiences of those bereaved by suicide to those bereaved by homicide, accidental death, natural anticipated death, and natural unanticipated death within five years of the research commencing concluded that those bereaved by suicide experienced different levels of grief compared to other modes of death (Silverman et al,
1994). Since the completion of this study, other studies have found two years after a suicide death the grief experience is comparable to those who have lost someone due to 15 other modes of death (Barrett et al.,1990; McIntosh, 1993). Jordan (2001) reviewed literature questioning the differences between suicide bereavement and other forms of loss and believes there is conflicting data meaning “we cannot say definitively whether the longer term trajectory of suicide bereavement is the same or different from that of other types of losses” (p. 98).
Audra Knieper (1999) identified “guilt, embarrassment, rejection, shame, [and] isolation” (p. 356) as unique feelings associated with suicide bereavement. Although everyone has experienced these emotions at different times in their life, seldom do we experience all the emotions at once. Those bereaved by suicide experience a flood of these intense emotions as a result of the death. Many studies have identified guilt, embarrassment, rejection, shame, and isolation as more profound and debilitating for those bereaved by suicide (Bailley et al., 1999; Barrett & Scott, 1990; Clark, 2001; Dunn
& Morrish-Vinders, 1987; Knieper, 1999; Mitchell et al., 2004; Pietilä, 2002; Reed, 1998;
Silverman et al., 1994).
Feelings of guilt and blame are closely connected to suicide bereavement. Often the first question asked in regards to a suicide death is, why? Why did their loved one decide to take their own life? Why did the family or close friends of the deceased not stop such a tragedy from happening? These questions are not only asked by others but also of the bereaved themselves, spanning blame across many relationships. “As an often inexplicable death for many survivors, the need to make sense of the frame of mind and motivations of the deceased are major preoccupations for many survivors” (Jordan, 2008, p. 281). One of the main purposes of blame is to shift anger from within the bereaved and 16 towards the deceased and onto others, creating a sense of control in a situation where they have had none (Dunn & Morrish-Vinders, 1987). Blaming exemplifies the sense of powerlessness the bereaved experience as a result of the suicide.
People bereaved by suicide carry unique feelings of responsibility for the death which can also be translated into feelings of guilt. Compared to other modes of death, the suicide bereaved acknowledge a belief that they could have done something different to prevent the death from occurring (Bailley et al., 1999; Barrett & Scott, 1990; Dunn &
Morrish-Vinders, 1987; Knieper, 1999; Reed, 1998). This sense of responsibility, that the bereaved could have intervened to create a different outcome, plays a key role in working through the grief and finding meaning in their loss. For some people bereaved by suicide, understanding how the feelings of responsibility and guilt are linked to feelings of powerlessness gives them permission to move forward in their grief.
The feelings of responsibility may also lead to feelings of rejection from the deceased. The belief their relationship was not enough to keep suicidal behavior at bay may haunt their grief process. A research study surveyed 66 survivors of suicide and 79 survivors of accidental death within 12 months of their loss and found feelings of rejection were reported at a greater rate for those bereaved by suicide than for those bereaved by accidental death (Reed, 1998).
Although there is limited research that explores the effectiveness of interventions specifically designed to support people who have lost a loved one to suicide (Jordan,
2008), some research suggests that accessing social supports is paramount in assisting individuals to move through grief and loss (Barlow & Coleman, 2003; Cerel, Jordan & 17
Duberstein, 2008; Grad et al., 2004; McMenamy et al., 2008). Having acknowledged the need to connecting to support systems, research has documented a relationship between social supports and grief symptomatology that may indicate risk factors for a complicated grief process (Reed, 1998). The impact of the feelings of embarrassment and isolation, which are rooted in the stigma that is connected to suicide, often prevent the bereaved from reaching out for vital support from family, friends, and the community. Whether the lack of support is perceived by individuals who have lost someone to suicide or a reality of their environment (Knieper, 1999), the sense of isolation and embarrassment is unique to suicide bereavement.
Labelling grief as “complicated” continues to be debated by counsellors on its usefulness for bereaved individuals. Some professionals question the value and impact of this mental health label on clients, with convincing arguments emerging from both sides for and against the use of the term complicated grief. Complicated grief (CG),
“also referred to as traumatic grief or prolonged grief disorder, is a condition in which acute grief is prolonged indefinitely, accompanied by complicating thoughts, behaviors, and dysfunctional emotion regulation. CG can be understood as a condition that arises when the normal progression from acute to integrated grief does not occur” (Shear & Mulhare, 2008).
Research has indicated that closely related survivors of suicide are more likely to develop a complicated grief response than those individuals bereaved by a natural death
(de Groot, de Keijser & Needleman, 2006; Mitchell et al., 2004). Mitchell et al. (2004) identify complicated grief as a subcategory of bereavement indicating it is “separate from normal grief and other psychiatric disorders, such as bereavement-related depression and anxiety disorders” (p.13). 18
Several studies have identified risk factors linking suicide bereavement and complicated grief (Melhem, Day, Shear, Day, Reynolds III & Brent, 2003; Mitchell et al.,
2004; Séguin et al., 1995). Research findings of 146 adolescents who have lost someone to suicide surveyed six, 12, 18, and 24 months after the suicide death indicated risk factors associated with complicated grief. Some of the factors included their feelings of responsibility or ability to prevent the suicide, history of mental health concerns, and lack of social support (Melhem et al., 2003). Although these risk factors may not apply to all individuals bereaved by suicide, awareness around the potential for interruption in the grief process may aid in identifying complicated grief prior to it manifesting unnecessarily. The movement of an individual’s grief experience from a normal grief journey to that of a mental illness-related complicated grief can further stigmatize the bereavement experience for those who have lost someone to suicide.
Suicide attempts. There is a small body of research that explores the impact of suicide attempts on caregivers. This research indicated caregivers experience anxiety, blame, increased stress, aggression, ambivalence, decrease in communication with the person who attempted, dissatisfaction with treatment, compromised mental and physical health, and a desire for professional support after the suicide attempt (Chessick, Perlick,
Miklowitz, Kaczynski, Allen, Morris, Marangell et al., 2007; Magne-Ingvar & Öjehagen,
1999a, 1999b; Talseth, Gilje & Norberg, 2001; Wagner, Aiken, Mullaly & Tobin, 1999;
Wolk-Wasserman, 1986). Lester and Walker (2006) acknowledged the importance of learning more about the impact of suicide attempts and suggest the lack of research around suicide attempts lies in the stigma that is connected with suicide. 19
Magne-Ingvar and Öjehagen (1999a) conducted semi-structured interviews with significant others of patients admitted to the hospital for a psychiatric assessment after a suicide attempt. The purpose of the interviews was to identify “...whether information from a significant other would be helpful in the psychiatric assessment...” (p. 73) and to assess the well-being and the need for support of the significant other. The researchers then completed a follow-up study (Magne-Ingvar & Öjehagen, 1999b) with the significant others one year after the initial suicide attempt to reassess their well-being and need for support.
Magne-Ingvar and Öjehagen’s (1999a) findings conveyed that significant others noticed possible suicidal ideations and behavior change of the patient. Significant others were also able to provide important information used in the treatment of the patient. The research identified shame, guilt, anger, worry, and a desire for further support from a professional as key feelings for the significant other. One year later, Magne-Ingvar and
Öjehagen (1999b) found that significant others indicated a lack of communication with their own social networks, continued stress due to the mental health of the patient, dissatisfaction with treatment, and feelings of being uninvolved in treatment, ill-informed and unprepared at the time of discharge.
Other research has identified feelings of anger, worry, and ambivalence as common responses to a suicide attempt. Included in these finding are feelings of detachment from the person who has attempted, especially if there have been multiple attempts (Wagner et al., 1999; Wolk-Wasserman, 1986).
These research projects exploring the impact of suicide attempts on significant 20 others accessed participants connected to the health care system, yet, not all people who attempt suicide are admitted to a psychiatric program for assessment or access support outside of their own support systems. People who die by suicide often attempt to take their own life several times prior to completing suicide, but it is difficult to measure the number of attempts due to the variance of lethality of the attempts (Langlois & Morrison,
2002). Some researchers have estimated 0.6 percent of the population in the United States of America attempt suicide while 3.3 percent experience suicidal ideations (Mann, Apter,
Bertolote, Beautrais, Currier, Haas et al., 2005).
To date, a Canadian social policy does not exist for suicide prevention. The
Canadian Association of Suicide Prevention, an organization supporting suicide initiatives, along with other community agencies and individuals interested in suicide prevention have proposed the Blueprint for a National Suicide Prevention Strategy for
Canada (Canadian Association of Suicide Prevention [CASP], 2005). This Blueprint, which has been encouraged to be adopted as the Canadian suicide prevention strategy, identifies populations who are at higher risk for suicide but there are no suggestions of support for families or friends who have a loved one who is considering or who has attempted suicide.
The impact of a suicide attempt on support systems is another unique quality that separates suicide bereavement from other forms of bereavement. The feelings that exist as a response to a suicide attempt may still be present at the time of a completed suicide.
Suicide attempts may add one more layer to the grief experience of those bereaved by suicide, possibly further complicating their grief process. To what extent, if any, do 21 suicide attempts play in the bereavement experiences of those left behind is a question that interests me and one that research has yet to ask.
Uniqueness Disputed
Although there is research that supports what Jordan (2008) refered to as
“thematic issues that are likely to be more prominent and intense after a suicide than after most other types of loss” (p. 680), there is a small body of research that has concluded that suicide bereavement is no different than other forms of grief. McIntosh (1993) is one researcher who disputes the claim that suicide bereavement is unique. He reviewed control group studies of individuals who had lost someone to suicide and explored the grief reactions and other related experiences of those bereaved by suicide. Based on the literature review, McIntosh believes there are many more similarities than differences in the bereavement process for those who are bereaved by suicide versus other modes of death. He identifies methodology limitations of the studies citing sample sizes, including predominantly female participants, non-standardized measurements, and no bereavement controls as primary criticisms of the reviewed studies.
McIntosh's findings indicate the number of differences present for the suicide bereaved are indistinguishable in the second year after the death. These findings were also confirmed by Barrett et al. (1990) who reported “some of the grief reactions that have been said to differentiate suicide bereavement from other forms of bereavement
(feelings of guilt, loss of interpersonal support, and self-destructive behavior) (brackets in the original) do not necessarily do so when reported 2-4 years after the death” (p. 12).
Initially, suicide bereavement may present as different than other forms of loss, but after a 22 period of time the grief process is congruent with other modes of death.
A study completed in 2003 exploring the psychosocial distress of parents who were bereaved by youth suicide, sudden infant death syndrome, and child accidental death found striking similarities between the sudden and traumatic deaths and suicide loss
(Dyregrov, Nordanger & Dyregrov, 2003). This research concluded there was no difference in the grief experience of parents bereaved by suicide or other traumatic or sudden modes of death. The commonality between the parent-child relationship may contribute to the similarities found in the grief experiences.
Another criticism of the research citing suicide bereavement as unique is the exclusion of influencing factors on the grief process. Feeling responsible or able to prevent the death is identified as a common theme in suicide bereavement but other influencing factors not relating to the mode of death can intensify the grief process. A history of interpersonal conflict, depression, and anxiety disorders in the family have been identified as factors contributing to complicated grief for individuals (Melhem et al.,
2003). McIntosh (1993) suggested these influencing factors, which are not exclusive to those bereaved by suicide, are not considered when exploring the grief connected to suicide bereavement. As a result, true measures of the grief experience have not been completed.
A question can be raised around the perception of stigma for individuals bereaved by suicide versus the reality of their experience. An investigation into the reactions towards those bereaved by suicide suggested stigma connected to suicide bereavement was not reflected in the quantitative data collected during the study. The study suggested 23 that “[t]he bereaved person's actual or imagined concern about blame and guilt may lead to [stigmatization]. When [suicide is] raised, the bereaved person feels stigmatized and the potential comforter is made to feel uncomfortable” (Allen et al., 1993-4, p. 46).
Calhoun, Selby & Abernathy (1984) also questioned how stigma is created for individuals bereaved by suicide and if the stigma is perceived or a reality.
Research around mental illness has defined stigma as a collection of both “public stigma (ways in which the public reacts to a group based on stigma about that group) and self-stigma (the reactions which individuals turn against themselves because they are members of a stigmatized group)” (Corrigan, 2004, p. 114). The internalization of self- stigma creates heightened negative emotions, such as anger and despair, and encourages isolation from others to hide their connection to the stigmatized group (Mak & Cheung,
2008). This understanding of self-stigmatization supports the studies’ findings citing stigma as an internalized response to the percieved belief that stigma is connected to a suicide death.
Finally, van der Wal (1989) concluded there is evidence supporting suicide bereavement as qualitatively different from other modes of death in the survivors' search for meaning, denial of the death, feelings of rejection, fear of susceptibility to suicide themselves, and questioning religious understanding of the death. Regardless of these unique qualities of suicide bereavement, van der Wal believes there is no evidence the process of grieving is different for a survivor of suicide versus other modes of death. He instead believes “[i]t is more important to investigate which characteristics are shared by those who show signs of a complicated grief process. Or, [to question] what factors are 24 related to the acceptability of causes of death in general and to suicidal death in particular” (van der Wal, 1989, p. 167). Like McIntosh, van der Wal encouraged the exploration of individual characteristics that may be identified as risk factors for complicated grief.
Conclusion
Not all communities view suicide death and grief due to suicide through the same lens. My belief in the common themes connected to suicide death is based on working closely with those impacted by a suicide death and living the legacy of suicide loss. For me, it is clear how suicide bereavement differs from other bereavement experiences and leaves many bereaved by suicide marginalized by their grief, therefore, normalizing grief responses for clients can be a vital part of their grief journey.
Research about suicide bereavement, such as the impact on family systems, older adults, youth, and social systems, is lacking. Although the uniqueness of suicide grief is identified, there are no best practices to guide how to counsel and support the bereaved.
Most of the research studies presented have accessed a part of the population interested in talking about their bereavement experience. In some cases, the population researched were in their late teens to early adulthood and were provided course credit to participate, therefore the motivation to help researchers better understand suicide bereavement may not have been a factor. The majority of people who are bereaved by suicide do not talk about their experience, meaning the research studies are based on people who are willing to share their stories. Those people who do not access services also have important information to share about their experiences. 25
Social workers play an integral role in supporting people bereaved by suicide through their grief process. Core social work values look beyond the individual and explore the impact of societal and cultural beliefs, family dynamics, and the role of the therapists on the grief experience, incorporating all aspects of this unique grief into the healing process. The popular theories of grief may inadvertently reinforce the stigma of abnormal grieving for those bereaved by suicide.
Grief is an individual experience. Loss often changes the way people see themselves in relation to the rest of the world. No two grief processes are alike but research seeks to find commonalities among the bereaved in order to understand the complexity of the grief process and the impact on their lives. The thread of commonalities allows family, friends, and professionals to empathize with the bereaved and support them as they mourn.
Edwin Shneidman believes suicide alters the lives of those bereaved by suicide forever. Most people who share their stories about suicide identify their grief as different than any other types of bereavement they have experienced. An understanding of the journey and social implications connected to suicide loss enables social workers to empower the bereaved to move though their grief. Yet, the impact of a suicide attempt on support systems has not been fully researched nor do we understand how those attempts affect a person’s grief journey at the time of a suicide death. Most treatment programs aim to provide support for the individual who is suicidal excluding their support systems in the treatment process. The purpose of this research paper is to explore the impact of suicide attempts on the bereavement experience of those impacted by a suicide death. 26
How did their responses to the suicide attempt affect their grief when their loved one died by suicide? I hope a deeper understanding of the impact of the suicide attempt may allow us, as health care providers, to provide better support by asking different questions and providing different services if necessary. 27
Chapter Three: Methodology
Choosing a Methodology
The question posed in this research study asks how the experience of previous suicide attempts impacts the grief journey for those bereaved by suicide. The study seeks an understanding about what the experience of a completed suicide following suicide attempts was like for participants. Information about experience can be derived quantitatively only if there is sufficient prior information available to enable the construction of a scale or survey. In this case, very little is known in the area of how suicide attempts affect significant others and therefore the approach must be qualitative.
Creswell (2007) identified five approaches to qualitative research: narrative, phenomenological, grounded theory, ethnographic, and case study research methods. It is important to briefly consider each of the five approaches and why I have chosen phenomenology as the method of inquiry for this study.
Narrative research employs “restorying” (Creswell, 2007, p. 56), the process of expressing how a person tells their story or experience and is often used to see how a participant’s story changes over time. Using the narrative approach, one or more participants are acceptable as a sample size for a research study. It is important for me to have the experiences of each participant in the study heard and I also want to ensure their stories come from their own experiences and are not intertwined with how I interpret their story, which could make the narrative approach a suitable choice for my study. Also, my study has four participants fitting within the narrative methodology sample size. I did not choose narrative research because of its focus on the change of a story over time. I am 28 looking to capture what aspects of the grief journey may or may not have been affected by the experience of previous suicide attempts. Finally, although I use aspects of narrative therapy in my clinical practice, it is not a model that I have been particularly drawn to incorporate completely.
Grounded theory aims to develop a theory from the data and requires saturation,
20 - 60 participants, according to Creswell (2007, p. 79), to accurately depict the theory.
The number of participants in my study was limited to four. Despite the fact I have an idea that certain patterns may present themselves in the data, a sample of four is insufficient for meaningful theory generation.
I did not choose ethnography or case study approaches for my thesis because I wanted to understand the essence of the participants’ experience. Ethnography inquiry requires a sample size larger than 20 participants and encourages a researcher to be
“immersed (italics in original) in the day-to-day lives of the people” (Creswell, 2007, p.
68). Again, my sample size is small and only one interview was conducted with each participant, with three of the four interviews conducted via telephone, so minimal contact was made with each participant.
Case study research involves “the study of an issue explored through one or more cases within a bounded system” (Creswell, 2007, p. 73). Creswell also identified the importance of knowing the “‘boundaries’ (quotes in original) of a case - how it might be constrained in terms of time, events, and processes...” (Creswell, 2007, p. 76) but given little information is known about the topic I am studying, creating boundaries around the case is difficult. I do not know how the participant’s bereavement journey has been 29 affected by the suicide attempts of their loved one, therefore, a case study approach to the research question is not a good choice.
I chose the phenomenological approach because the focus of the research is on
“understanding unique individuals and their meanings and interactions with others and the environment” (Lopez & Willis, 2004, p. 726). The phenomenological method encourages a researcher to explore the lived experiences of participants (Creswell, 2007) and to develop a rich description of how a phenomenon is experienced by them. Kleiman
(2004) stated “[p]henomenology 'is' (quotation marks in the original) the study of essences; accordingly, all problems amount to finding definitions of essences, such as the essence of an experience” (p. 9). I want to understand the essence of how suicide attempts affected support systems’ grief journeys after the suicide death of their loved one. Given no other research has been completed on this topic, phenomenological methodology allows for a deeper understanding of the essence of the participant’s experience which may, in turn, lead to further research studies.
Phenomenology branches into two primary schools of thought that guide how a researcher investigates a phenomenon - descriptive and interpretive (Finlay, 2009;
Laverty, 2003; Lopez & Willis, 2004; Wojnar & Swanson, 2007). The descriptive tradition was founded by Edmund Husserl (1859-1938), who began his academic career as a mathematician but his interest in philosophy became his focus as he questioned how we understand phenomena and consciousness (Laverty, 2003). Husserl believed that
“experience as perceived by human consciousness has value and should be an object of scientific study” (Lopez & Willis, 2004, p. 727). Husserl also believed in universal 30 essences, meaning that any person’s lived experience of a phenomenon has common features to others who have lived the same experience (Lopez & Willis, 2004). Therefore, the focus of phenomenology “is toward illuminating details and seemingly trivial aspects within experience that may be taken for granted in our lives, with a goal of creating meaning and achieving a sense of understanding” (Laverty, 2003, p. 7).
Interpretive phenomenology, also referred to as hermeneutics, emerged from the descriptive tradition. Martin Heidegger (1889-1976), a student of Husserl (Laverty, 2003) did not believe that biases, beliefs, and experiences could be bracketed from who a person is. Interpretive phenomenology goes beyond understanding a phenomenon to understanding how people are influenced by the world they live in or, as Heidegger termed, being-in- the-world (Lopez & Willis, 2004). “In relation to the study of human experience, hermeneutics goes beyond mere description of core concepts and essences to look for meanings embedded in common life practices....The focus of hermeneutic inquiry is on what humans experience rather than what they consciously know” (Lopez &
Willis, 2004, p. 728).
The one key difference between research using the descriptive or interpretive traditions is the process of bracketing. The descriptive tradition requires the researcher to take steps to remove themselves from the research process, bracketing their own beliefs and experiences to find the pure essence of the participant’s experience. Heidegger’s interpretive tradition disagrees with the process of bracketing arguing that a person cannot shed or put aside understanding or knowledge (Laverty, 2003). Interpretive phenomenology “is based on the perspective that the understanding of individuals cannot 31 occur in isolation of their culture, social context, or historical period in which they live”(Wojnar & Swanson, 2007, p. 174). The goal of this research project is to explore the impact of suicide attempts on the participants, focusing on their interpretation of how suicide attempts affected their lived experience. Although I believe bracketing is a difficult process, I wonder if it is not something that we do with clients when we meet them for the first time, trying to understand their experiences from their perspective. It is important to me to bracket out my own experiences and beliefs in order to allow the experiences of the participants to be heard.
I have selected a modified Husserlian descriptive phenomenological research method as presented by psychologist Amedeo Giorgi (2009) for this research study.
Husserl initially established phenomenology as a philosophy, whereas Giorgi has expanded Husserl’s works to develop a scientific approach to phenomenology that accounts for the necessity of validity (Giorgi, 2009). I have chosen this method because the modified descriptive phenomenological tradition seeks the essence of people’s experience as they are presented to the researcher but also requires rigor in the research.
“The descriptive phenomenological attitude neither adds to nor subtracts from what is
‘given’ (quotation marks in the original) regardless of how it presents itself” (Giorgi,
2009, p. 78). Exploring and analyzing data within this tradition will provide a rich description of how multiple suicide attempts of loved ones affected the bereavement journey of the participants after a death suicide.
Modified Descriptive Phenomenological Methodology
Understanding the history explaining the evolution of the interpretive tradition 32 from the descriptive tradition and the language within the descriptive tradition aids in understanding how I interpreted the methodology for this study. Three key concepts are embedded in the language of descriptive phenomenology: consciousness, lived experiences, and essences. Consciousness, in Husserlian terms, “refers to the totality of the lived experiences that belong to a single person” (Giorgi, 1997, p. 235). Kleiman
(2004) referred to lived experiences as “those experiences that reveal the immediate, pre- reflective consciousness one has regarding events in which one has participated. One uses such lived experiences as the basis for recalling how one lived through the event, thereby transforming them into objects of consciousness” (Kleiman, 2004, p. 10). Therefore, consciousness is the awareness of how lived experiences are described, understood, and integrated into our lives. Essences are defined as the most essential meaning for a particular context. Essences are “the articulation, based on intuition, of a fundamental meaning without which a phenomenon could not present itself as it is” (Giorgi, 1997, p.
239). Finding the essence in what the research participants are sharing is the goal of this research project.
The modified Husserlian phenomenological approach identifies three key criteria that must be employed to aid in finding the essences of the interviews: 1) phenomenological reduction is used throughout the study; 2) the most essential meanings of the phenomenon are delivered; and 3) a rich description of the phenomenon is provided (Giorgi, 1997). These criteria also work to ensure the rigor of the study.
Phenomenological reduction. Phenomenological reduction is the key component of descriptive phenomenology that guides the researcher for the duration of 33 the study to account for researcher subjectivity. The purpose of using phenomenological reduction is to ensure all knowledge obtained throughout the research process is free of skepticism and relativism (Giorgi, 2009), meaning that the researcher’s own beliefs, values, and perceptions do not influence the research findings. Phenomenological reduction supports the validity of the research. “Using this attitude, the researcher strives to be open to the ‘other’ (quotation marks in original) and to attempt to see the world freshly, in a different way” (Finlay, 2009, p. 12). Phenomenological reduction enables the researcher to see the essence of what each participant is saying.
Husserl identified levels of phenomenological reduction that could be obtained through various attitudes undertaken by the researcher. The first of these attitudes uses language to maintain an understanding that “one does not posit the existence of the object but sees it simply as a presence to be explored” (Giorgi, 2009, p. 90). In the case of my research around grief, I could not claim that a participant experiences grief but that a particular response made by a participant has presented itself as sadness or loss. Citing findings of other research that claims sadness and loss may be identified as part of the grieving process illustrates how those emotions relate to grief. Giorgi (1997) indicated this attitude distinction contributes to the rigor of the research. This first attitudinal shift is particularly important when analyzing data and will be seen throughout the data analysis and findings section of this research.
Bracketing, also known as epoché, is another attitudinal shift used in the phenomenological reduction by the researcher. Paley, (1997) described bracketing as “a technique designed to reduce bias and preconception” (p. 189). Lopez & Willis (2004) 34 explained bracketing by stating “[t]he goal of the researcher is to achieve transcendental subjectivity...[which]...means that the impact of the researcher on the inquiry is constantly assessed and biases and preconceptions neutralized, so that they do not influence the object of the study” (pp. 727-8). Giorgi (2009) reiterated bracketing “is not a matter of forgetting the past; bracketing means that we should not let our past knowledge be engaged (italics in original) while we are determining the mode and context of the present experience” (p. 92).
As noted above, bracketing is identified as one of the primary differences between interpretive and descriptive phenomenology. Interpretive phenomenologists argue a person can not hold in abeyance their own experiences. Giorgi acknowledged that although bracketing can be difficult, it is not impossible and cites experiences where bracketing is requested of us, such as jury duty when asked to disregard evidence presented in court or a scientific researcher trying not to influence his or her hypothesis
(Giorgi, 2009). I would argue, bracketing is also used in parenting when we encourage our children to make their own choices without our experiences or beliefs influencing them. Giorgi (2009) stated “[o]f course, there is not a priori way of guaranteeing that one has bracketed successfully. One can only judge from the results, and even then assessment of the results may not be perfect” (p. 92).
Giorgi identified the role of the researcher is to be present with the participant as they are sharing their lived experiences, being in the moment and “fully attentively present to an ongoing experience rather than habitually present to it” (Giorgi, 2009, p.
92). I would suggest being in the moment with clients is what helps establish rapport and 35 how trust is created. Also given my contact with the research participants was limited, it was important I stay present throughout the interview process to be fully immersed in the essence of their lived experiences as they shared their story.
As a social worker, the tenet of person-in-environment can be seen as an appropriate fit for bracketing because we want to work with people from where they are at. Our own beliefs and assumptions of how the world is experienced may not be the experiences or beliefs of our clients. “Bracketing means ‘holding in suspension,’ (quotation marks in original) keeping a tension between the past and the present in order to discern their respective roles” (Giorgi, 2009, p. 93). I cannot forget my own lived experiences but I want to be aware of how my biases influence me and, as a social worker, try and not have those biases influence others.
Wall, Glenn, Mitchinson, and Poole (2004) explored the use of a reflective diary before the beginning of the study (pre-action), during the interview process of the study
(in action), and as a reflection back on the process of the interviews (on action). The use of the reflective diary in this format encourages the researcher to consider their own biases throughout the research process, therefore assisting with the bracketing process. I used a reflective diary through all levels of this research study and will discuss what ideas were bracketed further on in the methodology section.
Another level of phenomenological reduction used during data analysis is called free imaginative variation. Free imaginative variation is used to help clarify what is considered meaningful within the structure of an experience. Take the following example extracted from an interview for this research study where the participant shared: 36
“We didn’t have a true understanding (of mental illness). We knew [Janice] had a (mental illness), we didn’t understand that she really needed an advocate. I mean we are strong people, Jack and I, we would have gone anywhere in the world. We financially have the ability. We could have taken her anywhere to get help. We did not know. Our ignorance was amazing” (Margaret interview, 2009).
Giorgi (2009) defined free imaginative variation as the process by which “one mentally removes an aspect of the phenomenon that is to be clarified in order to see whether the removal transforms what is presented in an essential way” (p. 69). If the removal of the aspect changes the meaning of what is being presented, it may be essential to the structure. Those essential parts of a structure identify the essence of what the participant is saying. In this example, removing the comprehension of mental illness makes what Margaret is saying, meaningless. The essence of this statement is that they did not understand the depth and breadth of mental illness.
These attitudinal shifts are integral components of the phenomenological reduction. The levels of the phenomenological reduction contribute to the validity of the study. Giorgi (2009) stated the following about the phenomenological research method:
“....[T]he approach offers both openness and rigor. Openness because anything experienced as experienced is considered a legitimate topic for investigation and the process of free imaginative variation gives a wide scope for determining the relevancy of the given. Rigor because whatever is given is described precisely as it presents itself” (p. 70).
The modified descriptive phenomenological method presented by Giorgi (2009) also indicates the importance of the researcher using this approach to research from the perspective of their own discipline. Social work explores the holistic understanding of a person in their own environment. As a social worker, I am interested in how the participants experienced the systems they were involved in, their relationships with 37 others, and how they identify the suicide attempts as impacting them and their grief journey. The social work perspective of person-in-environment also influences the direction of the interview and thereby influences how the analyzed data are presented.
The following sections speak specifically about the process of the research study and how the descriptive phenomenological method was used throughout the study. 38
Chapter Four: The Research Design
Sampling
Nonprobability sampling was used in this research study. Given the stigma that surrounds suicide and mental health (Allen et al., 1993; Bailey et al., 1999; Barrett &
Scott, 1990; Begley & Quayle, 2007; Corrigan et al., 2003; Corrigan, 2004; Feigelman et al., 2009; Grad et al., 2004; Jordan, 2001; Jordan, 2008; Silverman et al., 1994), encouraging those bereaved by suicide to talk about their experiences is often challenging. Recruitment of participants is necessarily by invitation, resulting in an availability sample. Three of the participants for the study were recruited from a recruitment notice (see Appendix 1) posted on the Survivor Advocate listserv, a
Canadian-based listserv for individuals bereaved by suicide and professionals who are involved in suicide prevention initiatives. The Survivor Advocate listserv was the only place a recruitment notice was posted. It is possible that agencies involved on the listserv posted the recruitment notice but I had no contact outside of the listserv. There were only three responses to the recruitment notice and all three respondents became participants in the study. The fourth participant is a colleague. He first heard about my research topic when I was beginning my Master in Social Work quest and he indicated interest in participating in the study when we were speaking about the preparation of my ethics proposal.
Many reasons can be cited as to why there were a small number of responses to the recruitment notice. Those people who work in the field of suicide and suicide prevention who would have qualified for this study may already be engaged in other 39 projects. Also, individuals bereaved by suicide may not be interested in talking about the time before the death of their loved one or, simply, the research project held no interest for them. Another possible reason for the low response rate is that support systems may not have known about the suicide attempts. There was also a period of two weeks when the email address of the researcher was not synced with the University of Calgary email address used in the recruitment notice. This error may have also contributed to a low response rate to the recruitment notice.
In order to be included in the study, all participants were adults who had lost someone due to suicide eliminating any need for external consent if under the age of 18 years. The participants were aware of two or more suicide attempts made by the deceased and had been bereaved between three and 13 years. Participants consented to a 60-90 minute interview regarding their experience of the suicide attempts prior to the suicide death of their loved one.
Face-to-face interviews were my preference in order to recognize non-verbal communication unidentifiable through phone interviews but, given three of the four participants lived outside of Alberta, face-to-face interviews with all participants was not possible within this study. Therefore, three of the four interviews were telephone interviews completed via Skype, an internet communications software that allows for calls to be recorded. One interview was completed face-to-face at the office of the participant and recorded with the same recording device used with the other three interviews.
Each participant was provided with a hard copy of the consent form outlining 40 confidentiality, information on how data will be stored, and when data will be deleted.
Participants were given an option to use their own name for the research study or a pseudonym; two of the four participants chose to use their own names. The limitations and expectations of confidentiality was also reiterated prior to beginning the interview process and participants were reminded that they could stop the interview process at anytime if they did not want to talk any further about their experience or if they were finding the conversation too difficult.
Semi-structured interviews were conducted in order to encourage the participant to share information they felt relevant to their experience (see interview schedule,
Appendix 2). I began each interview by asking the participant to talk about who it was they lost and what their experience with the suicide attempts was like for them. Open- ended questions were used to direct the participants to talk about the phenomena of suicide attempts and grief, encouraging them to start the interview process by recalling what was most important for them therefore presenting experiences that have already been established as meaningful (Kleiman, 2004, p. 10).
As the interviewing process continued, I was able to draw on meaning units, or themes, from earlier interviews and check to see if these meaning units were applicable to other participants. An example of one of the meaning units that I inquired about through all the interviews was about whether the death of the deceased was anticipated or completely unexpected. The goal of the semi-structured interview process was to encourage each participant to fluidly share the pieces of their experience that held most meaning for them. 41
Trustworthiness
Trustworthiness is important in qualitative studies to ensure the data that are provided are accurate. As a novice researcher with no prior research experience, I felt it was important to create several layers of trustworthiness and, therefore, for the purposes of this thesis, I will identify measures that were taken both within the tradition of descriptive phenomenology and criteria that are expected in other qualitative studies to ensure trustworthiness of the research. It is necessary that the findings be an accurate representation of the meanings presented by the participants given the exploratory nature of the research project. According to qualitative and phenomenological traditions, credibility, transferability, dependability, confirmability, and bracketing were used to ensure the trustworthiness of the study.
Credibility. Triangulation of data sources is difficult in this study given no other researchers have examined how suicide attempts influence the bereavement experience for support systems after a suicide death. However, the literature review indicates a small body of research that explores the affects of a suicide attempt on support systems
(Chessick et al., 2007; Magne-Ingvar & Öjehagen, 1999a; Magne-Ingvar & Öjehagen,
1999b; Talseth et al., 2001; Wagner et al., 1999; Wolk-Wasserman, 1986). Along with the research on suicide attempts and support systems, suicide bereavement research was widely accessed and included in the literature review in this study. Although the bereavement research does not directly apply to this study, the findings do provide a deeper understanding of how suicide attempts may affect support systems and shed light on how those finding, in turn, influences suicide bereavement. 42
None of the participants in this study were related or connected to the same suicide death which may limit the triangulation of the data. Neither was I able to interview any other family member or friend connected to the same suicide death as any participant.
To further the credibility of this study, I consulted with my thesis supervisor, Dr.
Margaret Williams, during every phase of the research. She provided feedback on the chosen methodology, interviewing process, data collection, and analysis and how to present the findings. Dr. Williams also helped identify my biases that were recorded in my reflective journal and bracketed during the research process. Given my background as a clinician, this research project has been daunting and with Dr. Williams’ support I was able to continue to move forward, consulting with her each step of the way.
According to negative case analysis, all data collected during the interviews are included in the study and data sources contradicting the uniqueness of suicide bereavement were included in the literature review. Although there are similarities in the experiences of the participants, there were also differences which have been cited and explored in both the findings and discussion sections of the study.
To ensure referential adequacy, the electronic recordings of the interviews have been archived to compact disc and both electronic and hard copies of the transcripts were made. All interview notes, thoughts, and biases along with journal entries have been stored together. The electronic recordings and transcripts have both been kept on a password and firewall protected computer. The compact disc of the interviews and paper copies of the transcripts have been kept in a locked file cabinet. My written notes, 43 thoughts, biases, and journal entries were used for reference to throughout the writing of this paper.
Member checks were completed with each participant. Transcripts were mailed to three of the four participants and one transcript was sent via email as per the participant’s request. Participants were asked to review the transcripts and forward any comments or concerns back to the researcher. One participant requested timeline information be sent to her regarding her interview and responded with further information and feedback regarding her experience. This feedback has been included in the analysis.
Transferability. Transferability is incorporated within phenomenological research studies through the development of a rich description of the participants, the participants’ situation, and how a phenomenon is experienced by the participants. The description allows for readers to decipher whether or not the essences pulled from the raw data applies to them.
Dependability. Efforts were made to maintain the consistency of the study. Due to geographical limitation, three of the four interviews were conducted via Skype where one interview was conducted face-to-face. Skype was used to contact participants via their land phone lines, therefore no face-to-face contact was made. All the participants were encouraged to start the interview where they wanted in their experience and share about whom they lost. All the interviews were semi-structured with specific queries being made about the suicide attempts of their loved one and how they believe the attempts affected their grief.
The same researcher conducted, analyzed, and transcribed all the interviews. The 44 data analysis followed the same format using free imaginative variation.
Confirmability. The component of confirmability when ensuring the trustworthiness of a study parallels Husserl’s notion of bracketing. Given the number of years it took for this research project to come to fruition, I developed a conscious understanding of why I wanted to research this topic and also what findings might be uncovered. In order to embark on a research project under a phenomenological methodology, I needed to completely understand my beliefs and biases and actively hold them in abeyance. The use of a reflective diary, or journal, not only helped in maintaining the confirmability of the study, it also ensured the process of bracketing was completed consciously throughout the study.
Bracketing. I used a reflective diary, or journal, throughout the research process to help me identify biases and responses. Wall et al. (2004) suggested the use of a reflective diary to aid in the development of bracketing skills in three phases: pre-action,
‘in’ action, and ‘on’ action. As mentioned above, bracketing is to hold in suspension your own biases. Prior to beginning the study, I needed to understand my biases which may influence the research and therefore need to be bracketed. These biases are as follows:
Pre-action.
Work with clients. What drew my interest in wanting to explore how suicide attempts affect support systems and then ultimately affect their bereavement journey was my direct work with clients. Many of the clients I worked with who had lost someone due to suicide had also experienced suicide attempts of their significant other and, often, did not access support for themselves at the time of the suicide attempt. For some of those 45 clients, the suicide attempts plagued them during their grief experience with questions of
“what could I have done differently”, “Why”, or statements such as “I thought this time things would be different”. Through my work with clients, I identified a cyclical pattern of loss and hope that seemed to be connected to the cyclical nature of suicidal ideation but ended in the trauma of the suicide death. This idea needed to be bracketed not only because it is my own belief drawn from others’ experiences but also because the cyclical nature may not be the experience of the participants.
Academic work. Post secondary academia demands the exploration, evaluation, and critique of research within your area of interest. This thesis was written after spending three years studying suicide and suicide bereavement through many different lenses. The academic work has molded my belief system specifically around the impact of stigma on suicide bereavement and the understanding of the need for further research connected to all areas of suicide attempts and suicide bereavement.
Being a social worker. Removing ego from this work, and life, is challenging. An important step of descriptive phenomenology is to hear the experiences of others. Years of post-secondary school and 12 years of clinical work make it second nature for me to hear where a client is at and help them move to a different place of healing. I needed to be clear that this was not a counselling session but an opportunity to simply be present as the participants told their story. At times throughout the research process, I found myself wanting to move into the helping mode but I needed to ensure I stayed in the present to witness the participant’s story.
‘In’ Action. During most of the interviews I took notes identifying demographics, 46 feelings expressed, and themes that were presented by the participant. The reflections written immediately after the interviews helped me capture my own thoughts, feelings, and questions about the interview. An example of one reflection written after an interview is:
Striking how unsupported, left out, this family felt given the history of Janice’s mental health....They truly believed life was improving which speaks clearly to the thread of hope woven throughout their experience....When families seek to support do they miss their own opportunities for understanding because they are not identified as the client? (Reflective diary, Kim Everingham)
These journal entries allowed me to become aware of my thoughts or biases that developed as a result of the interview process. The need to bracket these new biases is part of the phenomenological reduction process. The new biases that grew out of the research were:
Failure of system. The initial participant interviewed spoke about her experience with the system and how she felt the system failed her daughter. I know over the years as a social worker, I have also felt there were times when the medical systems did not provide clients with the support I thought they should have. The participant’s experience not only triggered my own bias but signaled me to ensure I did not carry my biases, only her ideas, into future interviews.
Misunderstanding of mental illness. Again, the initial participant spoke about a misunderstanding of mental illness and how that misunderstanding contributed to her grief experience. I did not know if other participants in the study misunderstood mental illness or even struggled with mental illness themselves therefore this is another bias that must be bracketed. 47
‘On’ Action. The reflective diary was helpful to critique the process of the interviews, the findings ,and my abilities as a researcher. I was able to identify aspects that I thought needed improvement such as how I conducted the interviews and a continual check on whether I bracketed my own lived experiences throughout. Reflecting back on interviews left me awed by the strength each participant had to share their story and the depth of how the suicide of their loved one continues to affect them.
Overall, the use of the reflective diary aided in keeping me on track prior, during, and after the interviews were completed. The process further aided in the completion of the data analysis where bracketing to achieve the natural attitude is used to identify meaning units and constituents.
Transcribing data. The data were transcribed omitting “um...ah...um hum” for ease in reading and analysis. Nonverbal communication such as laughing, crying, and longer pauses were included in the transcription.
Analysis. The raw data were analyzed through three steps outlined by Giorgi
(2009): 1) read for the sense of the whole; 2) determination of meaning units; and 3) transformation of participant’s natural attitude expressions into phenomenologically psychologically sensitive expression.
Read for the sense of the whole. The raw data were read over completely in order to have a clear understanding of the overall interview. The purpose of this first read is for the researcher to get a “sense of the whole while sensitively discriminating the intentional objects of the lifeworld description provided by the participant” (Giorgi, 2009, pp. 128-129). At this point, nothing is recorded but simply noticed. 48
Determination of meaning units. During this phase of the analysis, the raw data were broken up into sections determined by a “significant shift in meaning” (Giorgi,
2009, p. 130) signifying a new or changed theme presented by the participant. According to Giorgi (2009), this phase of analysis depends upon the lens the researcher is using to approach the raw data. As a social worker, I am interested not only in the feelings presented by the participant but also how the participants were impacted by their environment.
The meaning units are used to help make the raw data more manageable. Giorgi indicated different researchers may determine the meaning units at different transitions places in the interviews but “[w]hat ultimately matters is how the meaning units are transformed (which is the next step) (brackets in original) and how, and to what extent, they are reintegrated into the structure of the experienced phenomenon, if at all” (Giorgi,
2009, p. 130).
Transformation of participant’s natural attitude expressions into phenomenologically psychologically sensitive expressions. With the use of free imaginative variation, the meaning units extracted from the raw data are explored to determine if they are accurate and can be expressed more clearly. The researcher examines each meaning unit to see if that meaning unit supports the experience presented by the participant. Free imaginative variation means the researcher removes the meaning unit from the data to see if the experience presented by the participant continues to be supported, if not, the presented meaning unit is the essence of the participant’s experience. Giorgi (2008) further explained imaginative variation: 49
“...one considers not only the actual meanings discerned in a description, but before one tries to describe its role in the structure and before one tries to articulate it eidetically, one considers multiple other meaning possibilities that could have emerged instead of the one that actually did, and the consideration of these other possibilities helps the researcher to intuit and describe a more general meaning, one that is inclusive of the actual meaning discovered in the description” (Giorgi, 2008, p. 46).
Using Giorgi’s method, I reread the raw data, scrutinizing the meaning units for each interview and pulling out those meaning units to see if they stood on their own. I repeated this process for each interview until I was confident that I had pulled all the meaning units from the data. At this time, I took the extracted meaning units to my supervisor to explore whether a meaning unit remained a key meaning unit or if the meaning unit became a constituent supporting a key meaning unit.
The process of examining the meaning units and constituents was a laborious process. I needed to ensure the meaning units that emerged carried the actual meaning the participants expressed and whether, in a general meaning, that meaning units continued to describe the experiences of the participants. I listed all extracted meaning units on paper and worked to collate those units together from that stage, pulling out the constituents presented within each meaning unit.
According to the descriptive phenomenological method, I continued to reflect on my own beliefs and experiences to ensure I was bracketing throughout the data analysis process. Bracketing was supported through journalling and conversations with Dr.
Williams, my supervisor, to ensure the rigor of the research.
The end result of this analysis is presented in the findings chapter supported by a rich description of the participants and their experiences. 50
Chapter Five: Introduction of Participants
The data presented in this research study are meant to create a deeper understanding of suicide attempts and the grief journey for support systems bereaved by suicide but, I believe, no analysis can truly grasp how profoundly this lived experience has affected those impacted by a suicide death. I am indebted to the four participants in the study who honestly and courageously shared their loved one and their experience with me. All the participants spoke about wanting to take part in this research in hopes to help others whose lives have been touched by suicide. The participants also spoke about how meaningful it is for them to talk about the person they lost. I am grateful to these participants who agreed to be a part of this study and it is with great respect and honor that I introduce them to you as follows:
Margaret
“...very obviously, I’m an extrovert. I’m an outgoing person. I’m a very positive person. I’m always an optimistic person.”
These are the words Margaret used to describe herself and, after talking with her, I see these characteristics as a good description of her personality. I would suggest that
Margaret is also a woman who values family, her faith, and helping others. Margaret openly shares with “anyone and everyone” her experiences with Janice, her youngest child, and her struggle with mental illness, suicide attempts, and Janice’s death by suicide .
My interview with Margaret was the first of the four interviews conducted for this study. Margaret contacted me through the Suicide Survivors Listserv and expressed interest in being involved in the study. The interview was completed over the phone but 51
Margaret has an amazing ability to share her journey with a richness and insight that made me feel like we were in the same room. Her words reminded me how important and personal the work around suicide and suicide bereavement is.
Margaret is a successful business woman who, along with her husband, own their own company. She is the mother of two children, Justin, 26 years old, and Janice, who died by suicide December 4, 2006, two months before her 19th birthday. Margaret explains that throughout Janice’s teenage years, she and her husband, Jack, watched
Janice change from a fun-loving, brilliant young girl to someone who withdrew from her family and friends hiding her anxiety behind anger. Margaret shared Janice spoke about suicide on several occasions resulting in Margaret seeking support for Janice through their family doctor. It was not until Janice attempted suicide three times in five days that
Janice was admitted to a psychiatric ward where she underwent inpatient treatment.
Margaret worked tirelessly to advocate on Janice’s behalf throughout the treatment process.
Margaret and her husband established the BlueWave Foundation in memory of
Janice to provide information around mental illness to youth. Margaret continues to advocate to eliminate the stigma connected to mental illness and encourage those with persistent mental illness, such as depression, to seek help. Margaret shared that participating in this research project is just one way she hopes to help others who have been on a similar journey. Margaret chose not to change her name in the research study suggesting confidentiality, in her case, prevented her family from getting the help and 52 information they needed. She encouraged me to share her interview with “anyone and everyone”.
Jude
Jude contacted me as a result of the same recruitment notice posted on the
Listserv as Margaret. Jude brings a unique perspective to the study because she is a nurse who understands the culture of the medical system. She also speaks openly about her own battle with depression and suicidal ideations using her personal experiences to raise awareness about youth suicide.
Jude and her husband have two children. Ten years ago, Josh, her oldest child, died by suicide at the age of 15, after a year long fight with depression. Josh was 14 years old when he first attempted suicide and was connected to treatment prior to his suicide attempts. Jude’s daughter was 11 years old at the time of Josh’s death.
Jude’s honesty and passion were evident throughout our phone interview. Her awareness of the medical system and her willingness to question and challenge how this system is run is vital to any research completed in the area of suicide and suicide bereavement. Jude fights to raise awareness about youth suicide through an organization founded in the memory of her son. Jude acknowledges that her husband is not on the same journey as her but continues to support the work she does.
Hope
Hope also contacted me through the Suicide Survivors Listserv and was interested in participating in the research because she hopes someone else may be helped through her contribution. This interview was also over the phone, yet she told her story with such 53 depth and sincerity I could imagine her gesturing and moving as she spoke. Hope’s faith in God has helped her move through her grief journey, continues to help her heal from
Jimmy’s death by suicide, and is an integral part of who she is.
Hope is the mother of four children. She and her husband separated when the children were younger and she spoke about abusing alcohol during their relationship. Her son, Jimmy, lived with his dad after their separation and would visit with Hope and his other siblings at different times over the years. Hope has had many years of sobriety and throughout those years has worked hard on rebuilding her relationship with herself and with her children.
Hope shared that she was always concerned about Jimmy’s mental health and worried continually about his drinking and suicidal ideations. Jimmy died by suicide
August 22, 1997, at the age of 22. She shared how integral her dreams have been in her healing journey. She also spoke about how Jimmy’s suicide continues to impact how she worries about her other children making the same choice as Jimmy to end their lives and therefore influencing how she chooses to parent.
Hope works as a wellness worker in a small northern community and responds to any need presented within her community. She shared how in responding to another suicide or suicide attempt to provide support for families, her grief around Jimmy’s death is raw again, yet her desire to provide support to others continues to drive her.
Spirituality, friends and family are critical for Hope’s own mental health and she works hard to ensure she has the support that she needs. Powerful words of faith, healing, 54 and sadness were woven throughout the interview and I feel honored Hope chose to share her experiences with me.
Matthew
Matthew and I first met when I was working at a treatment agency in Calgary. I was talking about completing my Master in Social Work and writing my thesis and he began asking questions about what my thesis was focused on. After sharing my questions about suicide attempts and support systems, Matthew indicated that he had lost an ex- girlfriend due to suicide and would be interested in participating in the research.
Matthew’s ex-girlfriend of nine years, Pamela, died eight years ago. At the time of her death, Matthew and Pamela had not spoken for approximately one year and the last time they spoke they had been angry at each other. Matthew explains his relationship with
Pamela had been ‘on and off’ over the years but it was an intense and passionate relationship. Matthew also shared that his relationship with Pamela had changed him in many different ways and he believes he probably would not be working in the social services field if it were not for their relationship.
Matthew is a clinician who ensures he carries a caseload of people who are experiencing depression both because of his own history of depression and his experience with Pamela’s struggle with mental illness. He also works as a supervisor and educator focusing on addiction and mental health.
Matthew spoke eloquently about how his experience in the relationship has changed him both positively and negatively. He shared about how Pamela had isolated 55 herself over the years and, as a result of her isolation, he felt there was no one who misses
Pamela, no one he could talk to about her. He stated:
“[Pamela] more than anyone who I met before has disappeared from the world utterly. I don’t think you could find a dozen people in the country who knew her well or for long, or who could say they were deeply impacted by her existence and so there is almost a sense of, ‘Geez, I might as well have hallucinated her.’”
Matthew’s ability to articulate his experience in their relationship profoundly impacted me. This statement, in particular, leaves me wondering if others have experienced the same feelings of isolation after their loved one became disconnected or ostracized from family, friends, and support services but also raises questions around how we keep our loved ones alive within ourselves.
All four participants brought a depth and diversity to the research that I sincerely appreciate. Their experiences were unified in the following chapter and I can only hope that the power of their words and the passion they feel is captured in these findings. 56
Chapter Six: Findings
According to the descriptive phenomenological method, data are presented in meaning units that represent the ‘lived’ experience of the participant and are not intellectualized by the researcher (Giorgi, 2009). These meaning units, represented by the shaded circles, are used to create the structure of the analysis. Mental illness, suicide attempts, treatment, and relationship with loved one are the meaning units extracted from this research (See Figure 6.1). This structure presents the essence of the phenomenon of suicide attempts prior to a death by suicide and how suicide attempts in turn affected the grief journey for the participants bereaved by suicide.
Figure 6.1: Map of Meaning Units and Constituents
Own Comprehension Mental Mental Illness Illness
Shocked Stigma Isolation but not Confidentiality Surprised
Hyper- Suicide Treatment Professional vigilance Attempts Hope as the and Fear Expert
Helplessness Disbelief Relationship with Loved One Failure to Loss of Connect Voice 57
Constituents, represented by the non-shaded circles, support established meaning units by creating a structural description of the meaning unit. As shown in Figure 6.1, comprehension, stigma, mental health of the participant, and isolation were identified by the participants as constituents of mental illness. The constituents presented were directly influenced by the meaning unit, mental illness. Giorgi (2009) explained further that “[i]n creating structures one delineates constituents, but one has to be mindful that the constituents are interrelated. Or better, the structure is the relationship among the constituents” (p. 102). Therefore, comprehension, stigma, mental health of the participant, and isolation cannot be identified as meaning units because without the understanding of mental illness, these constituents do not express the essence of the phenomenon. Accordingly, constituents can be connected to more than one meaning unit, leaving a structure that is connected in many different ways. For example, the constituent hope is connected to the suicide attempt, treatment and relationship with loved one meaning units. According to this research study, the participants experienced moments of hope after a suicide attempt, during treatment, and within their relationship with their loved one. These moments of hope affected their grief experience. Figure 6.1, a map of meaning units and their constituents, represents the structure of the impact of suicide attempts on the bereavement journey for individuals bereaved by suicide.
Mental Illness
Messages about mental illness and stigma connected to mental illness are slowly becoming more prevalent in our communities. How we understand the depth of mental illness depends on what contact we have had with others who have a mental illness, our 58 personal history with mental illness, and our belief systems around mental health. In this research study, mental illness was presented as a key influencing factor in the behaviour of loved ones and how their behaviour was understood, why treatment was accessed, and how hope was connected to treatment and prevention of future suicidal behaviour. For the participants in this study, how they understood mental illness impacted how they grieved the loss of their loved one. The participants presented four constituents directly related to mental illness that impacted their grief: comprehension, stigma, mental health of the participant, and isolation.
Comprehension of mental illness. How mental illness was interpreted presented itself throughout all four interviews. Some people can move through life having no contact with mental illness as Margaret shares:
“We’re dealing with an aspect of life that we know nothing about. Mental illness had never touched our lives.”
A person may have experienced depression at different times in their life but the idea of prolonged mental anguish is something many people are unable to comprehend.
Margaret continues:
“We truly, truly did not understand that [Janice] had mental health issues. There is a big difference. It’s not just...everyone can get depression, depression is normal.”
Margaret’s experience of not understanding the depth of mental illness and the idea that suicide attempts and suicide can be a part of mental illness affected not only how she responded to her daughter’s behaviour but to how she grieved her death.
“We didn’t have a true understanding....We didn’t understand that she really needed an advocate. I mean we are strong people, Jack and I, we would have gone anywhere in the world. We financially have the ability. 59
We could have taken her anywhere to get help. We did not know. Our ignorance was amazing.”
To further the incomprehension of mental illness, Margaret speaks passionately about not being informed by any resources the family was connected to about the depth of Janice’s mental illness after the suicide attempts.
“Never once did we have anyone indicate to us we could be dealing with mental health issues and we didn’t pick it up ourselves because we have no knowledge.”
Margaret speaks about how her family understood Janice’s mental illness:
“My brother in London, England,...Jack’s brother in Edmonton and Jack all were saying that they felt she was just trying to get attention. Yes she’s had depression but you know again, ignorance - not understanding.”
Her family’s misunderstanding of mental illness influenced how they coped with
Janice’s depression and may be influenced by the societal myth that links suicide ideations and suicide attempts as a ploy for attention.
Deeper understandings of mental illness also affect how we grieve. For Matthew, his understanding of his partner’s mental illness changed over time due to her numerous suicide attempts and that became a ‘normal’ experience in their life.
“Had I been genuinely in fear for her life at that point I think I would have reacted differently but it is the sort of thing that when it happens to you a few times...you start reacting to it differently, you know? You stop seeing it as life threatening in the same way and more as, well, this is just part of my life.… my relationship is with somebody who has a mental illness and who occasionally … occasionally I have to put up with, you know, whether it is sorrow or suicide attempts, or rage, or destruction, or whatever, that is just part of the relationship and it becomes chaotic and unpredictable and that is just how it goes.”
How the participants understood mental illness and to what extent mental illness could influence their loved one’s decision to take their own life, impacted the 60 participant’s grief process. For Jude, she had felt suicidal and experienced depression when she was younger and believed that Josh could also heal and learn to cope with his mental illness. Everyone’s experience of mental illness is different and for Jude, she believed that Josh could overcome his mental illness but also states that she does not blame him for taking his life.
Hope did not talk about a misunderstanding of mental illness but indicated that
Jimmy moved back and forth between times of alcohol use and times of sobriety. She spoke about feeling fear when she knew he was drinking because his behaviour was unpredictable.
Stigma. Each participant spoke directly and indirectly about a link between stigma and mental illness. Whether they felt this stigma through people not talking to them about their loved one’s thoughts or behaviours or by not being able to share their experiences with others, stigma presented itself. In Jude’s case, she shared how she believes stigma prevented her son from talking about how he was feeling and, in turn, accessing appropriate help.
“...getting rid of the stigma so we can talk about it....I always cite the example of cancer. When I was a nurse, a student nurse, nobody talked about cancer because there was huge stigma around it. So we need to do the same with mental illness and depression and suicide. Now we do talk about depression more. If we did the same with suicide then a kid like my son would not feel that he had to keep it to himself because there’s all this shame around it....It’s very hard...if someone like Josh...if it was diabetes he would have come to me and said “Well, Mom I have all these symptoms.” He would have told me “I’ve got a headache, [I’m] thirsty,”....he would feel free to tell me. Whereas with the depression, there were all kinds of ways to hide it...” 61
Margaret reiterates Jude’s belief about stigma and mental illness and used the same example of cancer research and education as well. Margaret speaks about how the
BlueWave Foundation, founded by her and her husband after Janice’s death, focuses on educating young people about mental illness:
“the stigma...the stigma is a huge statement....it’s one of the major themes right at the top of the tree that we are addressing with the BlueWave Foundation. ...[W]e are taking the BlueWave Days into junior schools, universities and colleges (to talk about mental illness and stigma)....that [stigma] has to change and you know what it can change....of course it has to continue with mental health....”
Matthew references the attribution theory when he spoke about accessing support from others. His understanding of the attribution theory indicates that how you present yourself in a situation depends on your understanding of the ‘nuances of the social situation’. Choosing not to talk about mental illness and Matthew’s experience in his relationship, may also be associated to the stigma that is linked to mental illness.
Matthew shares:
“the person that I was socially...was all very fun and rich in its own way, but..in the context of the relationship with Pamela it was totally insubstantial....Did it intrude on the much more fundamental, full colour, three dimensional reality of what was going on between us and what was going on for me in terms of fear, and worry, and passion, and disgust and all of those other things in relation to her. I mean nothing … nothing real got shared....and yet if I was to tell you…did it provide relief? Yes. Did it provide support? No”
Matthew speaks about how his social relationships provided him with an outlet from his relationship with Pamela but because of the nuances of the social situation, in this case stigma or a lack of understanding around mental illness, he chose not to share 62 details of his relationship with Pamela. Stigma of mental illness may also create isolation, another constituent presented by the participants.
Isolation. Feelings of isolation were indicated by two of the participants and can be linked with suicide attempts, treatment, and mental illness. Matthew indicated above, he was able to have social connections outside of his relationship with Pamela which were important to him at the time but is clear that those friendships did not provide support for him within his relationship because he could not share what was happening between him and Pamela. The lack of support presented by Matthew around his relationship can be identified as a sense of isolation within his relationship due, in part, to
Pamela’s mental health. Conversely, Matthew also shared that his connection with friends was probably an important factor in maintaining his own mental health.
Margaret experienced feelings of isolation from her daughter, Janice, because she did not know about mental illness. Margaret did not know to whom to turn to access support. Janice played girls hockey for ten years and Margaret shared she would ask other mothers about their daughters’ behaviour:
“I am asking other mothers over the next couple of years ‘what is your daughter like?’.... Does she stay in her room? Does she still go out? Does she refuse to mix with anybody? I couldn’t get my daughter to go shopping.”
Not only was Margaret feeling isolated from Janice, she also presented feelings of isolation from others because she could not directly express her concerns about Janice’s behaviour because she had no words for her mental illness.
Another experience of isolation was presented by Margaret when she spoke about the school her daughter attended. Margaret shares two incidents when the school 63 contacted her and her husband about Janice’s behaviour but mental illness was not broached in either conversation:
“Some teachers apparently commented (about Janice’s appearance) and the comments went to the principal. We (Margaret and her husband) were contacted and asked to come in [and the principal shared] that Janice Lee appears to have a dark cloud over her head.”
Nothing further occurred at this meeting. Several months later, Margaret and her husband were asked to return to the school after the school counsellor located an exchange on the Internet between Janice and another person where she indicated she wanted to put a hex on the teachers. Margaret shares:
“[The counsellor] went online and found a website where [Janice] was dialoguing with whomever and saying she was going to put a hex on the teachers and take the school down. All through her school years she’d never put a foot wrong....She was eventually brought in to answer the charges. Jack and I were battling to work out what on earth is happening here. (Janice) was expelled.”
Margaret presented feelings of isolation from the school with a lack of support around the change in Janice’s behaviour. Margaret shared Janice had always excelled in academics and was well liked by her peers and teachers, yet, this incident led to Janice being expelled from school without follow-up or questioning around the dramatic change in behaviour or her mental health.
Mental health of participant. Prior mental health concerns were presented as a constituent of mental illness because the mental health of the participant may have played a role in how they were experiencing their loved ones’ mental illness. Matthew clearly articulates how his own mental health was affected by the relationship:
“I had definitely struggled with depression before I met her, I had had some counselling... but I didn’t really get into full gear and serious kind of 64
clinical level illness until after, and I don’t know how much to put that down to just age and development, and changes in metabolism and a hundred other factors, and how much to put it down to, gee, a lot of (the depression) seems to link to times when we had really put each other through the wringer and when I had really been tortured emotionally and shared that reality for several – that reality and that bed – for several years, and then was left on my own to stare at four walls and try and piece things back together; those were the times that were most dangerous and miserable for me.”
Matthew’s experience in the relationship helped him partially understand
Pamela’s choice to take her own life but he also suggests that the nature of the relationship may have perpetuated his own mental health concerns. Although he states that it is difficult to differentiate between what factors were primary in influencing his mental health, he acknowledges there was change in his mental health. Matthew talks about how his mental health was influenced by Pamela’s depression:
“I don’t think I knew how depressed a person could get until I had been with her and there is something infectious about it, having somebody that you can’t help is depressing in itself. And having an understanding of the bleakness of their view of the world, because, of course, when there is just two of you, you don’t know the other person is crazy, and you don’t know that you are bringing things to the relationship that is maybe making them crazier, you know?”
! Matthew is the only participant who questioned how his own mental health and interactions with Pamela influenced her. He also shares his involvement in the relationship impacted his own mental health. This understanding of depression in a different way may also have influenced his own grief experience.
Jude has experienced her own depression and spoke of not attending to her own mental health after learning about Josh’s first suicide attempt because she was so focused on accessing support for him: 65
“I had a lot of anger. I was very angry...I’m still angry....I don’t remember (what happened for me) at the time, I probably got depressed myself, I wouldn’t be surprised. I don’t I don’t really remember. I was just...I was very busy kinda making sure he was ok and getting what he needed...”
Jude put aside her own needs in order to focus on supporting her son. She also speaks about how anger continues to be an emotion she experiences.
Suicide Attempts
Suicidal behaviour can be one aspect of mental illness incorporating another layer of experience expressed by participants and, therefore, another meaning unit identified in this study. The constituents of suicide attempts are stigma, isolation, disbelief of suicide, shocked but not surprised, hopefulness, and hyper-vigilance and fear.
Stigma. Suicide bereavement research cited in the literature review identifies stigmatization of suicide as a component of the bereavement experience for people who have lost someone to suicide (Allen, Calhoun, Cann & Tedeschi, 1993; Bailey et al.,
1999; Barrett & Scott, 1990; Begley & Quayle, 2007; Dunn & Morrish-Vidners, 1987;
Feigelman, Gorman & Jordan, 2009; Grad, Clark, Dyregrov & Andriessen, 2004; Jordan,
2001; Silverman et al., 1994). There is limited research that indicates how support systems experience suicide attempts. For three of the participants in this study, stigma was presented as a part of their experience and influenced how they responded to the suicide attempts of their loved one. In turn, this stigma also impacted their grief experience.
Margaret identifies with the stigma connected to suicide through the following statement:
“The stigma and shame that surrounds the whole issue (for) many 66
families...just look at the family members...(who) feel shamed that they have lost someone. I mean it is bad enough that those families have lost someone but that they feel that they can’t even talk about it because there is so much stigma connected to suicide and they don’t even want to use the words.”
! Margaret also comments on how she believes stigma prevented a community member from wanting to talk openly about the suicidal thoughts Janice had been expressing to her friends on an online chat forum, MSN. This was the second time
Margaret had heard about Janice’s suicidal ideations but in this case, the community member provided a print out (which Margaret refers to as a transcript) of what Janice was saying. Margaret shares:
“We had a lady at the church (ask to meet us). She sounded a bit embarrassed...Her daughter was friends at school with Janice. Same thing, MSN. Now this mother had actually printed off the transcripts and then she said “I hope you don’t mind me to bring this up. This is what Janice has been saying.” I reassured her “I couldn't I can’t thank you enough. Thank-you very much”. Here you see this is part of the stigma and shame again. People don’t talk about things like (suicide) but I reassured her absolutely we are so thankful that she brought it up.”
Stigma can be perpetuated through silence, the idea that we should not talk about suicide. In this research, Jude and Hope shared that they were not provided with information regarding their sons’ suicidal thoughts by both youth and adults who knew about the suicidal ideations. This silence is similar to Margaret’s experience and may further indicate the presence of stigma surrounding suicide. Talking about the night Josh died and others’ knowledge of his suicidal ideations, Jude said:
“...the night Josh disappeared...his friends phoned and said they were worried. The kids knew lots, you know. They never told anyone and there was also an adult that also knew lots but she chose not to pass it on either.” 67
In a similar vein, Hope said:
“I found out later...April of that same year which nobody told me about. Only when I was talking to some of the teens outside (at the funeral). ...I was talking to these kids there and they were saying that he tried and now it did work. I said “What do you mean he tried? I know he tried before.” “No” they said “just not that long ago, Hope, this very same place.”.....But nobody said nothing to me you see.”
In Hope’s case, her son had recently attempted suicide using the same method he eventually used to take his own life but no one informed her of his behaviour.
In this study, the stigma of suicide prevented the participants from learning about some of the behaviours and thoughts of their loved ones. This lack of knowledge contributes to the grief structure because it adds another layer of not understanding the death and another possibility to intervene with their loved one’s behaviour. More information could have led to a different intervention and understanding of their loved one’s death. Hope shares her struggle of understanding her son’s death:
“All kinds of questions. Unanswered, all in my mind. Besides the grieving for the death of my son, the big question was, why? Why did this happen? Why did you do this to yourself? All that, you know? It was so hard.”
Isolation. In this research, participants spoke about how suicide ideation and attempts isolated them from others as well as isolating them further from their loved one.
Matthew talks about his response to one of Pamela’s suicide attempts:
“....at the time I thought that was kind of a gesture to draw me in to where she was, that she was so isolated and lonely and this was a time where I really wasn’t and so I felt that the whole thing of, you know, calling me – I mean I was in the apartment – but I mean why was nobody else involved in this in any way? You know? Why was it just something in our relationship? You know?” 68
Margaret also speaks about feeling isolated and knowing she needs to be an advocate for Janice because Janice could not advocate for herself. For Margaret, advocating for her daughter meant she could not address her own feelings connected to
Janice’s suicide attempts and isolated Margaret further within a medical system that she did not understand:
“...(there) is a huge desperation because...I’m feeling like a complete lone ranger, you know...I mean...I just had to deal with it...but the desperation of feeling I had to hold it together, I couldn’t lose it because there is no one that is going to be an advocate for her....I am the only one that can be an advocate for her. I have to get help for her, she is incapable of getting it herself.”
Hope experienced isolation differently from Matthew and Margaret. She describes a profound experience of how she was feeling weeks before Jimmy died by suicide.
Throughout the interview Hope spoke of her fear that he would, one day, follow through with suicide but always prayed he would find his way out of the depression. Hope was not living in the same community as Jimmy at the time of his death but was having intense feelings of loneliness that she could not explain. She shares:
“The next about two and a half weeks was the loneliest times of my life. I just, I could not explain why it was like that but I was lonely and I was crying every day. Crying, crying. And I couldn’t do nothing about it. I didn’t...I had no reason to I just came home, I’d seen my mom. I’d seen my brothers and sisters and my kids they were all OK and why was I feeling so empty and so lonely? On August the 22nd (the day of Jimmy’s death) was the worst day. I cried right from that morning and I went to work like that. I just told them I am not seeing anybody because I couldn’t really talk to anybody because I just kept crying....”
Hope’s feeling of loneliness prevented her from connecting with others. She was unable to explain how she was feeling, yet as she speaks about this time the sense of uneasiness and foreboding is clearly heard. 69
Disbelief of suicide. Even if there is an understanding of the link between suicide attempts and possible death, there was also disbelief presented by the participants that their loved one may eventually take their own life. All of the participants were aware of some of the suicidal ideations and suicide attempts of their loved one. Regardless, they did not believe their loved one would take their own life. Matthew states:
“I wasn’t agitated by (the suicide attempts) and I totally didn’t think there would come a day where she would follow through.”
As if speaking to her son, Jimmy, Hope states:
“I know you talk about it but you never went that far.”
Jude, who experienced suicidal ideation when she was younger, shares her feelings of disbelief and anger around her son’s death:
“Well of course I am angry. I loved my son and he isn’t here and the other thing is that I have been suicidal and I’m here.”
Jude felt suicidal herself but she did not make the choice to take her life. In this research, in spite of the fact a person had experienced suicide at some point in their life, the participants did not completely understand how suicidal ideation was experienced by their loved one. For Jude, the idea that she was able to endure suicidal thoughts and her son did not, indicates how we do not truly understand how others respond to their own mental illnesses and presents questions of disbelief around their loved ones’ ability and desire to take their own life.
Shocked but not surprised. While expressing feelings of disbelief around the possibility that their loved one would decide to take their own life, the participants also expressed an understanding that death by suicide was probable. Margaret, Hope and 70
Matthew watched their loved ones struggle with mental illness and suicidal ideations for a minimum of five years. They shared that they were shocked to hear about their loved ones death but not surprised to hear they had followed through with taking their own life.
Margaret clearly articulates this when referring to Janice’s death:
“I was shocked to finally get the news that she’d completed that she had taken her life but I was not surprised.”
Hope also shares:
“Interviewer: ....I don’t know if this fits for you but it sounds like there was a disbelief prior to him taking his life that he could....(take his own life).... Hope: Yeah, yeah, yeah big time. Yeah. I was scared that was going to happen but not like...no way...he won’t do that.”
Referring to Pamela’s suicidal behaviour and her completed suicide, Matthew states:
“If you had asked me ‘do I see her living to a ripe old age?’ I would have said, ‘No,’ but if you had asked me ‘do I think she is going to complete sometime in the near future?’ there is no time at which I would have imagined, and yet of course, in hindsight, how foolish, it was very evident that it could have happened at any time. I think there was an escalation of attempts – excuse me – I hate that term ‘suicidal gesture’ because to me it implies deceit, you know, there is the whole idea of, ‘What a nice gesture,’ and it kind of implies there is something empty and insubstantial about it, and the reality is early on I think I regarded these as gestures, that they were, you know, it was just a way of expressing distress the way I thought of cutting and hair pulling and so on as being. But of course, you know, people talk about the risk of, ‘well sometimes people complete by accident, they swallow a bottle of pills thinking someone is going to find them but they don’t.’ Well I don’t think she thought someone was going to catch her half way down (she completed suicide by jumping off a bridge).”
Hopefulness. Closely connected to the constituent disbelief of suicide, the participants in this research indicated feelings of hopefulness. For each participant there 71 was a sense of hope woven throughout their relationship with their loved one. The hope lies in the belief that the attempts, as Matthew says, were a “way of expressing distress” but that each loved one would not follow through with taking their own life. The belief that over time, with proper supports, their loved one will heal from the wounds that were haunting them and reconnect with those who care and love them created hope in spite of the suicide attempts. Jude shares:
“I did not know it was going to happen. In fact, we thought he was much better.”
Margaret, Hope, and Jude spoke about believing their loved one was feeling better, trying to reconnect with them and making life changes. Whether this hopefulness was a result of their connection to treatment, aging or other life experiences, or a combination of many different things, there was a sense of hope experienced for the participants after the suicide attempts that their loved one was healing.
Hyper-vigilance and Fear. Regardless of the hope of change experienced by participants after a suicide attempt, this study found that there was also a sense of hyper- vigilance fueled by fear, and worry their loved one may attempt suicide again.
In the interview Hope spoke about knowing Jimmy had attempted suicide, but when asked about whether she thought he would be able to follow through with taking his own life she responds:
“Interviewer: Did you think that Jimmy would actually be able to or actually follow through with taking his life? Hope: That was my worst fear. That was the worst fear”
Hope knew there were moments when Jimmy was suicidal but she was also hopeful he had made changes in his life moving him away from those thoughts of suicide. 72
Despite the change Hope saw in Jimmy before he died, she carried a palpable fear that he would decide to take his life.
Jude speaks about being fearful of Josh taking his life even though the family believed he was doing much better. She states:
“I know I was fearful. Certainly the night he disappeared I was very fearful.”
Regardless of the treatment Josh was connected to and the fact that the family believed he was doing better, Jude experienced a fear that he may decide to take his own life. The night he disappeared, Jude allowed that fear to present itself.
Margaret speaks of fear on several different levels. She speaks of the fear of saying something to Janice that would stop her from accessing treatment. Margaret related the following experience when she was driving Janice to the hospital after her three suicide attempts:
“I was frightened to talk to her even because I didn’t want her...I was scared she was going to say, pull the car over. I’m not going.”
Margaret feared that Janice would not attend treatment, which does eventually happen when she gets older. This fear kept her from talking to Janice about the suicide attempt or how she was feeling.
Margaret also speaks about fear, worry, and hyper-vigilance after they had brought Janice home from the hospital treatment program she had completed. She relays the following story of her husband’s response to Janice returning home:
“We go home...and Janice said ‘I am going to take a shower’....My husband...stood outside her bathroom door....He stood outside the closed bathroom door like a cat on a hot tin roof looking at his watch. He can hear the water running but he can’t hear any movement and because he knows she had already attempted to take her life. He’s wondering ‘What’s 73
happening in there?’ He’s ready for action. He needs to save this child of his....Finally he says ‘Janice...anything that you need? Do you need a towel?’....[H]e just needs to hear her voice. To make sure she is still ok.”
Margaret shares this story of her husband’s experience to re-iterate that “both parents that are suffering” and that both parents in this relationship are experiencing hyper-vigilance and fear around the possibility that Janice may attempt to take her life again.
Treatment
The loved ones of all four of the study participants had attended some form of treatment, either individual and group treatment programs or a combination of both, prior to their death. Treatment is another meaning unit because it played a key role in how each participant perceived their loved ones’ healing and how the participants grieved the death.
In this meaning unit, treatment implies individual support with a counsellor or doctor or in a group therapy program through a hospital or a traditional First Nations healing program. Each participant presented several aspects of treatment that have been identified as constituents to this meaning unit. These constituents are: hopefulness, confidentiality, professional as the expert, isolation, and feelings of helplessness.
Hopefulness. In this research study, accessing treatment for loved ones after a suicide attempt created a sense of hope their loved one would move away from suicidal ideations and suicidal behaviour towards mental wellness. For all participants, treatment was identified as a necessary beacon of hope.
Margaret’s daughter, Janice, saw doctors and counsellors,\ and attended an adolescent treatment program at various times throughout her struggle with mental 74 illness. The first time Janice saw her family doctor about her thoughts of suicide, her behaviour was normalized by the doctor. Margaret believes, in hindsight, their family doctor had limited knowledge of mental health issues but at the time his diagnosis offered up hope that Janice’s behaviour would change over time. She shares:
“[The family doctor] said not to worry (about Janice). He talked to (Janice), one on one, as well with [Margaret and her husband] and said ’Not to worry, this is normal (behaviour). It’s ok.’. Our fears (around her suicidal ideations) were allayed, if you wish, because teenage moods, attitudes and hormones with some depression (and possibly feelings of) not wanting to live (was normal) and we thought teenagers are often dramatic.”
A year later, Margaret returns to the same family doctor with Janice who has, again, been talking about killing herself. Margaret retells the experience:
“So, we were at the doctors and he, again, was reassuring....he said ‘We’ve had this before....(teenagers) talk like this, you know, it is attention getting...they talk like that but you know but not to worry because, you know, life is so dramatic for teenagers, which we know that is a fact, we have all been there.’ So again, our fears are allayed, but, sort of.”
Although they still were fearful of Janice’s thoughts about taking her own life, the pearls of hope the doctor provided around normalizing Janice’s behaviour were important to Margaret and her family because it kept them believing Janice’s behaviour was normal and would change as she grew older.
After Janice had attempted suicide three times in five days, Margaret speaks about knowing Janice’s behaviour was not normal teenage moods but that Janice needed professional help. Again, the belief professional help would make a difference for Janice is heard when Margaret states:
“my daughter has had issues for some years now where she has not been happy within herself and these three attempts in five days, to take her own 75
life, she needs psychiatric help.”
Treatment provided a sense of hope for Margaret, a sense that accessing treatment would create change for her loved one. In her interview, Hope also parallels Margaret’s connection between treatment and feelings of hopefulness. She speaks about accessing treatment for Jimmy after he tried to take his life one day while he had been drinking:
“Interviewer: When you talked to (Jimmy) about (the suicide attempt),...he didn’t remember walking out on the ice....That really would reinforce your fear (of him dying by suicide)... Hope: Yep....Yep. That’s when I had found a therapist for him to go and see. I went with him the first time and I told the therapist (about the suicide attempt)....So, we started from there you see and then he would do good.”
For all the participants in the study, the suicide attempt of their loved ones ensured a connection to treatment which created feelings of hopefulness for change.
After Josh’s first suicide attempt at school, he was connected to a psychiatrist with the children’s hospital where he accessed treatment on and off over the year prior to his death. When questioned about feelings of hope as a result of him accessing treatment,
Jude states:
“Well, you know, when he came home looking so great (after a trip to England and the ongoing treatment), we thought he was going to be fine.”
Jude presented a sense of hope that their worries over Josh’s health were over and that he was going to be fine.
Throughout Matthew’s relationship with Pamela he helped her access treatment after suicide attempts by taking her to the emergency room and to her doctor. Although
Matthew never spoke directly of accessing treatment as creating hope, the act of taking someone for help outside of the relationship may be presented as an indication of hope 76 the treatment may make a difference. Matthew’s commitment to support Pamela to access support indicates a connection between hope for change and treatment
Three of the four participants presented feelings of their loved one being more connected with living than dying as a result of accessing treatment, clearly linking hope with treatment.
Confidentiality. Confidentiality is a cornerstone in the work we do with clients as social workers and it is imbedded in our Social Work Code of Ethics. Most treatment programs reinforce the importance of confidentiality by ensuring patients and support systems are aware of what the limitations of confidentiality are. Two participants in this study clearly indicated confidentiality hindered their ability to both understand what was happening for their loved one and how they could provide support after treatment was completed.
Jude speaks about confidentiality impacting her in two different ways. Firstly, whether due to confidentiality or a choice made by the physician Josh saw, Jude did not know about Josh’s first suicide attempt that happened at school when he was 14 years old. She shares:
“what happened was (Josh) went to his school counsellor and told her that he had taken an overdose and the school counsellor did not see fit to call us. She sent him to the GP, who was totally useless, and the GP told my son that he had three weeks to tell us (that he had attempted suicide). Which is outrageous.”
In Jude’s case, both the school counsellor and the doctor made a decision not to inform the family immediately about Josh’s suicide attempt. Although there is merit in
Josh being responsible for telling his parents about the suicide attempt, the three week 77 time period that elapsed between the suicide attempt and his parents being informed meant three weeks of no support and, most importantly, his feelings of wanting to take his life were not addressed. When someone is feeling suicidal the rules of confidentiality no longer apply meaning there is an obligation to inform. Jude believes the school counsellor and the doctor should have informed the family without waiting for Josh to do so.
Secondly, Jude and Margaret both share how confidentiality affected their ability to support their loved ones when they were involved in treatment. Jude states:
“We were totally cut off, you know, we weren’t allowed to know what was going on because of the confidentiality.”
When Janice attempted suicide at 16 years old and was admitted to the adolescent unit, Margaret and her husband completed a family assessment with the psychiatrist who was working with Janice. Although informed about confidentiality, Margaret indicates that the limitations of confidentiality prevented them from learning about Janice’s behaviour and how best to provide support to her. At the end of the family assessment the psychiatrist let them know they were good parents, which was comforting to hear, but as
Margaret shares:
“We still know nothing about what is happening for Janice. We know she was involved in CBT (Cognitive Behavioral Therapy); due to confidentiality no information was given to us. We did have a sense of hopefulness that things were going to change but we were sent home from the hospital with Janice knowing nothing of how we can support her or what to expect.”
Confidentiality is important in order to protect clients and facilitate trust in the therapist-client relationship, but for both of these participants in this study, confidentiality 78 limited their ability to understand what was happening for their child and how to provide support.
Professionals as the expert. Linked closely with the confidentiality constituent is the third constituent, professionals as the expert. This study found professionals were given ‘expert status’, meaning treatment modalities or clinical decisions were not questioned. Margaret states:
“everything in our mind was all about Janice, all about her well-being, all about what was going to get her to a place of health and wellness again. So, if you are telling us, doctor, that we can’t know anything (about Janice’s treatment) that is the way it is, we’ll accept that - and we did. We already had.”
At times Margaret challenged the decision of the professionals working with
Janice but there were also many times when she accepted what the professionals were saying about Janice’s mental health. On two different occasions, Margaret’s family doctor diagnosed Janice’s suicidal ideations as teenage moods with no mention of possible mental illness. Although Margaret states she always thought there was something else going on for Janice, she had no tangible information to question the diagnosis at the time.
What the doctor said about Janice’s mental health was accepted.
Jude speaks about questioning the doctor’s decision to give Josh three weeks to tell his parents about his first suicide attempt:
“when I asked the doctor about (the three week window given to Josh to tell us about the attempt), he was all defensive, you know”
Jude questioned the doctor and he defended his decision, asserting himself as the expert. Once Josh was connected to treatment, Jude was told to let Josh take responsibility for himself and to separate herself from his treatment process. She shares: 79
“You want to protect your kids and, you know, once we got him into treatment (the medical staff) said, ‘Oh, let him look after himself. Let him take his pills...’ [I]n the end he didn’t take the pills but he was very clever about pretending that he did.”
The above examples provided by Margaret and Jude indicate how they felt they were not given opportunity to question the medical professionals and followed through with requests by the medical staff in the best interest of their child due to the belief of the professional being the expert.
Jude also reiterates the message of the professional as the expert when she shares
Josh’s experience with the psychiatrist he was connected to:
“I knew he didn’t get the treatment he should have got, I mean, he knew as well. He was a very smart boy. He said to me ‘Mom, that psychiatrist is a waste of time. All she does is prescribe pills.’ He had her sorted right out. The [psychiatrist] was about 20 and had hardly any experience. And she, you know, she didn’t know what she was doing. But we weren’t allowed to be in on anything so we couldn’t have anything to say to her.”
In this case, confidentiality ensured the psychiatrist was the expert because Jude was not given an opportunity to question her clinical decisions and treatment process. A question may also be raised as to why Josh did not challenge the psychiatrist’s abilities or decisions. By enforcing confidentiality, professionals do not have to allow others to enter into the treatment process ensuring they are not challenged by outside sources.
Finally, Margaret speaks about what her and her husband believe to be true around
Janice’s mental health:
“We ourselves, now maybe we’re wrong, maybe professional medical doctors would roll their eyes at our audacity of attempting to, but we believe she was bi-polar. In hindsight, as we continue to educate ourselves after she died, we believe she was bi-polar and she absolutely had anxiety disorders.” 80
Margaret refers to the medical profession and her “audacity” to diagnose Janice.
The belief that only trained professionals can identify and diagnose mental health concerns continues to confirm the belief of professionals as the experts. Margaret believes there was a clear, undiagnosed mental illness with her daughter, something the system should have been able to determine and possibly help Janice to cope with.
Frustration and helplessness. Even though the idea of treatment carried a sense of hope for the participants in this research study, they also presented that accessing treatment left feelings of helplessness and frustration in supporting change for their loved one.
As a nurse, Jude spoke about understanding the politics within the medical system and was appalled with the treatment Josh received. Jude expressed one example of her frustration with the medical system and doctors not wanting to take on others’ patients.
Jude was recommended to a psychiatrist who had success with a family friend’s son and wanted to connect Josh with this psychiatrist but was put on a wait-list. While waiting to access the psychiatrist, Josh become involved in another treatment program as a result of a suicide attempt and the desired psychiatrist declined to treat Josh. Jude speaks about this experience:
“When we first knew (Josh) was depressed we tried to get him an appointment with a psychiatrist that we knew of who had been very effective with another friend’s son but that guy couldn’t take him for three months. In the mean time, (Josh) took (his second) overdose....He was taken to the hospital and referred to the mental health team there and they were God awful. Awful. When the appointment came up with the guy that we really wanted (the doctors) started playing politics. And so the doctor that we wanted, felt that he couldn’t intervene because (Josh) had already been seen by these other doctors. Which I think is totally, totally ridiculous. But...I’m a nurse so I understand all the politics. I felt that 81
nothing was being done for my son.”
Margaret’s experience accessing the medical system also left feelings of frustration and anger. She speaks about knowing she needed to advocate on behalf of
Janice, knowing treatment was necessary for her but not being allowed to participate in helping Janice access help. Margaret shares her experience with the triage nurse at the hospital after Janice had just attempted suicide three times in the past five days:
“She was like an ex-sergeant major. Her demeanor was very cut, dried. No compassion in her face, no sympathy, no softness, no attempting to relate to the young person across from her. More an irritation of you know ‘what the hell do you think you are doing here? What do you think you are doing? Smarten up’.”
Margaret’s desperation to access appropriate and effective help for her daughter was priority but her first contact with the hospital system did not reflect what she believed it should have. Secondly, the lack of available beds became an issue for Janice because she was placed in an adult psychiatric unit, at 16 years, that did not provide treatment. Margaret shares:
“...everything was so cold, so clinical...”
After a week of advocating to have Janice moved to the adolescent unit, a bed became available. Margaret shares the following regarding the adolescent unit:
“There were two female psychiatrists...all the nursing staff they have there were totally dedicated and trained for the adolescent unit. I was very impressed with that unit. That gave me some comfort and reassurance.”
Although Margaret was initially impressed with the adolescent treatment unit, upon Janice’s discharge from treatment she was referred to a private counsellor that worked with the unit. Margaret shares how she felt helpless and frustrated in being able 82 to ensure that Janice would continue accessing support for her mental illness. Although
Janice was 17 years old, Margaret could not ensure she accessed treatment:
“(Janice) saw (the family counsellor) either once or twice....[S]he came home ‘I don’t like him, I’m not seeing him anymore’. So, here I am again. I am trying to stay calm. I’m thinking ok, she needs help....I said ‘well, how about a woman (counsellor)’. (Janice says) ‘No’. When they reach a point where they say no, you can’t force them. The medical profession are telling you by law if they don’t agree to have help, we, as parents we no longer count (can no longer help access help)”
Margaret’s choices were limited for her to access help for Janice without her consent. Margaret clearly articulates her sense of helplessness and frustration when she states:
“We felt, at all times, Kim, that we were having to deal with this problem ourselves. We felt that there was no one.”
Margaret’s frustration was validated following a visit from a Family Services psychologist after Janice’s death. She shares:
“After she died we had a psychologist from the Family Services unit come to see us for our thoughts and we told them all what we thought and (the psychologist) pretty much admitted that (Janice) fell through the cracks of the system.”
Jude speaks about being very angry with the system because she felt nothing was done to help Josh. She shares:
“I had a lot of anger. I was very angry...I’m still angry.”
Jude speaks directly about how her feelings regarding the treatment Josh received impacts her grief experience:
“I think it impacted it hugely because I knew he didn’t get the treatment he should have got.”
She also says: 83
“Well of course I am angry. I loved my son and he isn’t here.”
Neither Matthew nor Hope talked about their experience of getting help for their loved one.
Relationship with Loved One
The relationship between each participant in the study and their loved one is another meaning unit because the relationship influenced how they grieved their loved one’s death. The constituents of this meaning unit are failure to connect, hopefulness, and loss of voice.
Failure to Connect. Failure to connect is a constituent that identifies a change in the relationship between the participant and their loved one. Two of the four participants in the study were mothers of teenaged children and one participant was the mother of a young adult. Each parent was continuously engaged in connecting or trying to connect with their child pretreatment, during treatment, and post-treatment. Each parent was invested in their child making change and being well. Margaret speaks about how she felt about the change in Janice’s behaviour:
“[T]o see the change (in behaviour) you think ‘What kinda caused this?.... [Y]our brain jumps all over the place. [Janice] had always been a fairly deep thinker, very sensitive, but now she showed nothing....it was frustrating. [We would try to] sit with her quietly every opportunity, just to give her a hug, but she wouldn’t allow that much. We tell her ‘we love you’...I would rack my brains and try everything I could to lift the self- esteem of this child that was obviously really struggling but Janice wouldn’t allow you to discuss any issues.”
Margaret continues to discuss their inability to relate to Janice:
“[W]e were just continuing as best we could you know like living from day to day, week to week, month to month you just kept going trying to deal with our child that obviously wasn’t happy....totally failing to connect.” 84
Hope shares her fears about Jimmy’s thoughts of suicide and how she often questioned whether hearing about a suicide close to their community would encourage
Jimmy to follow through on taking his own life. Hope speaks about her fears:
“I went to Fort Simpson...and a suicide happened on the Reserve.... I was scared when I heard that. I was so scared because of my son (Jimmy). I didn’t know how many times he tried (to kill himself) and I didn’t know what he would think.”
This statement indicates the limited knowledge Hope had regarding Jimmy’s suicidal ideation and suicidal behaviour and how disconnected Hope and Jimmy were in terms of his mental health.
Jude also experienced a disconnection with Josh regardless of her attempts to keep him close. Jude shared that Josh attended treatment because he knew she wanted him to but Jude did not know how, or if, Josh was following through with treatment. Jude states that after Josh’s first suicide attempt at 14 years old, she and her husband:
“wanted to keep (Josh) next to us in a room but we couldn’t do that. We had to let him go to school and be with his friends so we were very, very overprotective....as much as you can be of a kid that age.”
Even though Jude and her husband were “overprotective” of Josh, the failure to connect continued:
“I was very busy making sure he was okay and getting what he needed....he was very sneaky. We didn’t know lots of things he was doing. He’d come and ask me for his prescription but then he hadn’t taken the pills at all. We found (the pills) when he died. He would ask me ‘Mom, can you take me to the sailing club?’ I would think he was going out sailing but no...he’d actually just gone for a walk...The school, the crazy school, he was missing classes but do you think we knew? No. We weren’t told.” 85
Jude experienced a failure to connect with Josh but also found a lack of support from the school which presents another area of Josh’s life where Jude did not have information regarding Josh’s behaviour.
Matthew was the only male participant in the study and shared about the death of his ex-partner. He speaks about his relationship with Pamela as “passionate” but at the time of her death they had not spoken in a year. For Matthew, the relationship held times of great intensity coupled with times where they were not connected at all. It was at the time of this disconnect that she died by suicide. Matthew shares:
“[I]t had been – for me – a very passionate relationship; there were lots of fights, there were lots of wonderful times, she was one of the most …in every way, one of the most exciting people that I have been close to, you know? And...yet on the other hand I would have said, well she messed with my head a lot, she made me unhappy, she made me confused, she filled me with self doubt, shattered my confidence; all kinds of things that way.”
Due in part to Pamela’s mental health, past history in an abusive family of origin, and the nature of their relationship, Matthew speaks about feeling isolated in his grief when he learned about her death:
“[I]n many ways I felt - perhaps narcissistically - that I was her only support or her closest support, and certainly that is what she told me for whatever reason, you know? And so I had this strange sense...that a huge part of my world is gone and has changed radically, someone who at that point, I had known her for a third of my life - all of my adult life - and so that loss was profound on just a number of levels and yet it felt very strange because it was a consciousness of missing somebody that nobody else is missing and that awareness that there is not really a lot of people to commiserate with because there is not… there is nobody that I can think of that I could have a conversation with about the fact that she is not in the world anymore.”
The connection of the participant to their loved one creates other layers of loss throughout the relationship. Margaret grieves the loss of years connecting with her 86 daughter in ways she would have wanted to do, the grief around what their relationship could have been if not because of the mental illness and suicide death.
Hopefulness. Hope’s relationship with Jimmy changed over the years. She speaks about being worried and scared that he would follow through on his suicidal ideations, especially when he had been drinking, but she was always hoping he could move to a different place in his life. Hope identified the biggest change in Jimmy just before he died. The changes she saw in Jimmy’s behaviour created hope for her that he may be choosing a different path for himself. She shares her experience with Jimmy when she was in the same community as him for three days:
“[Jimmy] came to stay with me all the time I was in town for those three days. I saw a side of Jimmy that I had never seen before....[H]e helped me even with laundry, folding clothes, separating clothes or even helping me with the dishes and taking out garbage - which he never did before. Sharing his human gift of delight and then he came home and shared that with me and...I was so happy. It’s just that little things that I figured you know that’s the way I wanted him to be all the time and all this time he could do it. You know, I was so so proud of him.”
The interaction between Hope and Jimmy just before Jimmy’s death proved the greatest change in Jimmy’s behaviour. There were other moments where Jimmy would connect with Hope and promised not to take his own life. If Jimmy had been drinking and was suicidal, Hope would contact the RCMP who would come and remove Jimmy from her home. Hope shares:
“They (the RCMP) would come there and I’d tell them you know he was talking crazy. He was talking suicide and all that and I can’t handle him, so they used to take him. And the next day he would be sober, you know, but then I used to tell him how scared I used to be and everything. He’d say that he would never do it again. You know, he’d never do it again.” 87
Although Hope speaks about the fear she always carried that Jimmy would, one day, follow through on his thoughts to take his own life, moments of hopefulness were presented by Jimmy when he promised her he would not kill himself.
These moments of hope were also experienced by Margaret and Jude. Jude talks about when Josh had returned from England. She states:
“...[W]e thought he was much better. He went on a trip to England....when he was there he had a great time and when he came home he looked like a million dollars.”
Margaret had moments of hopefulness throughout her relationship with Janice.
During the interview, Margaret spoke of two times when Janice shared drawings she had done and how happy the connection with Janice made her feel. The older Janice grew, the more withdrawn she became and initiations by Janice to be involved with her family were always warmly welcomed. Margaret shares:
“[Janice] and I are sitting at the kitchen table...I’m thrilled because she is actually speaking to me....She’s looking down at her cereal and she said “Mom, I don’t want you and Dad to do anything for me this birthday...you know you have done so much for me and instead I am going to do something special for you.” I had no idea....I’m thrilled because she is actually talking in a warm, loving way.....I’m pleased a few words that appeared actually loving and a little bit normal and (she was) trying to connect and I thought ‘Oh great!’. It made me feel a bit happy that day. She was actually saying that she was going to take her own life.”
The pieces of hopefulness all three children gave their parents were shown throughout their relationship. At times, these moments of connection and hope were attached to suicidal ideation or attempts of their loved one but these moments helped mold the relationship and their grief experience. 88
Matthew did not talk about the experience of hopefulness within his relationship with Pamela. There may have been hopefulness present within their relationship because of how he and Pamela continued to renegotiate their relationship after a break-up but this was not overtly addressed.
Loss of voice. Hope and Margaret speak about how their voice in their relationship changed as a result of the suicide attempts and suicide death. Hope speaks about how Jimmy’s death changed how she parents her other children and how she is hyper-vigilant around her fear they may choose to die by suicide. She shares the following:
“I used to be so scared because of my other children, you know. Am I ever really going to have peace now? ....I’m always going to be worried that what happened to one son is going to happen to my other kids and I find myself just paying really good attention to their every move.....I think it’s not the healthiest way. Sometimes I try and keep in touch with them and everything because I don’t want them to (die by suicide)...I don’t want to hurt their feelings and I shouldn’t be like that. If they are in the wrong, I should be talking and telling them what I think is right and wrong instead of trying to make it easy (on them) and they get away with stuff....because...I’m scared of what they may try and do.”
For Hope, Jimmy’s death intensified her fear that her other children may also have feelings of suicide, therefore, she watches what she says and how she parents even though she recognizes that may not be the best learning for her children.
Margaret speaks about losing her voice for moments in her relationship with
Janice. Several times throughout the interview, she shares that although she was feeling fear, worry, despiration, anger, and hopefullness, she only showed Janice calmness. She speaks about not wanting to say anything in fear that Janice will abruptly end the 89 conversation or that Janice would not agree to access treatment. Margaret shares the following about taking Janice to the doctor after her three suicide attempts:
“I’ve got Janice and I’m driving with her to the doctor’s. I am like a cat on a hot tin roof. Outwardly, I’ve got it together; I’m calm. I’ve got to be calm with this kid sitting there - she still reeked of helium in her hair, in her clothing....I was expecting at any moment she’d say... pull over, I’m not going. All the time I am just praying within myself please God let her come. Please God don’t let her refuse to go.”
Margaret shares how she felt she needed to hide her true feelings from Janice for fear Janice would not access support or connect with her any further.
The findings in this study identify the intense and evolving relationship each participant experienced with their loved one. The discussion chapter will explore how these findings fit with existing literature and implications for practice and future research. 90
Chapter Seven: Discussion of Findings
The purpose of this research study was to identify how suicide attempts impacted the grief journey of those bereaved by suicide. This chapter explores the highlights for me as a researcher, the study’s findings, and how the findings connect with existing research.
The strengths and limitations of the study are also presented, including the implications for practice, and further research implications.
Study’s Highlights
Several significant considerations came out of this study. The first of these considerations is identified in the participants themselves. It may be argued that the sample from which the data was taken provided biased data because all four participants are connected to the human service field and work with people who are impacted by all aspects of suicide. Two of the participants have created their own organizations in memory of their loved ones in order to educate others about suicide and mental illness.
The other two participants work in the human service field directly with clients at risk of suicide. Three of the four participants spoke specifically about how the suicide death of their loved one has changed their life path by reshaping their perspective on the world and encouraging them to engage with those who are impacted by suicide. The fourth participant spoke about how the suicide loss of her son continues to influence how she engages in her work as a Wellness Worker and how she uses her experience to educate and support others. For all the participants in this study, the impact suicide has had on their life as well as their continued involvement with suicide prevention may be a 91 common characteristic that lead them to want to participate in the study, creating bias data.
One could also argue that as a result of how each participant is engaged in their work with those are touched by suicide they have solidified their own narrative around their loss. In other words, how each participant talks about suicide and their experience with suicide death is a result of telling their story numerous times, possibly removing emotion and insight from the story. According to phenomenological research, these narratives are what they hold true for themselves and are what has become the essence of their lived experiences (Giorgi, 2009). I believe it is safe to argue that, for these participants, the suicide has altered their life course. It has changed how they interact in the world and encouraged them to reach out in a way they may not have before.
Throughout the interviews, the passion and love each participant felt about their loved one, their frustration with the medical system and their desire to make change was palpable. The participants were not separate from their emotion when they shared their experiences. Without the suicide loss, the participants may not have made the choices they have so far in life. The suicide has influenced all they do.
My wondering when I entered this thesis process was how the suicide attempts affected the grief journey for those impacted by a suicide death. What I quickly identified is how difficult it was for the participants to separate their experience with the suicide attempts from the suicide death. At the time of the death, each participant spoke about being focused on their loved one and spoke easily about the step by step process, as best as they could remember, about what happened and what they did to support their loved 92 one. For most of the participants, it was difficult for them to reflect back on how they were feeling at the time of the attempts. I would suggest there are several different reasons for this. One of the reasons might be the participants were being asked to reflect back to a time where they were actively involved with their loved one but the reality of their death overshadows how they were feeling at the time of the suicide attempts.
The second influencing factor may be the grief journey itself. The participants were grieving the loss of many aspects of their relationship with their loved one as well as their own beliefs and perceptions of the world. This grief cannot be separated out and identified as different from the grief of the suicide death because they are a continuation of each other. The primary loss for the participants might have begun when their relationship changed with their loved one, it may have begun when they recognized signs of distress experienced by their loved one or it may have begun at some other point they are not able to specifically identify. The secondary losses, including the death of their loved one, created additional layers to their grief journey. For some participants, the death of their loved one has strengthened their faith and their connection with other family members. For some participants the anger continues to be a part of their grief experience.
Regardless, grief is still a part of their life and continues to influence choices they make.
The main purpose I chose the phenomenological descriptive methodology is to understand the lived experiences of the participants and their recollection of their experience. The findings pulled from the study may not reflect all they were feeling at the time but identified what part of their experience has become part of their consciousness, leaving the most impact. This finding is significant when examining treatment and 93 developing support programs for those impacted by suicide. The participants spoke eloquently about how isolated they felt within a system designed to help because the system focuses on the individual who is exhibiting the highest distress.
Study’s Findings
Some of the findings in this study can be connected to existing literature while other research findings stand alone, requiring further inquiry. My literature review explored the grief experiences of those bereaved by suicide (Bailley et al., 1999; Barrett
& Scott, 1990; Begley & Quayle, 2007; Dunn & Morrish-Vidners, 1987; Jordan, 2001;
Jordan, 2008; Knieper, 1999; Mitchell et al., 2004; Reed, 1998; Séguin et al., 1995;
Silverman et al., 1994) and the experience of support systems after a suicide attempt
(Chessick et al., 2007; Magne-Ingvar & Öjehagen, 1999a; Magne-Ingvar & Öjehagen,
1999b; Talseth et at., 2001; Wagner et al., 1999; Wolk-Wasserman, 1986).
Using a modified phenomenological approach to research, the raw data from the interviews were organized into meaning units and constituents. The map of the meaning units (Figure 6.1) presents an understanding of the structure developed from the data and how the constituents interrelate with the meaning units, further supporting the structure of the presented data. The meaning units presented by the participants were mental illness, suicide attempts, treatment, and relationship with loved one. This discussion will follow those meaning units and constituents, linking to existing literature and further research suggestions. 94
Mental Illness.
Comprehension of mental illness. One of the key themes presented by the participants was their lack of comprehension of mental illness. The participants spoke about not truly understanding mental illness and, in turn, not believing the mental illness experienced by their loved one could lead to suicide. Our society does not talk openly about mental illness. The lack of information and knowledge about what mental illness is, how it presents itself and how it affects those with a mental illness and their support systems prevents society from learning about signs and symptoms in order to provide further support. One participant continued to repeat she had “no understanding of mental illness” (Margaret interview, 2009). If society encouraged candid conversation around mental illness, the possibility that potential support systems would have the knowledge needed to access support for themselves would be greater.
This finding raises the question of how support systems learn about mental illness.
Those families who did not have prior contact with mental illness struggled to understand the breadth of the illness for their loved one. Compounded with lack of connection between the support systems and their loved ones, the ability to develop understanding about the mental illness was limited. I acknowledge there is a gap in my literature review exploring mental illness and how mental illness impacts support systems. In order to maintain a focus on suicide and suicide bereavement exclusively, I did not explore the issues surrounding support systems with a loved one who experiences mental illness.
Working as a social worker with addictions, suicide, and mental health for over 14 years,
I was surprised by this constituent yet know rarely have support systems been included in 95 the treatment process in the agencies I have worked for unless specified by the person accessing treatment, nor is any information provided about treatment, what to expect and how to help. Attention is given to the individual who presents with the issue, not those who surround them.
Stigma. The participants in this study spoke about the undercurrent of stigma in many aspects of their journey, preventing both the participants and their loved ones from talking openly about mental illness. These findings are congruent with Corrigan et al.
(2003) and Corrigan (2004) who indicated stigma can be debilitating and continues to marginalize people, preventing them from accessing support. Congruent with Larson and
Corrigan (2008) one participant believes the stigma connected to mental illness prevented her son from talking about his mental illness or feelings of suicide. She believes if he felt he was able to talk about his feelings his suicide might have been prevented (Jude, interview 2009). Corrigan et al. (2003), Larson and Corrigan (2008), and Mak and
Cheung (2008) indicated stigma can influence how individuals choose to share the mental illness and suicide attempt of their loved one with others. These findings fit with the perception of one participant in my study who shared that the people around him would not understand what was happening in his relationship, so he did not talk about it, making the stigma surrounding mental illness true for himself.
Isolation. Closely related to the constituent of stigma, feelings of isolation were presented by the participants. Matthew identified that the chaotic nature of his relationship with his ex-partner, including her mental illness and numerous suicide attempts, isolated them from others. The isolation he experienced was more pronounced 96 when she died because he felt there was no one he could talk to about her and the grief he was experiencing due to her death. Matthew indicated the profoundness of the isolation he experienced left him questioning whether the relationship truly existed because there was no one he could talk to who knew Pamela, because of the extent to which she had separated herself from the world, leaving him with moments where he wondered if he was imagining the whole experience. Current research supports this finding indicating support systems experience feelings of isolation from the person who has the mental illness and external support systems (Corrigan et al., 2003; Corrigan, 2004; Larson &
Corrigan, 2008).
Own mental illness. In this study, the history of the mental health of the participants influenced how they understood mental illness but did not help them understand how their loved one would respond to the suicidal ideations. One participant shared how her feelings of depression must have been present at the time of her son’s suicide attempt, which is congruent with the Magne-Ingvar and Öjehagen (1999b) finding where support systems experienced mental health concerns of their own, such as depression, one year after the suicide attempt of their loved one. This participant indicated she could not remember exactly how her mental health was impacted by the suicide attempt and that her primary focus at the time was helping her son. Her statement is reflected in Beautrais’ (2004) literature review of support for families after a suicide attempt. Beautrais (2004) stated, “...the issue of providing support for family members and significant others after a suicide attempt appears to be almost always obscured by the immediacy and urgency of addressing the treatment needs and further suicide risk of the 97 attempter” (p. 24). Further research around how the mental health of support systems and history with mental illness influences their understanding of the mental illness experienced by their loved one needs to be undertaken. This exploration may assist in understanding the role our own mental health has on how we understand mental illness and may, in turn, help identify how that understanding influences the grief journey given the presence of mental illness.
Suicide Attempts.
Stigma. The participants identified stigma connected to the suicide attempts of their loved one. Research indicates stigmatization as a common theme for those bereaved by suicide (Allen et al., 1993; Bailey et al., 1999; Barrett & Scott, 1990; Begley &
Quayle, 2007; Feigelman et al., 2009; Grad et al., 2004; Jordan, 2001; Jordan, 2008;
Silverman et al., 1994) but I found no literature directly connecting feelings of stigma to support systems after a suicide attempt. The participants in my study spoke about feelings of stigma as a result of the suicide attempt. According to this study, stigma was present prior to the suicide death and connected to both mental illness and suicide attempts.
Understanding what role stigma plays in how people feel and respond to a suicide attempt needs further exploration.
Isolation. Prior research studies exploring suicide bereavement experiences found participants indicated feelings of isolation as a result of the suicide death (Bailley et at., 1999; Barrett & Scott, 1990; Clarke, 2001; Dunn & Morrish-Vinders, 1987; Jordan,
2008; Kjellin & Östman, 2005; Knieper, 1999; Mitchell et al., 2004; Pietilä, 2002; Reed,
1998; Silverman et al., 1994; Wolk-Wasserman, 1986). In these research studies, the 98 isolation is experienced primarily from other support systems. The participants in this study indicated feeling isolated from their loved one as they entered treatment as well as from other support systems, as a result of the suicide attempt or suicide ideations. The current research literature does not indicate feelings of isolation as a result of suicide attempts.
Disbelief of suicide. Magne-Ingvar and Öjehagen (1999a) found “...nearly half of the SOs (significant others) were found to have been so alarmed by the patient’s suicidal signals and change of behaviour that they had urged the patient to seek help “ (p. 78), which is congruent with the findings of this study. What is interesting to me is each participant was aware their loved one had attempted suicide on more than one occasion, yet still found it difficult to believe they actually did follow through and take their own life. I wonder if the disbelief of suicide is a human experience, that the idea we can end our own life is beyond our scope of understanding at times, especially when we are talking about someone we care for and have a relationship with.
A unique process associated with suicide bereavement is the questioning about why a loved one decided to take their own life (Jordan, 2008), which is consistent with the findings in this study. Several of the participants shared they questioned why their loved one took their own life but what is noteworthy is the participants did not mention any questioning around why their loved one attempted suicide. Given the semi-structured interview process, the support systems were never asked if they questioned why their loved one had attempted suicide. I wonder how prevalent the questioning of ‘why’ is for support systems after a suicide attempt and if it is important to acknowledge this 99 questioning in order to provide appropriate support and counselling to support systems.
Conducting a research study with support systems whose loved one had recently attempted suicide may help understand this finding further.
Shocked but not surprised. Linked to the above finding of disbelief around the suicide attempt and suicide death, participants in this study indicated they were shocked to learn about their loved ones death but not surprised they had taken their own life.
Magne-Ingvar and Öjehagen (1999a) found “...SOs (significant others) also reported that nearly one-third of the suicide attempts were not unexpected, and this was more often the case if the patient had a mood disorder and/or was a repeater.” (p.78). For the participants in this study, the suicide attempts did not lessen the shock and disbelief they felt around their loved one’s death, but acknowledges an understanding they carried that suicide was an option they may follow through with. The three participants who acknowledged feeling shocked but not surprised about the suicide death had been concerned about loved ones’ mental health for over three years. I believe this is an interesting finding in the study and wonder if time plays a role in their feelings of disbelief or feeling shocked but not surprised. Exploring further research around this constituent is necessary because it may help to understand how multiple suicide attempts over time may influence the grief experience for those bereaved by suicide.
Hopefulness. For the participants, each suicide attempt created a sense of hope influenced by the belief that this time their loved one would access the appropriate support or they would find what they needed to be well. I did not come across any current research correlating with this constituent but it is possible that there is literature around 100 hopefulness and accessing treatment available. Research may exist around attitudes and readiness for treatment that may correlate with this constituent. It would be interesting to research what happens with these feelings of hopefulness, whether they continue to exist after multiple admissions into treatment and how hopefulness is integrated in how the support system decides to provide support. Furthermore, does the nature of the relationship play a role in hopefulness? Do parents experience more hope around change for their children than other relationships such as spouses, siblings, children, or partners?
Hyper-vigilance and fear. Feelings of hyper-vigilance and fear are associated with suicide attempts (Beautrais, 2004; Kjellin & Östman, 2005; Magne-Ingvar &
Öjehagen’s, 1999b; Talseth et al., 2001; Wolk-Wasserman, 1986). This worry that their loved one will attempt to take their life again as well as a fear of them not accessing services and of saying the wrong things to them after the attempt was felt by all the participants in the study. Fear was present at the time of hearing about the attempts as when their loved one was released from the hospital treatment programs. Lack of communication with their loved one and information around suicide attempts being withheld by schools and treatment workers contributed to the fear and hyper-vigilance for some of the participants. A study exploring the impact of suicide attempts and physical violence on family burden found fear of further suicide attempts as negatively influencing social supports and the mental health of the support systems (Kjellin & Östman, 2005).
Kjellin and Östman (2005) stated: “[r]elatives who reported fear of suicide attempts by the patient also more often than other relatives reported negative effects on their social network, more often experienced mental health problems of their own and more often 101 reported need of help and support from the psychiatric services” (p. 10). These researchers stress these findings support the need for relatives of psychiatric inpatients, especially those who are suicidal, to be involved in the treatment process and to be provided their own support.
Treatment. Magne-Ingvar and Öjehagen’s two-part study interviewing support systems after a loved one’s initial suicide attempt and hospitalization for a psychiatric assessment and a one year later follow-up with the support systems wanted to identify
“...whether information from a significant other (support system) would be helpful in the psychiatric assessment...” (Magne-Ingvar & Öjehagen, 1999a, p. 73) and to assess the well-being and the need for support of the significant other. Among the findings, their research identified shame, guilt, anger, worry, and a desire for further support from a professional as prevalent feelings for the significant other. These findings were congruent with the findings in this research project where the constituents of hopefulness, confidentiality, professional as the expert, and frustration and helplessness were presented by the participants within the meaning unit of treatment.
! Magne-Ingvar and Öjehagen’s (1999b) findings in the second interview a year later indicated the support systems continued to experience stress due to the mental health of the patient, dissatisfaction with the treatment, and feelings of being uninvolved in treatment, ill-informed and unprepared at the time of discharge. These findings are congruent with what the participants in this study spoke about.
Hopefulness. Accessing treatment created feelings of hopefulness after a suicide attempt because there was a sense for the participants their loved one would be getting 102 the professional help they needed for their mental health concerns. All loved ones in this study had accessed treatment at some point prior to taking their lives and getting their loved one involved in treatment seemed to be a natural progression based on the loved ones’ behaviour. Despite the lack of controlled research around interventions supporting those who have lost someone due to suicide (Jordan; 2008), those impacted by suicide attempts indicate the act of having their loved one involved in treatment brings feelings of hope and relief.
Confidentiality. The participants in my research study indicated feeling of isolation both while their loved one was in treatment as well as when their loved one had completed treatment and was discharged. Two of the participants clearly state the limits of confidentiality left them feeling uninvolved with treatment and ill-informed and unprepared for their loved one returning home. Participants in Fielden’s (2003) study exploring grief after a completed suicide expressed similar feelings. Her research participants “described situations where they felt that interpretations of the Privacy Act
(1993) and the Health Information Privacy Code (1994) by health professionals were oppressive” (Fielden, 2003, p. 79) and that they were not given enough information about mental illness.
Layered onto the feelings of worry and desire for further professional support, the participants in my study wanted to be involved in the treatment process, were committed to the treatment process and needed their own support and information in order to continue providing support for their loved one when they returned home. The participants identified confidentiality as not only preventing them from understanding the breadth of 103 their loved one’s illness but also from being able to provide support to their loved ones at home. Beautrais (2004) also identified issues of confidentiality expressed by those who have had a loved one attempt suicide.
Confidentiality is imperative in protecting our fundamental right to privacy but this questions whether confidentiality can be negated when agreed on by a client or when someone threatens to take their own life. A suicide attempt is an attempt to take one’s own life. At what point do the medical or treatment systems believe that someone is no longer in danger of taking their own life? Equally questionable is who is it acceptable to release information to? The participants of this study would argue that although their loved one might not have been in imminent danger throughout the treatment process, they were still at risk of taking their own life and did in fact do so. The participants believe that it would have been important to involve the family in the treatment of their loved one.
Professionals as the expert. Closely associated with the use of confidentiality is the constituent of the professional as the expert. As social workers we are taught about the hierarchy existing between client and service provider. Regardless of how hard we work to make the relationship equal, the assigned roles imply hierarchy. According to this study, the participants spoke about being powerless within the treatment system. The participants indicated the treatment process did not provide them with any options in terms of being heard or being involved in their loved one’s treatment. The participants questioned the process of treating only the identified person and not including family or friends in the treatment. This finding raises questions for me around whether we can tell 104 if someone will try to kill themselves? Can we tell what is talk about taking their own life versus normal teenage or life stages? When does someone cross the line between mental illness and serious mental illness leading to suicide? Is treatment effective in providing enough support for those people who are feeling suicidal to move towards living and away from dying? As social workers, we are encouraged to ask these questions when completing suicide assessment with a client but I wonder if we truly ever know what someone will follow through with.
Frustration and helplessness. When I asked one participant directly if she believed that the suicide attempts affected her grief experience, she responded, “Oh, I think it impacted it hugely because I knew he didn’t get the treatment he should have got.” (Jude, interview, 2009). For Jude, the knowledge that her son did not receive the treatment she believed he should have created feelings of anger that she continues to experience as she grieves the loss of her son. This finding was also reflected in
Dyregrov’s (2002) study exploring the support needs for those impacted by a suicide loss who felt they were “not sufficiently helped by health services in [their] local communities” (p. 660). Feelings of anger and helplessness added to the trauma of the suicide attempts and suicide loss because there was no support provided for the participants by the medical system. The social belief that treatment should be able to help someone heal provides hope, but the participants in this study also had feelings of helplessness as a result of their experience of their loved one’s treatment.
Also, the sense of helplessness participants felt as a result of being involved in the treatment process is connected to the belief of the professional as the expert. In this study, 105 support systems were removed from the treatment process leaving them feeling as though they were doing nothing to support their loved one (Magne-Ingvar & Öjehagen’s, 1999b).
In these cases, the support systems also believed the treatment was not helpful for their loved one but they had no say in how to make change. Treatment perpetuated a sense of helplessness for the support systems. The very system people advocate to access became the system that isolated the support systems further from their loved ones.
The experience of having the participants’ loved ones accessing treatment is woven throughout the grief journeys of the participants in this study. The frustration, anger, hopefulness, and helplessness they experienced as a result of their loved one being involved in treatment influenced how they grieved their loved one’s suicide and, in some cases, continues to be a part of the grief they feel today.
Relationship with loved one.
Failure to connect. Participants spoke about a failure to connect or an inability to understand what was happening with their loved one because of the loved one’s choice to isolate and the lack of sharing and talking about their feelings. With numerous attempts to embrace their loved ones, the participants spoke about their loved ones refusing involvement in their lives, which may be identified as rejection. This constituent is congruent with Wagner et al.’s (1999) and Wolk-Wasserman’s (1986) research studies that indicated feelings of detachment from the person who has attempted, especially if there have been multiple attempts. For some participants in this study, rejection happened over a long period of time whereas other participants did not understand the extent to which they were disconnected from their loved one until after their death and hidden 106 secrets were discovered. Regardless of the time, feelings of rejection were present around the time of the suicide attempt and were part of the grief experience after the suicide death.
Matthew expressed how he was disconnected from his ex-partner throughout their relationship when they moved through a cyclical pattern where there were periods of understanding and connection between them into periods of being withdrawn and isolated from one another. The cycle would be completed when Pam attempted suicide and he connected her to treatment programs only to repeat itself numerous times during their relationship. Until the day she died, the cycle had always returned to a place where the two of them were connected again. With her death, he was left with the broken cycle in their relationship and no sense of closure through completion of the cycle.
Drawing from past clinical experience, clients have often acknowledged a cyclical nature in their relationship with their loved one. They move from a place where they have established their relationship and fallen into a routine that is common in healthy relationships. If suicidal behaviour is present, tension may be felt within the relationship indicated by withdrawn behaviour, isolating from the family or a change in what would be considered normal behaviour which is congruent with the feelings presented by all the participants in this study. The tension is followed by suicidal ideations or a suicide attempt. At that time, support systems respond by accessing treatment for their loved one, hyper-vigilance and fear around their loved one’s behaviour, worry, and further feelings of disconnect. When their loved ones are connected to treatment, or promising not to harm themselves, each person works to re-establish their relationship. Due to the suicidal 107 ideation or suicide attempt, the relationship has changed. As they try and negotiate their new relationship and fall into a routine, the worry, fear, hyper-vigilance, and anger around their loved one’s behaviour may still be present along with feelings of hope. If there is another suicide attempt, the cyclical nature of the relationship is reinforced enhancing the feelings that already exist but if their loved one accesses treatment, feelings of hopefulness around change may increase. As indicated by Matthew, when there is a death by suicide, the opportunity to complete the cycle and enter into the feelings of hopefulness and desire for change is stopped.
Figure 7.1: Cyclical Nature of a Relationship with Suicide Ideation
Establishing Relationship
Suicide Routine Attempt
Tension
In this study, Matthew was not the only participant who spoke about the cyclical nature of their relationship. Margaret and Hope also spoke about moments of connecting with their loved one followed by feelings of isolation and withdrawal. I found no research literature exploring this phenomenon.
Hopefulness. As indicated in the cyclical pattern above, feelings of hopefulness were presented by the participants when their loved one reached out for support or tried to connect with them in different ways. These feelings of hopefulness reenergized the 108 relationship and were cherished by some of the participants as part of their grief experience after the suicide death.
Loss of voice. Participants also spoke about their need to focus on their loved one, ignoring their own feelings around the suicide attempts. I would suggest the naturalness to focus on providing support and to ignore our own feelings connected to suicide attempts may also be influenced by stigma. Participants did not access treatment or support for themselves and often spoke about not wanting to say anything to their loved one in fear of how they may respond. Their own thoughts and feelings became overshadowed by the suicide attempt, mental illness, and treatment journey of their loved one.
Additional Findings
Suicide bereavement literature identifies trauma as a part of the experience of those bereaved by suicide. Trauma is defined as an event that “includes the experiencing, witnessing, or confrontation with actual or threatened death, injury, or threat to the physical integrity of oneself or other people” (Kaltman & Bananno, 2003, p. 132). Each participant spoke about the trauma they experienced as a result of the suicide attempt and suicide loss. The participants in this study had lost their loved one to suicide between three years and 14 years ago, yet when they spoke about the suicide attempts and suicide death, the trauma of their loss was palpable and continues to live with them today. I believe for the participants in this study it was difficult to separate the trauma of the suicide attempts and the trauma of the suicide death. It is possible the participants experienced trauma as a result of the suicide attempt but the trauma was not identified as 109 such and therefore not addressed. To compound their grief, they experienced further trauma as a result of the suicide death. Therefore in this study, the participants could talk about the events and some of the emotions, pre- and post-suicide attempt, but being able to distinguish between trauma connected directly to the suicide attempt and trauma connected specifically to the suicide death was difficult at this point in their grief experience. All the participants were able to clearly recount the time surrounding the suicide attempts of their loved one. The lucidness of the essence of the experience has not been lost over time.
This study also presents other phenomena connected to suicide attempts that continue to be a part of the participants’ grief experience. One of the findings identified throughout the study indicated participants did believe the suicide attempts influenced their bereavement journey but with the exception of one participant, they were unable to identify how. This finding presented itself throughout the interviews and may be derived from two possible rationales. The first rationale is that our relationships and interactions with people influence how we see ourselves and change who we are. When we experience a traumatic event, it is easy to take on the energy of the experience and make it our own. The participants in the study could not talk about what was happening for them unless they spoke about what was happening with their loved one, meaning they created a parallel journey. The essence of their story was focused on their loved one, not their own journey. Secondly, trauma can change who we are and can keep us returning back to the experience emotionally and cognitively, making it difficult to separate ourselves from the whole experience. 110
Grieving is a natural human process. We are always grieving the loss of something in our lives, and therefore it is probable that the grief experience for the support systems began prior to the suicide attempt. Congruent with Stroebe and Schut’s
(1999) dual processing model of grief, the participants spoke about weaving between feelings of grief and healing both after the suicide attempt and after the suicide death.
They grieved the failure to connect with their loved one and how their family changed as a result of the suicide attempts as well as the helplessness they felt when connected to treatment or not being able to understand mental illness. They also focused on restorative-coping by helping their loved one access treatment and providing support through that process.
Strengths of Study
The strengths of this study are found in the rigor used during the research and data analysis process. According to Giorgi (2002), the factors contributing to the validity of phenomenological research lies in how much subjectivity is included in the presented findings. As noted in the methodology section, the use of bracketing both by journalling and consulting with my supervisor, ensuring all data from the interviews has been included in the findings, and member checks completed with the transcripts maintains the credibility of the findings. Together, these processes helped ensure I understood my own biases and removed as much subjectivity as possible from the findings. Each element contributing to the trustworthiness of the study was outlined in the methodology chapter.
According to the descriptive phenomenological approach, the use of the phenomenological reduction was used throughout the study. Free imaginative variation, 111 also explored at length in the methodology chapter, was applied when analyzing the data meaning that the essence of what the participants were saying was extrapolated from the interviews.
Beyond the methodology, the strength of this study comes from allowing the participants to share their stories.
Limitations of Study
There are several limitations to this study that must be noted. To begin with, the sample size of the study is small. Although this is a qualitative study that does not need a large sample size according to the descriptive phenomenology methodology, having a larger participant size would provide a greater opportunity to confirm or challenge the presented meaning units.
Participants were asked to recall how they were feeling at the time of the suicide attempt and relate how those feelings influenced their grief. As mentioned previously, it may be difficult for the participants to recall all of their thoughts and feelings at the time without thinking about their thoughts and feelings as a result of the suicide death.
The nature of the relationship between the participant and their loved one may also have influenced the findings. Three of the four participants were mothers. Of those participants, two of the mothers had young adult children who died by suicide; one mother’s child was 15 years old when he died. Maple (2005), who reviewed research literature around parental bereavement and youth suicide, stated “[a]mong researchers in the grief and bereavement fields there is general acknowledgement that the death of a child is the most traumatic and serious of all bereavements. Such a bereavement impacts 112 on all aspects of the parent’s life” (p. 181). Maple (2005) continued to state there is little research exploring the bereavement experience of a parent who has lost a child to suicide.
The fourth participant’s ex-partner died by suicide. The nature of the relationship may influence how the grief is experienced and shared. The responsibility that parents often feel towards their children may have been reflected in the findings.
Styles of grieving may have influenced these findings. Three of the participants were female and one participant was male but, beyond gender, they may experience grief as intuitive grievers or instrumental grievers (Doka & Martin, 2010). Also, all the participants’ loved ones were connected to treatment. A larger sample group may have brought larger diversity of gender, grieving styles, relationship between the person who died and their support systems and a wider range of experiences connected to the suicide attempts, meaning the findings may have been different.
The lack of triangulation around the data may also be identified as a limitation to this study. I never spoke with other people who were connected to the participants at the time of the suicide attempts therefore I was not able to determine if their perception of their experience was observed by others connected to their loved one. Although the phenomenological approach indicates that one’s experience can represent a phenomenon for that person and is worthy of study, knowing if the experience of others paralleled the participants experience would have strengthened the data. 113
Chapter Eight: Conclusion
Practice Implications
This study has challenged me to look at suicide attempts, suicide deaths, mental illness, and support systems through a different lens. In terms of practice implications, the idea that the grieving process began prior to the suicide death is vital because most programs do not provide assistance for support systems at the time of the suicide attempt.
Secondly, we live in a society that often associates grief with death and does not acknowledge the grief that occurs throughout our relationships. Suicide attempts not only provide an opportunity to provide treatment and support for the person who is suicidal but also for those support systems who are impacted by the suicide attempt.
Confidentiality limits information that can be provided to support systems but involving support systems into the treatment process might be beneficial all around.
Providing information and support to people who want to assist a suicidal loved one is important on two fronts. Firstly, if the individual who is suicidal is returning home, support systems can be helpful in encouraging them to continue the treatment work they have begun. Second, such support aids the support systems in understanding suicide and mental illness to decrease their own stress and worry.
In terms of further research, it would be interesting to explore whether involving families in treatment with those individuals who are suicidal decreases their involvement with treatment in the future. Secondly, providing information allows support systems to have knowledge of what behaviours their loved one may present returning power of 114 information to those support systems, potentially decreasing feelings of powerlessness and helplessness.
Jordan (2008) wrote about the importance of providing psychoeducational treatment to those who have been impacted by a suicide loss. He states:
“there is an important function for psychoeducation about the nature of psychiatric disorder and its role in contributing to suicide that can be invaluable to survivors. This perspective can help survivors make sense of the death and put into realistic perspective their guilt and feelings about the preventability of the suicide” (p. 684).
I would argue that psychoeducational treatment could also be invaluable to support systems connected to someone who has attempted suicide providing them a deeper understanding of mental illness and its relationship to suicide.
The idea of normal behaviour versus problematic behaviour has altered how I view my own clinical practice. The participants speak about how their loved ones accessed treatment for mental illness and suicidal ideations but even the professionals they saw could not differentiate between what was presented as normal behaviour versus life-taking behaviour. I have completed suicide intervention training, follow the assessment protocols developed from the Suicide Prevention Training Programs
(www.suicideinfo.ca) and complete suicide assessments daily in my work with addictions, yet, how am I to know for sure the seriousness or sincerity of a person’s desire to end their life?. Yes, I feel competent in intervening at the time when someone is suicidal. But, I have rarely included the support systems in the treatment process unless they accompanied the client I was seeing to the office. The system I work in continues to identify the problem, suicide or grief, and does not identify the whole system as needing 115 support. Being able to identify what is normal versus problematic may be unattainable without focusing on the support system as a whole.
The participants spoke about feeling surprised their loved ones ended their life regardless of the fact they had attempted suicide. On a larger scale, the culture of the systems we work in may also carry that same understanding. Can we possibly believe someone could choose to take their life? Do we really take suicide seriously or is there a sense of exasperation for those individuals who talk about taking their life? The participants in this study spoke about the lack of support and feelings of helplessness once their loved one was in treatment. I wonder if systems treated suicide differently by including willing and healthy family and friends in the treatment process, responses for both those individuals who are suicidal and their support systems might change.
The more we talk about suicide and mental illness, the more we may be able to decrease the stigma connected to it which in turn, may create change in how those who are suicidal and those who have been impacted by a suicide attempt or suicide death may access help.
Finally, involving support systems in treatment may not be what those support systems want but providing an opportunity for them to explore their own feelings and thoughts as a result of the suicide attempt of their loved one is important.
Social workers aim to work with whole systems connected the individual in the person-in-environment view. This research study shows how important it is to consider all aspects of a client when they enter treatment. As social workers, our desire to be transparent for clients so they understand our own concerns and biases as well as 116 including other professionals when working with clients can only be a strength when working with someone who is suicidal and their families.
This study provided an opportunity for participants to discuss and explore the impact of the suicide attempts of their loved ones on their grief experience. I believe this study reinforced that grief is an ongoing process in our lives and is not initiated by death but by loss but further research needs to be undertaken to truly understand how suicide attempts affects support systems.
Research Implications
This has been an exploratory study and there are many aspects of this study that call for further research. Due to the limited amount of research on the impact of a suicide attempts on support systems, much more research needs to be done with support systems at the time of the suicide attempt. Connecting with support systems when their loved one enters treatment may help understand further their own feelings and needs helping establish appropriate programs and education.
Research around grief connected to changes in relationships, perspectives, and dreams as a result of a suicide attempt is encouraged. Understanding how this grief impacts support systems further may help establish appropriate programming and support for those whose loved one is feeling or actively suicidal. Also, I agree with Clark (2001) who suggested “[f]amily functioning is another area for investigation, in particular the associations between the family dynamics before and after a suicide, and what effects these might have on outcome of an individual’s grief” (p. 105). 117
As indicated by Beautrais (2004), all aspects around the issue of suicide attempts and support systems needs further study. This research project provides a base line from which future research studies can grow.
Personal Journey
The writing of this thesis began from my own experience living the legacy of suicide bereavement. The death of my mother’s dad, Jim, has left an emptiness that has woven itself throughout many aspects of our family. The silence around his death and his life has raised curiosity around who Jim was to his daughters and wife. The process of writing this thesis has opened some doors of communication around Jim’s death that may have otherwise stayed closed. My mother shared that she felt the stigma of her father’s death when she was at school or out in the small community where she lived and she opened up about the relationship between Jim and my grandmother. Having never heard these stories before, it helps me develop a picture of who Jim was.
I cannot acknowledge Jim’s death without acknowledging the gifts his death gave our family. If he had not chosen to take his life, I would not have had 36 years with the most amazing, accepting, and loving woman I have ever met—my grandmother. After
Jim’s death, my grandmother moved to Saskatchewan to be with family, where she accessed emergency medical treatment which saved her life. Jim also gifted me my grandfather. Prior to him taking his own life, he would tell my grandmother that he did not want anyone but Roy, an ex-boyfriend of hers, looking after their girls. If Jim did not take his own life, events leading to Roy returning to my grandmother’s life would never 118 have happened and Roy would not have been my grandfather. In turn, I would never have met one of the most incredible, loving men who has influenced every aspect of my life.
The personal journey of this thesis is not yet over. I still have much to learn but I appreciate and honor all that this journey has given me until now. 119
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Figures
Figure 6.1: Map of Meaning Units and Constituents
Own Comprehension Mental Mental Illness Illness
Shocked Stigma Isolation but not Confidentiality Surprised
Hyper- Suicide Treatment Professional vigilance Attempts Hope as the and Fear Expert
Helplessness Disbelief Relationship with Loved One Failure to Loss of Connect Voice 129
Figure 7.1: Cyclical Nature of a Relationship with Suicide Ideation
Establishing Relationship
Suicide Routine Attempt
Tension 130
Appendix 1: Recruitment Notice
I am a master’s student in the Faculty of Social Work, University of Calgary and am carrying out a study to explore the impact of two or more suicide attempts on the bereavement journey of survivors of suicide for my thesis research.
The purpose of the study is to begin to understand how suicide attempts affect support systems and influence grief once a suicide has been completed.
I am seeking adult survivors of suicide who where aware of two or more suicide attempts made by the deceased, who have been bereaved a minimum of one year and who would be willing to be interviewed for about 60-90 minutes regarding their experience.
Participants will be provided with a transcript of their interview to verify accuracy and one follow-up phone interview may needed to clarify information provided. Please email or phone me if you fit the given criteria and would be willing to participate in this study.
Kim Everingham [email protected]
Phone: 403-968-7968 131
Appendix 2: Questions for Participants
Preliminary questions for participants
1. How did you feel when you found out about the suicide attempts?
2. Did your feelings change each time there was another suicide attempt?
3. How did the suicide attempts affect how you experienced the grief after the completed
suicide?
Alternative questions if participants have only experienced one suicide attempt prior to death
1. How did you feel when you found out about the suicide attempt?
2. How did the suicide attempt affected how you experienced the grief after the
completed suicide?
Probes to be used with either set of questions
1. How did you respond physically, emotionally, spiritually and socially to the suicide
attempt?
2. How was this response different or the same after the suicide?