Article

OMEGA—Journal of Death and

A Qualitative Dying
2017, Vol. 74(4) 426–454
! The Author(s) 2015
Systematic Review Reprints and permissions:
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of the Bereavement DOI: 10.1177/0030222815612281
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Process Following
Suicide

Chris Shields1, Michele Kavanagh1,

and Kate Russo1

Abstract
Despite the fact that a large number of people are bereaved by suicide each year,
the experiences of those bereaved by suicide are poorly understood. It has been
suggested that a contributing factor in relation to this lack of understanding has been
the use of quantitative methods, which may not be sensitive to the bereavement
process and its thematic content. Therefore, the current article outlines a systematic
review of 11 qualitative studies that address issues related to the bereavement
process following suicide. The results indicate that those bereaved by suicide
encounter a range of difficult feelings following suicide including blame, guilt, and
emptiness and that these feelings are affected by participants’ ability to make meaning
of the event. The meaning-making process is a complex one that occurs within a
difficult social context in which both those bereaved by suicide and members of the
wider community struggle to interact with each other in a beneficial way. Clinical
implications of these findings are discussed.

Keywords
bereavement, suicide, qualitative

1
Queen’s University Belfast, Belfast, Ireland, UK
Corresponding Author:
Chris Shields, School of Psychology, David Keir Building, Malone Road, Belfast, Northern Ireland, UK.
Email: cshields07@qub.ac.uk
Shields et al. 427

Introduction
Following the loss of a loved one, there are a number of challenges faced by
those who have been bereaved. These include coping with the emotional pain,
incorporating the loss into a changed identity, finding new goals and purposes
for one’s life, finding meaning in the death and continuing a bond with the
deceased (Baddeley & Singer, 2009; Begley & Quayle, 2007; Neimeyer,
Baldwin, & Gillies, 2006; Owens, Lambert, Lloyd, & Donovan, 2008; Park &
Folkman, 1997). The ability to successfully negotiate these challenges may be
impacted by the type of bereavement, and some research would suggest that this
may be particularly difficult for those bereaved by suicide (Cerel, Jordan, &
Duberstein, 2008).
It has been proposed that the effects of a death by suicide on those left behind
are poorly understood and conceptualized (Feigelman & Feigelman, 2008;
Maple, Edwards, Plummer, & Minichiello, 2010). Given that Shneidman
(1969) claims that for every death by suicide, six other people are affected and
that research suggests that over one million people die by suicide each year, this
leaves approximately 6 million people each year whose experiences of being
bereaved by suicide are poorly understood. Indeed Clark (2001) suggests that
the figure of 6 people affected by each suicide is a conservative estimate, and it is
probable that the actual number of people affected by suicide is much higher
(Cerel, Padgett, Conwell, & Reed, 2009) with relatives, friends, and members of
the wider community all being affected (Maple et al., 2010).
While suicide has been described as a death like no other (Feigelman &
Feigelman, 2008) and it has been suggested that those bereaved by suicide are
faced with a unique set of problems (Cerel et al., 2008), there appears to be much
debate concerning the notion that the grief process of those bereaved by suicide
is different to those bereaved through other methods (Jordan, 2001). While
mourning following a suicide is certainly perceived by those affected to be dif-
ferent from other forms of bereavement, research on the matter is less clear
(Jordan, 2001; Jordan & McIntosh, 2011).
Some research would suggest that there are few differences between suicide
bereavement and other forms of bereavement. For example, Clark (2001) states
that there are few quantitative differences between those bereaved by suicide and
those bereaved by other modes of death. Sveen and Walby (2008) in a more
recent systematic review found no significant differences between those bereaved
by suicide and other bereaved groups in relation to general mental health, post-
traumatic stress disorder, depression, anxiety, and suicidal behaviour.
However, these findings concerning the overall level of grief were less clear
and were impacted by whether general grief instruments or suicide-specific
instruments were used. Sveen and Walby (2008) claim that, when suicide specific
instruments were used, the evidence would suggest that those bereaved by sui-
cide experience a significantly higher level of rejection in comparison with other
bereaved groups and that blaming is also an issue for those bereaved by suicide.
428 OMEGA—Journal of Death and Dying 74(4)

The authors also suggest that those bereaved by suicide tend to struggle more
with shame and stigma and as a result may conceal the cause of death. However,
there was no clear evidence that those bereaved by suicide experience higher
levels of guilt and responsibility in comparison to other bereaved groups. Sveen
and Walby do suggest that there may be a weak tendency toward higher levels of
guilt and responsibility within the first 18 months following a suicide. They also
found little evidence that those bereaved by suicide experience more anger, lone-
liness, or isolation than other bereaved groups. The evidence concerning the role
of social support was conflicting and the meaning-making process of those
bereaved by suicide was not mentioned, perhaps reflecting difficulties of exam-
ining this using quantitative methods.
Jordan (2001) argues that there is considerable evidence that qualitative
aspects of grief following a suicide may be different to other forms of bereave-
ment. Jordan goes on to suggest that those qualitative areas related specifically
to suicide bereavement can be categorized into three broad areas: questions
related to making meaning of the suicide; higher levels of guilt, blame, and
responsibility related to death by suicide; and greater feelings of rejection by
the loved one, coupled with anger toward the deceased.
Other research would also suggest that there are a range of problems and
emotions that are unique to those bereaved by suicide (Cerel et al., 2008; Clark
& Goldney, 1995). These problems may include a sense of responsibility for the
death, feelings of guilt and of being blamed for the death, and anger directed
toward the person who has died (Cerel et al., 2009). Runeson and Asberg (2003)
suggest that those bereaved by suicide are more likely to complete suicide them-
selves. Other researchers state that there is also a higher risk of developing
psychiatric disorders such as PTSD and depression in families where there has
been a suicide (Cerel et al., 2009).
The ongoing debate concerning the bereavement process of those bereaved by
suicide and the comparison with other forms of bereavement is highlighted in a
recent book edited by Jordan and McIntosh (2011), who emphasize that the
individual course of grief and bereavement experiences are incredibly complex.
While it has been suggested that methodological issues may, in part, explain
some of the discrepancies between conflictual findings related to the bereave-
ment process following suicide (Jordan, 2001; Jordan & McIntosh, 2011; Sveen
& Walby, 2008), the impression that is left is one of confusion concerning the
grief process of those bereaved by suicide. Within this context, Ellenbogen and
Gratton (2001) argue that the emphasis should be placed on differences between
individuals bereaved by suicide rather than on differences between those
bereaved by suicide and other forms of bereavement.
It has also been suggested that qualitative analysis and techniques may pro-
vide different perspectives concerning suicide bereavement (Jordan & McIntosh,
2011) in comparison to research that examines the differences between suicide
bereavement and other forms of bereavement using quantitative techniques.
Shields et al. 429

Quantitative measures may not detect some of the thematic content of grief
following suicide. As stated by Jordan and McIntosh (2011), bereavement is a
personal experience and the loss of a loved one can have a unique impact on
those left behind. Quantitative research methods may not be sensitive enough
to provide information concerning the experience of being bereaved by
suicide. Qualitative research methodologies, which allow participants to describe
their experiences in their own words, may be more suited to investigating and
understanding these types of experiences (Jordan, 2001; Neimeyer & Hogan,
2001).
Shneidman (1969) developed the term postvention, which he defined broadly
as the activities that occur after a suicide and which are aimed at mollifying the
psychological sequela of a suicide in those left behind. This definition has been
refined by Andriessen (2009) to refer to those activities developed by, with, or for
those bereaved by suicide to facilitate recovery and to prevent adverse outcomes,
including suicidal behaviour. Postvention can be seen, then, as a form of pre-
vention for those bereaved by suicide. However, in order for this postvention to
be of value, an understanding of the grief process for those bereaved by suicide is
needed. As stated previously, those bereaved by suicide are a neglected and
poorly understood population (Feigelman & Feigelman, 2008) due to factors
such as the focus on quantitative methods (Hjelmeland & Knizek, 2010) and the
focus on the comparison of bereavement by suicide to other forms of bereave-
ment rather than the experience of those bereaved by suicide specifically. What is
missing is an understanding of the grief process following suicide. Therefore, the
current systematic review may add to the understanding of this group by exam-
ining the thematic content of the grief process in those bereaved by suicide. If it
is possible to identify recurrent themes in the grief of those bereaved by suicide,
then it may be possible to target more effective interventions for this population
(Jordan, 2001).
Begley and Quayle (2007) suggest that the process of dealing with the painful
feelings related to suicide and finding meaning within the event is a complex one
and may not occur in a linear fashion as posited by stage theories of grief (Begley
& Quayle, 2007). Begley and Quayle (2007) suggest that, for those bereaved by
suicide, there is a constant reappraisal back and forth between stories of the
deceased and the suicide itself in order to find meaning and to cope with it.
Gaining a greater understanding concerning this process may have important
clinical implications. If the grief process of those bereaved by suicide contains
certain themes that may not occur among those bereaved by other means, it may
be argued that interventions targeted specifically at this group are needed. For
example, those bereaved by suicide may feel that only others who have also been
bereaved by suicide can truly understand their experiences (Jordan & McIntosh,
2011). This may have implications for the make-up of support groups for this
population with the possibility that groups consisting only of those bereaved by
suicide may be most beneficial.
430 OMEGA—Journal of Death and Dying 74(4)

Given the importance of understanding the thematic content of the grief

process for those bereaved by suicide, coupled with the fact that much of the
research has focused on comparing bereavement following suicide with other
forms of bereavement, rather than developing understanding of the experiences
of those bereaved by suicide, the current article will examine research that deals
with this area. Jordan (2001) has postulated that quantitative measures are
unable to identify some of the possible thematic content of the grief process.
Therefore, the proposed review will focus on qualitative research.

Aims
The current article aims to examine studies that investigate the grief process of
those bereaved by suicide. The review will aim to examine the thematic content
of the grief process for those bereaved by suicide to help to provide some clarity
concerning this process.

Method
Search Strategy
A comprehensive search of three databases (PsycINFO; Medline; Web of
Science) was carried out using a range of keywords related to suicide, grief,
and bereavement. These databases were chosen given that the topic areas
involved in the current article related to the bereavement process following
suicide. This process has aspects that relate to psychology and psychiatry as
well as aspects related to social factors. PsycINFO searches journals primarily
related to psychology, Medline focuses on medical journals, including those
related to psychiatry and Web of Science searches a range of journals related
to general social science. Each database was searched from 1980 through
January 2012.
Using PsycINFO and Medline, the search terms, “suicide OR non-accidental
death AND bereavement OR grief OR loss OR survivor” returned 362 titles
on PsycINFO and 499 on Medline. These searches were limited to the
English language, human populations, peer-reviewed journals, and qualitative
studies.
Using Web of Science, the search terms “(suicide OR non-accidental death)
AND (grief OR bereave*OR loss OR survivor)” yielded 627 titles. This was
further limited by combining the search with terms specifically aimed at
identifying qualitative studies “(Qualitative OR narrative; OR discourse analysis
OR interpretative phenomenological analysis OR IPA OR phenomenology OR
grounded theory)”. This reduced the number of identified titles to 101. The
search using Web of Science was limited to the English language and to journal
articles.
Shields et al. 431

Criteria for Study Selection

In total, 962 articles were identified using the above mentioned searches. The
first author then further limited these articles by applying the inclusion criteria to
the title and abstract to determine the eligibility of the articles. Concerning the
inclusion criteria, studies were included if they used qualitative research meth-
ods, were peer-reviewed articles, were written in English, and identified themes
related to the grief process of those bereaved by suicide. Studies were included
that referred to the grief process of family members bereaved by suicide. Studies
were excluded from the review if they focused on quantitative measures of grief,
focused on professionals who were bereaved by suicide, focused primarily on
family or group processes, rather than grief content, focused on those under the
age of 18 years old or did not include those bereaved by suicide. Case studies,
unpublished dissertations, and studies or personal reflections alongside dupli-
cated articles were also excluded from the review. Studies were also excluded if
they failed to meet quality criteria as outlined by Meyrick (2006).
The search strategy was also carried out by a second reviewer to ensure
agreement concerning the studies selected. Initially, difficulties were identified
concerning the quantity of studies identified using Web of Science, and so this
search was redone incorporating the qualitative search terms outlined earlier.
When both researchers had completed the search using all three databases, the
identified articles were compared. At this stage, there were a number of articles
identified by the second researcher that had not been identified by the primary
researcher. Inclusion and exclusion criteria were clarified in light of these articles
and agreement concerning the eligibility of articles was reached. Following this
process, the number of studies was reduced to 20. It became apparent following
a full-text review of these articles that several focused on personal stories with-
out details of participants, on cultural factors or family processes rather than
bereavement, or on professionals or services. Therefore, the number of eligible
studies was further reduced to 11 (see Table 1).

Data Extraction
Data related to the number of participants, demographics, sampling method,
methodology, transferability, and findings were extracted from the relevant art-
icles. Following Hughes, Closs, and Clark (2009), findings were defined as the
“data-driven and integrated discoveries, judgements or pronouncements which
researchers offer about the phenomena, events, or cases under investigation”
(Sandelowski & Barroso, 2003).

Quality of Studies
Judging the quality of qualitative studies can be a complex process with various
different criteria suggested within the literature (Meyrick, 2006; Yardley, 2000).
432 OMEGA—Journal of Death and Dying 74(4)

Table 1. Identified Studies and Process of Reduction.

Web of
Database PsycINFO Medline Science

Number of articles identified by search 362 499 101

Removed following title and abstract 334 479 92
review—focused on quantitative methods, did
not focus on bereavement process or suicide
specifically, focused on children or adolescents
or compared with other forms of bereavement
Removed following review and discussion with 17 13 7
second reviewer—clarification of inclusion or
exclusion criteria and removal of studies focusing
on professionals or services or non-family
members, focused on psycho-social factors
rather than bereavement and duplicates
Removed following full-text reading—personal 5 4 0
stories with no information concerning partici-
pants, focused on cultural factors, focused on
those in services, focused on family processes
rather than bereavement

Total number of eligible articles 6 3 2

The appraisal of quality within the studies discussed in the current review was
based on guidelines outlined by Meyrick (2006). The primary researcher read
and re-read the full text of eligible articles and rated each article under a number
of headings related to quality criteria for qualitative research (Meyrick, 2006).
A second researcher rated a random sample of 4 of the 11 articles and rated each
one concerning quality. The primary researcher and second researcher compared
their data extraction across the quality criteria. A score from 1 to 3 was given to
each quality indicator across the four randomly selected studies and compared
with that of the primary researcher. Both researchers independently profiled the
four studies consistently and thus deduced that independent agreement was
reached concerning the process of judgement quality. The primary researcher
sought clarification concerning issues related to areas such as reflexivity
and transferability within qualitative research. Following this process, the
researchers met to discuss the quality of the articles and agreement was reached
concerning the judgement of quality. Comments related to the quality of the
studies, alongside other study details, are outlined in Table 2.
The systematic review of the articles outlined in the current article was a
difficult enterprise for a number of important reasons. There were a number
of factors concerning the sample and sampling technique that may have an
Shields et al. 433

impact on judgements concerning transferability. A number of studies used self-

selecting samples and this may be biased toward those who are more willing to
respond. Those who are willing to respond may be qualitatively different from
those who would choose not to respond. A number of studies sampled from
organizations or groups involved in providing services for those bereaved by
suicide and the fact that these participants were being provided with support
may have implications for their journey through the grief process, which may be
different for those without support. Also, the studies reviewed were carried out
in a range of different countries and there is a possibility that a number of studies
may have been culturally specific, and this also may have impacted on the grief
process for these participants. Other important factors include the range of
relatives used as participants in the studies, which included parents, siblings,
spouses, and children. It is possible that the nature of the relationship between
the participants and the deceased may have implications for the bereavement
process. However, despite these difficulties there would appear to be enough
convergence between the themes elucidated from these studies to justify includ-
ing them together in the current review.
Within the current review, all the studies included were deemed to be of an
appropriate quality to merit their inclusion in the review and no studies were
excluded based on a lack of quality. Some studies were of lower quality and
areas of potential weakness within the studies tended to concern reflexivity, with
little or no attention given to the influence of the researcher’s own background,
perceptions, or interests on the data. The exceptions to this were the studies by
Smith, Joseph, and Das Nair (2011) and Dunn and Morrish-Vidners (1987).
Several studies also failed to provide adequate information concerning an
audit trail throughout the research process, and this may have implications
for judgements concerning the links between data and the themes and categories
generated.

Grouping Findings
Following repeated reading of the 11 relevant articles, themes for each article
were identified and recorded in Table 2. Themes from each article are then
grouped under three main headings, developed by the authors to reflect the
range of findings in the literature: the feelings of bereavement, the meaning of
bereavement, and the context of bereavement. These headings refer to the person
bereaved by suicide and their journey through the process of making meaning of
a suicide and an attempt to answer the “why” question, the feelings associated
with being bereaved by suicide, and the context in which this bereavement and
subsequent feelings and problems occur. Although themes representing these
three areas are reported separately, they are, of course, interlinked and inter-
related. The process of making meaning of a suicide, for instance, may have a
large impact on the feelings associated with bereavement by suicide. The social
434
Table 2. Details of Studies Included in the Review.
Authors and Findings related to the Findings related to the
publishing Findings related to feelings meaning of context of
journal Country Sample characteristics Recruitment method Analysis of bereavement bereavement bereavement Quality and limitations

Begley & Quayle Ireland 8 adults bereaved by Those who attended a Interpretative phe- Intense pain, distress, fear Struggle to match to Social interaction Self-selecting recruit-
(2007) suicide voluntary support nomenological and turmoil; beliefs about cause inner ment strategy may
Crisis (Father ¼ 2; network and their analysis Fear of suicide in other world, self and turmoil; have biased sample
Mother ¼ 2; family members or family members; loved one; Preoccupation with toward those psy-
Sister ¼ 3; others bereaved by Avoidance of expressing Seeking out of the own and others chological ready to
Brother ¼ 1); suicide who were feelings; death story; reactions; participate;
Age range: known to them Personal blame Finding an explan- Initial support which Limited information
27–72; and guilt ation for the sui- fades after concerning reflex-
Age range of cide; funeral—feel aban- ivity;
deceased: Personalization doned; Information concern-
18–47; Impact of difficulties ing audit trail pro-
Time since bereave- with social support vided but unclear
ment: lessened if made as to whether val-
3–5 years aware of them idity checks were
beforehand carried out by the
primary
researcher or
second researcher;
Unclear if findings
could be trans-
ferred to sample
participants who
did not attend
support
organizations

(continued)
 Table 2. Continued
Authors and Findings related to the Findings related to the
publishing Findings related to feelings meaning of context of
journal Country Sample characteristics Recruitment method Analysis of bereavement bereavement bereavement Quality and limitations

Dunn & USA 24 adults bereaved by N ¼ 13 recruited from Exploratory study Blame of self and others; Finding an explanation Pressure to stop Self-selecting recruit-
Morrish-Vidners suicide (Male ¼ 7; files of a suicide using qualitative Guilt and responsibility; for the suicide; grieving and lack of ment strategy may
(1987) Female ¼ 17; prevention and methods (no fur- Anger; shock; Struggle with permission to have biased sample
Omega Spouse ¼ 7; crisis intervention ther detail disbelief; fear; intentionality; express grief; toward those psy-
Parent ¼ 7; service; provided) Rejection and punishment Changes in atti- Limited support from chological ready to
Child ¼ 2; N ¼ 9 responded to tude towards self, close friends; participate
Sibling ¼ 8); public flyers adver- life and death Lack of understand Limited information
Age range: tising the research from others concerning qualita-
Over 30 years; (posted on three tive methods used
Time since bereave- university cam-
ment: Within pre- puses);
vious 5 years N ¼ 2 from personal
referrals
Loss of control related Inability to understand No information pro-
to inability to con- sadness; vided concerning
trol the death; Difficulties expressing an audit trail
Ambivalence grief; throughout the
toward life and Normlessness and research process
death; stigma so it is difficult to
Development of judge trustworthi-
sensitivity and tol- ness;
erant of others Limited number of
problems; quotations from
Positive changes the data to sup-
and growth port findings
Fielden (2003) New 6 adults bereaved by Invited to take part by Hermeneutic Shock, disbelief, numbness; Search for plausible Telling others of sui- Self-selecting recruit-
International Zealand suicide co-ordinators and phenomenology Emptiness, guilt, fear; explanation; cide as causing ment strategy may
Journal of (Mother ¼ 4; counsellors of Blame and stigma Characteristics of distress; have biased sample

435
(continued)
 Table 2. Continued

436
Authors and Findings related to the Findings related to the
publishing Findings related to feelings meaning of context of
journal Country Sample characteristics Recruitment method Analysis of bereavement bereavement bereavement Quality and limitations

Mental Health Father ¼ 1; three support deceased as con- Feelings of stigma towards those
Nursing Sister ¼ 1); agencies tributing to suicide and shame con- psychological
Age range of tributed to limiting ready to partici-
deceased: less than support pate;
30 years; No information
Time since provided concern-
bereavement: 2–9 ing reflexivity;
years previous Unclear if findings
transfer to those
who are not
involved in support
agencies
Kalischuk & Canada 41 family members Participants responded Secondary analysis Feelings of rejection and Search for explanation Self-selecting recruit-
Hayes bereaved by sui- to a newspaper using grounded betrayal; for suicide; ment strategy may
(2003) cide (Female ¼ 26; article and net- theory Intense grief; Reliving of time have biased sample
Omega Male ¼ 15); work sampling. Anger and pain; before suicide to toward those psy-
33 individual inter- Cocooning look for motive chological ready to
views and 11 family participate
interviews
Age range: 6–80 years Review lives and find Limited information
(Mean ¼ 37.8); healing strategies provided concern-
Age range of and ways of conti- ing reflexivity and
deceased: 10–19 nuing bond with an audit trail.
years; deceased Inclusion of older
Time since participants to
bereavement: 6 address
months—12 years transferability
Maple, Plummer, Australia 22 parents bereaved Narrative analysis Self-selecting recruit-
Edwards, & by suicide from 18 ment strategy may

(continued)
 Table 2. Continued
Authors and Findings related to the Findings related to the
publishing Findings related to feelings meaning of context of
journal Country Sample characteristics Recruitment method Analysis of bereavement bereavement bereavement Quality and limitations

Minichiello families Responded to media Preparedness linked to have biased sample

(2007) (Mother ¼ 16; exposure of the relief or intense grief toward those psy-
Suicide and Father ¼ 6); research and guilt chological ready to
life-threatening Age range of participate;
behavior deceased: 17–31 No information
years of age; provided concern-
Time since ing reflexivity
bereavement: 6
months—26 years
Maple, Edwards, Australia 22 parents bereaved Responded to media Narrative inquiry Need to find ways to “Silenced voi- Self-selecting recruit-
Plummer, & by suicide from 18 exposure of the approach—repor- keep their child ces”—lack of per- ment strategy may
Minichiello families research ted one part of alive mission to speak have biased sample
(2010) (Mother ¼ 16; larger narrative about deceased; toward those psy-
Health and Father ¼ 6); study (see above) Isolated and chological ready to
social care in Age range of desired more participate;
the community deceased: 17–31 support Involves a re-ana-
years of age; lysis of previous
Time since data (see above);
bereavement: 6 No information
months—26 years provided concern-
ing reflexivity
Owens et al. (2008) UK 14 parents bereaved Qualitative analysis of Moral Moral responsibility Data from larger study
Sociology of by suicide data collected as responsibility and blame linked and no information
health and (Mother ¼ 8; part of a larger and blame to explanation of provided concern-
illness father ¼ 6) case-controlled suicide ing sampling
Age range of psychological aut- method;
deceased: 18–25 opsy study No discussion of
years of age reflexivity or audit
Time since trail making it diffi-

437
cult to judge

(continued)
 Table 2. Continued

438
Authors and Findings related to the Findings related to the
publishing Findings related to feelings meaning of context of
journal Country Sample characteristics Recruitment method Analysis of bereavement bereavement bereavement Quality and limitations

bereavement: 5–41 trustworthiness;

months previous Given the lack of
information con-
cerning the sam-
pling method it is
difficult to make
judgments con-
cerning
transferability
Sands & Tennant USA 16 adults bereaved by Recruited from Group case study Blame and guilt; Search for explanation Self-selecting recruit-
(2010) suicide (partner; suicide bereave- method Disconnectedness of suicide; ment strategy may
Adult education parent; sibling; ment group from deceased linked Review of rela- have biased sample
quarterly adult child); workshops to feelings of emptiness tionship deceased; towards those
Age range: >19 and sadness Reconstruction of psychological
years; death story; ready to partici-
Time since Moving forward pate;
bereavement: and continuing No information
more than bond; provided concern-
2 months Integration of ing reflexivity or
traumatic event audit trail and dif-
and positive ficult to make
remembering judgement con-
cerning trust-
worthiness;
Unclear if findings
generalize to those
not involved in
workshops
UK 6 adults bereaved by Participants responded Posttraumatic growth Gaze of others Self-selecting recruit-
suicide (Male ¼ 3; to information Search for Locked into ment strategy may

(continued)
 Table 2. Continued
Authors and Findings related to the Findings related to the
publishing Findings related to feelings meaning of context of
journal Country Sample characteristics Recruitment method Analysis of bereavement bereavement bereavement Quality and limitations

Smith et al. (2011) Female ¼ 3; provided by char- Interpretative explanation of particular role of have biased sample
Journal of Loss Partner ¼ 1; ity organizers who Phenomenological suicide bereaved by towards those
and Trauma Parent ¼ 3; worked with those Analysis Greater awareness suicide psychological
Sibling ¼ 1); bereaved by sui- of aspects of their Worry about how ready to
Age range:>18 cide and lives and place in viewed by others participate
years; snowballing world Adopt public guise
Time Since Desire to get most Drop masks when
Bereavement: 2– from life and with others
33 years greater sense bereaved by
of self suicide
Tzeng et al. Taiwan 13 adults bereaved by Responded to flyers Interpretative phe- Sadness and disconnected “Invisible family”—felt Self-selecting recruit-
(2010) suicide (Male ¼ 3; posted on out- nomenological from deceased; lost family because ment strategy may
Western Journal of Female ¼ 10; patient depart- analysis Unable to acknowledge so immersed in have biased sample
Nursing Research Sibling ¼ 4; ment bulletin grief of others; own grief toward those psy-
Child ¼ 4; board at a hospital Blaming self and others chological ready to
Grandchildren ¼ 3; participate;
Other rela- No information
tive ¼ 5); provided concern-
Age range: 24–55 ing reflexivity;
years (mean ¼ 33); Transferability may
Time since be limited by cul-
bereavement: 2 tural aspect of
months—40 years study which
focused specifically
on Japanese beliefs
concerning
afterlife
Van Dongen USA 5 adults bereaved by Participants were Grounded theory Emotional burden; Strong social support; Limited information
(1991) suicide (Male ¼ 10; identified through Shock and over- Questions of how concerning the

439
Female ¼ 25; the use of death whelmed by disbelief; they should behave rationale and aims

(continued)
440
Table 2. Continued
Authors and Findings related to the Findings related to the
publishing Findings related to feelings meaning of context of
journal Country Sample characteristics Recruitment method Analysis of bereavement bereavement bereavement Quality and limitations

The Journal of Parents ¼ 17; certificates, from Irritation, anger, in front of others; of the study;
Family Practice Adult support organiza- depression and guilt Unsure how to Information con-
Children ¼ 5; tions involved in answer questions cerning the
Siblings ¼ 8; working with related to suicide; method of analysis
Spouses ¼ 5); those bereaved by Estranged from is limited;
Age range: 25–68 suicide and others outside No information
years through referrals family (felt they concerning reflex-
(mean ¼ 41.7); from participants could not relate to ivity or audit trail
Age range of already in the their pain; and difficult to
deceased: 15–64 study Fear of burdening make judgement
years (mean ¼ 30 other family mem- concerning
years); bers by discussing trustworthiness
Time since suicide
bereavement:
Average of 5.8
months
Shields et al. 441

context may also have a tremendous impact on the ability to make sense of a
suicide as well as the associated feelings.

The Feelings of Bereavement

Of the 11 articles included in this review, nine referred to the feelings associated
with bereavement following suicide. The studies identified a range of feelings
associated with bereavement by suicide, but those most commonly reported were
guilt and blame (Begley & Quayle, 2007; Dunn & Morrish-Vidners, 1987;
Fielden, 2003; Maple, Plummer, Edwards, & Minichiello, 2007; Owens,
Lambert, Lloyd, & Donovan, 2008; Sands & Tennant, 2010; Tzeng, Su,
Chiang, Kuan, & Lee, 2010; Van Dongen, 1991).
Dunn and Morrish-Vidners (1987) claim that the blaming of others was the
predominant pattern, with family members receiving more blame than any other
category. This is echoed by Fielden (2003), who suggests that this blame tends to
come from estranged family members and those with inadequate knowledge
concerning the suicide. Dunn and Morrish-Vidners (1987) suggest that blaming
others represented an attempt by the bereaved to regain control and structure, to
absolve themselves from guilt, and to displace anger toward the deceased and
themselves onto others. The authors also suggest that there was a strong need to
protect themselves and the deceased, and the blaming of others stood in contrast
to the lack of blaming toward the deceased.
Dunn and Morrish-Vidners (1987) also claim that self-blame was pervasive,
reflecting the bereaved’s distorted notions concerning responsibility and their
inability to have prevented the suicide. This was consistent with the findings
of Begley and Quayle (2007), who suggest that those bereaved by suicide struggle
with a sense of personal blame for not having prevented the death and with
feelings of guilt, and with Sands and Tennant (2010). Self-blame was usually
accompanied by guilt, or the emotional pain connected with the belief that one
has thought or done something unacceptable (Dunn and Morrish-Vidners,
1987). Fielden (2003) suggests that the death left a huge sense of emptiness
and that feelings of guilt and fear paralyse the bereaved.
Sands and Tennant (2010) suggest that this self-blame may be related to an
inability to make meaning of the event, which leaves those bereaved to search for
clues as to how they may have contributed to the deceased’s actions. Tzeng et al.
(2010) also suggest that blame directed at the self or others is a response to the
difficulty of understanding the suicide and wondering if they could have done
anything to prevent it. Dunn and Morrish-Vidners (1987) suggest that the feel-
ings of guilt and blame stem from the view of suicide as an act of rejection and
punishment, with those bereaved feeling a sense of responsibility for the death.
These feelings of blame and guilt occur within a cacophony of other painful
and intense emotions that interact with and enmesh with each other. A number
of studies report that the early months following a suicide are filled with intense
442 OMEGA—Journal of Death and Dying 74(4)

pain, distress, and fear (Begley & Quayle, 2007; Dunn & Morrish-Vidners, 1987;
Fielden, 2003; Owens et al., 2008). During this time those bereaved by suicide
remain watchful for other suicides within the family and avoid expressing their
emotions for fear of distressing others. This is similar to a process reported by
Tzeng et al. (2010), who suggest that the bereaved become so immersed in their
own grief that they are unable to acknowledge the grief of other family members
or offer support to others. Those bereaved by suicide, then, felt that they had lost
their family as well as losing the deceased. Van Dongen (1991) suggests that
those bereaved by suicide are left with an emotional burden and unfinished
business concerning the suicide, coupled with uncertainty regarding how the
suicide will continue to affect their lives.
Similar to the finding by Dunn and Morrish-Vidners (1987) that the bereaved
feel a sense of rejection and punishment by the deceased, Kalischuk and Hayes
(2003) report that those bereaved by suicide felt rejected and betrayed as a result
of suicide. Kalischuk and Hayes (2003) suggest that participants experienced a
period of intense grief during which they were forced to deal with the emotional
impact of the unwanted change in their life. Their participants spoke about a
sense of woundedness and the sense of personal violation and trauma following
a suicide. To deal with these feelings the bereaved engaged in a self-protective
strategy, which Kalischuk and Hayes (2003) refer to as “cocooning” (p. 55)
to find ways of dealing with their anger, pain, and suffering. Kalischuk and
Hayes (2003) suggest that the rejection felt by those bereaved by suicide brought
negativity into their lives, which caused an enormous amount of pain and
suffering.
The feelings associated with death by suicide are intertwined with and affected
by how the bereaved make sense of and find an explanation for the suicide, the
social context, and other factors. Owens et al. (2008) refer to a process of moral
responsibility and suggest that the guilt and blame felt by parents who had lost a
child to suicide were impacted by whether parents viewed their child as being the
victim of others, the victim of social injustice, or responsible for their own
destruction. Within this process, parents questioned their own role, the role of
others, and the role of the deceased in the suicide.
Maple et al. (2007) consider other factors, such as preparedness, which may
impact on the feelings associated with being bereaved by suicide. The authors
state that preparedness refers to the way in which parents anticipated, or not,
their child’s suicide. Maple et al. (2007) provide data related to parents who had
been living with a suicidal child; those who never thought suicide would happen
to them and those who felt they didn’t recognize the signs. Each of these path-
ways contributed to a different emotional impact of suicide. Those who had been
living with a suicidal child described a feeling of relief after living with their
child’s pain for many years and actively trying to intervene. Those who never
thought suicide would happen to them were left in a state of heightened grief,
which impinged on social and familial functioning, and struggled to adjust.
Shields et al. 443

Those who felt that they hadn’t seen the signs were left with a feeling of guilt at
their inability to recognize the signs (Maple et al., 2007).

The Meaning of Suicide Bereavement

Of the 11 articles identified as part of this review, seven had themes related to the
process of making meaning of death by suicide. Begley and Quayle (2007) dis-
cuss how participants try to make sense of a suicide and struggle to match the
deliberate nature of the act with what they believe about the world, themselves,
and their loved one. The deliberateness of the suicide act was in contrast to their
beliefs concerning the predictability of the world and led participants to blame
themselves for failing to prevent the death. This confusion concerning death by
suicide is echoed by Tzeng et al. (2010), who suggest that their participants felt
confused and did not know why the deceased had completed suicide and did
whatever they could to discover the reason for the suicide.
Begley and Quayle (2007) suggest that the meaning-making process following
death by suicide is a complex one that involves seeking out the story of death, by
matching prior beliefs about the deceased to a possible cause for death while
protecting their sense of self in the process. This process is similar to that out-
lined by Sands and Tennant (2010), who found that the intentional nature of a
death by suicide sends a message to those bereaved. However, it is a message
that is difficult to decipher as those who had died by suicide cannot explain why
they have taken their own lives. The bereaved, then, are left to “try on the shoes”
of the deceased in order to develop an account of the state of mind, thoughts,
feelings and events that led to the suicide.
Within this context, the bereaved are left to review their relationship with the
deceased, the deceased life, and the death event itself. Engagement with the
intentional nature of the suicide led participants to consider the why question,
which prompted attempts to reconstruct the death story (Kalischuk & Hayes,
2003; Sands & Tennant, 2010). The reconstruction of a death story can enable
participants to “move forward” (Sands & Tennant, 2010, p. 111) and to move
from a position of feeling guilt and stigma to a position in which they can
experience a continuing bond with the deceased in a more positive way, letting
go of any guilt (Kalischuk & Hayes, 2003; Sands & Tennant, 2010). The authors
suggest that once participants were able to negotiate the reconstruction of mean-
ing concerning the deceased’s decision to die, they became able to integrate the
traumatic event and create space for positive remembering and the restoration of
a continuing bond with the deceased (Fielden, 2003; Sands & Tennant, 2010).
Fielden (2003) also suggested that the discovery of a plausible reason for the
suicide was important in enabling those bereaved by suicide to move on with
their grief.
The idea of creating a space for positive remembering and continuing a bond
with the deceased as suggested by Sands and Tennant (2010) is commensurate
444 OMEGA—Journal of Death and Dying 74(4)

with Smith, Joseph, and Das Nair (2011) regarding their themes related to posi-
tive growth. Smith et al. (2011) suggest that the suicide death of a loved one
forced participants to face the question of why someone would choose to die and
what mortality means to them. Within this context, participants develop a
greater awareness of certain aspects of their lives and their place in the world.
Smith et al. (2011) report that there was a sense of what it meant to be alive. The
authors suggest that, among participants, there was a desire to get the most from
life and a development of a greater sense of self.
Dunn and Morrish-Vidners (1987) highlight many of the points outlined
earlier suggesting that those bereaved by suicide invest a great deal of energy
in finding an explanation for the suicide but never finding a really convincing
explanation and struggling with the intentional aspect of the death. As in the
study by Fielden (2003), Dunn and Morrish-Vidners (1987) suggest that the
content of explanations by those bereaved by suicide focused on personal
traits and often referred to the personality characteristics or temperament of
the deceased. Dunn and Morrish-Vidners (1987) go on to suggest that a major
purpose of the explanation is to make the suicide believable in relation to what
the bereaved does know and to fit the deceased into the picture. This is similar to
the contention of Begley and Quayle (2007) that participants try to make sense
of a suicide and struggle to match the deliberate nature of the act with what they
believe about the world, themselves, and their loved one.
Dunn and Morrish-Vidners (1987) suggest that within the process of making
meaning of suicide, the bereaved undergo a number of profound changes in their
attitude toward the self and toward life and death. The authors suggest that the
most profound effect relates to the sense of loss of control concerning the inabil-
ity of the bereaved to control the suicide. This led to feelings of ambivalence
toward life itself and undid the notion that everything would turn out well
(Dunn & Morrish-Vidners, 1987). However, the authors also suggest that this
experience helps the bereaved to connect with feelings of frailty and hopeless-
ness, which the authors view as a necessary step toward growth and healing.
Indeed, Dunn and Morrish-Vidners claim that participants became more
sensitive to and tolerant of others’ problems and adopted a more positive
outlook on life. Although those bereaved by suicide experienced terrible feelings
of loss, many subsequently developed positive attitudes toward themselves and
their lives and were able to construct new life meanings (Dunn & Morrish-
Vidners, 1987).

The Context of Bereavement

The feelings associated with bereavement by suicide and the process of making
meaning concerning suicide occurs within a particular social context. Of the 11
articles included in this review, seven explored the social context of the bereave-
ment process. Maple et al. (2010) described the issue of “silenced voices”
Shields et al. 445

whereby parents who had lost a child to suicide rarely felt permitted to talk
about their deceased child. Following a suicide, parents needed to find ways of
keeping their child as an active part of their life and reported feeling unable to
talk about them openly and honestly due to social awkwardness associated with
suicide (Maple et al., 2010). Participants in the study by Maple et al. reported
that they felt compelled not to discuss their experiences publicly and the authors
reported that there appeared to be an internal conflict within those bereaved by
suicide between wanting to talk, but feeling the need for permission, which was
rarely given. Maple et al. suggest that parents bereaved by suicide could become
isolated at the time when they most desired and needed support. Participants in
this study felt that there was an expectation that their grief would end within a
reasonable amount of time. However, they felt that the experience of grieving for
their child would remain in some form throughout the rest of their lives (Maple
et al., 2010).
This pressure to stop grieving before they were ready was echoed by Dunn
and Morrish-Vidners (1987) with participants in their study also feeling a lack of
permission to express their grief. While participants in the study outlined by
Dunn and Morrish-Vidners did report receiving some social support, they
reported that this support was of a limited nature and tended to be from close
friends. Those less personally involved with the bereaved tended to distance
themselves. Dunn and Morrish-Vidners suggest that others responded to those
bereaved by suicide in ways that the bereaved found objectionable, and partici-
pants complained about a lack of understanding, inability to relate to sadness,
negative attitudes toward the deceased, and a pressure to stop grieving. Those
bereaved by suicide had low expectations concerning the response of others
(Dunn & Morrish-Vidners, 1987), and there was a wish for a more sympathetic
attitude from others. However, Dunn and Morrish-Vidners also report that
those bereaved by suicide acknowledged having difficulties expressing their
pain in front of others and thus welcomed the social silence at times.
Dunn and Morrish-Vidners (1987) locate the reactions of others within the
concepts of stigma, normlessness, and fear, suggesting that there are no guide-
lines concerning how to react to death by suicide and the void following suicide
gets filled by awkward behaviour on both sides. Within this void, Dunn and
Morrish-Vidners suggest that suicide still occurs within the shadow of stigma,
with others often behaving as if the suicide had never happened, failing to
acknowledge it or acting as if the deceased never existed.
Van Dongen (1991) reported that the majority of participants felt that there
had been strong social support from others. However, this may have reflected
the fact that the mean time since bereavement within this study of 5.8 months
was the lowest of all the studies reviewed, and social support may have yet to
become problematic. Participants did question how they should behave in front
of others and were aware of the potentially stigmatising nature of suicide and
were unsure how to answer questions related to the event. They also reported
446 OMEGA—Journal of Death and Dying 74(4)

feeling estranged from others outside the family because they felt they would not
be able to relate to their pain (Van Dongen, 1991). This is echoed by Fielden
(2003), who found that telling others about the suicide caused the bereaved a lot
of distress. Fielden (2003) suggests that this reflects the feelings of stigma and
shame felt by those bereaved by suicide, and that such feelings limited the sup-
port they received.
Begley and Quayle (2007) suggest that social interactions caused much inner
turmoil for the bereaved because they had constantly thought about their own
and others’ reactions. The authors report that immediately following suicide the
bereaved had felt supported by their communities but that this support dwindled
following the funeral. After this point, the bereaved felt abandoned and found
that others acted with unease around them (Begley & Quayle, 2007). The suicide
made participants so uneasy that they avoided social activities. Begley and
Quayle suggest that the impact of the loss of suicide support was lessened if
those bereaved were made aware of it beforehand.
Smith et al. (2011) refer to the gaze of others as referring to how those
bereaved by suicide believed themselves to be viewed by other people. The
authors suggest that the gaze of others can leave the bereaved feeling that
they are locked into a particular role, different from how they view themselves.
Smith et al. suggest that participants considered how disclosing their emotions
could impact on how they would be viewed by others and worried about appear-
ing weak, incompetent in other roles, or embarrassed of showing upset. Smith
et al. suggest that participants adopted a public guise that masked their true
emotions and gave the impression of functioning. This public guise not only
allowed the bereaved to choose when and to whom they revealed their true
emotions but also protected others from these raw emotions (Smith et al.,
2011). Participants were able to drop their masks when with others who had
been bereaved by suicide and felt that only those who had been bereaved by
suicide could really understand their experience.
A number of studies point to the impact of suicide on the family. Tzeng et al.
(2010) refer to an “invisible family” because participants felt that they had not
only lost a loved one but their whole family because they were so immersed in
their grief that they were unable to acknowledge the grief of other family mem-
bers. Disturbances in family functioning had an impact on participants’ ability
to make meaning of the suicide and on blaming, with participants either blaming
themselves or other family members, including ancestors (Tzeng et al., 2010).
Van Dongen (1991) also suggests that while those bereaved by suicide expressed
concern related to how the suicide was impacting on other family members, they
hesitated to raise the issue for fear of burdening others.
Dunn and Morrish-Vidners (1987) also found a lack of communication
within families but suggest that this was related to the propensity to blame.
Begley and Quayle (2007) echo this point suggesting that siblings of the deceased
avoided expressing their feelings to parents as they didn’t want to upset them.
Shields et al. 447

Begley and Quayle (2007) suggest that the reluctance to share feelings within the
family was related to the fact that participants were struggling with a sense of
personal blame for not preventing the suicide and that they felt guilt.

Discussion
The current review identified findings related to three main aspects of the grief
process following suicide. These aspects are the feelings following bereavement
by suicide, the process of making meaning of the event, and the social context in
which the feelings and meaning-making process occur. This is congruent with
earlier work. For example, Calhoun, Selby, and Selby (1982) suggested three
areas that they felt may be unique to suicide. These areas referred to a search for
understanding following suicide, greater feelings of guilt, and lower levels of
social support.
However, the current review adds to the understanding of the bereavement
process following suicide by considering only qualitative studies that examine
the process in depth and allows us to examine and understand links between
different aspects of the bereavement process. To our knowledge, this is the first
systematic review that examines the bereavement process following suicide in
such depth.
While the current review examined only qualitative studies that referred to the
bereavement process following suicide and did not include articles in which
suicide bereavement was compared with other forms of bereavement, the find-
ings provide tentative support for previous reviews that indicated that there were
particular areas that those bereaved by suicide struggled with (Clark & Goldney,
1995; Jordan, 2001).
The current review found that those bereaved by suicide were faced with a
range of troubling emotions following the suicide. The most common of these
feelings related to guilt (Begley & Quayle, 2007; Fielden, 2003; Sands & Tennant,
2010; Van Dongen, 1991) and blame (Begley & Quayle, 2007; Dunn & Morrish-
Vidners, 1987; Owens et al., 2008; Sands & Tennant, 2010). However, the feel-
ings related to bereavement by suicide are impacted by the ability of the
bereaved to find meaning within the event and to find some form of meaningful
explanation (Begley & Quayle, 2007; Kalischuk & Hayes, 2003; Sands &
Tennant, 2010; Smith et al., 2011). If this complex process of meaning-making
can be negotiated successfully, it can lead to feelings of positive growth and
healing and an ability to move forward (Fielden, 2003; Sands & Tennant,
2010; Smith et al., 2011).
The feelings related to suicide and the complex process of making meaning
are further complicated by a lack of social support. There were difficulties
related to interactions with others in which those bereaved by suicide felt
that they did not have permission to discuss their loss and felt a lack of under-
standing and a pressure to stop grieving (Dunn & Morrish-Vidners, 1987;
448 OMEGA—Journal of Death and Dying 74(4)

Fielden, 2003; Maple et al., 2010). This may have important ramifications.
Baddeley and Singer (2009) outline a social interactional model of bereavement
and suggest that bereavement narrative disclosure may be instrumental in
addressing psychosocial challenges associated with bereavement, including iden-
tifying reconstruction and meaning making.
The difficulties within the social context seems to indicate a two-way inter-
action in which those bereaved worried about the perceptions of others and
struggled to communicate their loss and those within the community felt awk-
ward and struggled to find ways to provide appropriate support (Dunn &
Morrish-Vidners, 1987).

Implications for Previous Research

There is ongoing debate within the suicidology research concerning the grief
process of those bereaved by suicide and whether or not it differs from grief
experienced following other forms of bereavement (Clark, 2001; Jordan, 2001;
Jordan & McIntosh, 2011). McIntosh (1993) suggested that there are few differ-
ences between those bereaved by suicide and those bereaved by other types of
death, and, to some extent, this view is reiterated in a more recent review by
Sveen and Walby (2008). However, in their review, Sveen and Walby (2008)
found that when suicide-specific instruments were used, the evidence would sug-
gest that those bereaved by suicide experience a significantly higher level of
rejection in comparison with other bereaved groups and that blaming is also
an issue for those bereaved by suicide.
This review also supports the contention that those bereaved by suicide strug-
gle with rejection and blame and that blame is directed both toward others and
toward the self. Sveen and Walby (2008) also suggest that those bereaved by
suicide tend to struggle more with shame and stigma and, as a result, may
conceal the cause of death. This is also supported by the current review.
Sveen and Walby (2008) also suggest that there may be a weak tendency
toward higher levels of guilt and responsibility within the first 18 months fol-
lowing a suicide. Studies outlined in the current review contained a range of
participants bereaved for various amounts of time, and it is thus difficult to map
the feelings experienced onto a timeframe. Sveen and Walby (2008) found little
evidence that those bereaved by suicide experience more anger, loneliness, or
isolation than other bereaved groups and the evidence concerning social support
was conflicting. Within the current review, the emotions most reported were
guilt and blame; however, studies also reported a range of other emotions
including anger (Dunn & Morrish-Vidners, 1987; Kalischuk & Hayes, 2003;
Van Dongen, 1991). The current review would also indicate that social support
was generally problematic for those bereaved by suicide.
The current systematic review differs from previous reviews in the focus
on qualitative research examining the grief process of those bereaved by
Shields et al. 449

suicide specifically. From this perspective, the current review provides informa-
tion as to how the feelings of bereavement following suicide, the process of
making meaning, and the social context interact and intertwine to influence
the grief process of those bereaved by suicide. The feelings associated with
bereavement, while painful for the bereaved, can be influenced by the way in
which the bereaved make sense of the event. If this meaning making revolved
around themes of rejection and punishment (Dunn & Morrish-Vidners, 1987),
then the associated feelings may be more problematic.
However, it is also true that if the meaning-making process can be negotiated
in a more positive way, this can lead to growth and healing (Kalischuk & Hayes,
2003; Smith et al., 2011). Furthermore, the process of meaning making is itself
impacted by the social context in which it occurs. For example, Baddeley and
Singer (2009) suggest that, in order to make meaning of bereavement, the
bereaved need to talk about their experiences with others. However, studies
outlined within the current article suggest that those bereaved by suicide may
feel that they do not have permission to talk about their loved one and their
experiences (Maple et al., 2010).
While the authors were unable to identify any qualitative systematic reviews
which focused on bereavement generally and with which we could compare our
findings, we identified a review related to the bereavement process of family
members of cancer patients (Lev & McCorkle, 1998), which examined the
bereavement process qualitatively and quantitatively. Similar to findings related
to suicide in the current review, the authors found difficulties with anger, shock,
and disbelief following the death of their loved one. Lev and McCorkle (1998)
also reported difficulties with social interaction; however, unlike the social con-
text following suicide, these difficulties stemmed from the social withdrawal of
the bereaved despite the efforts of others to maintain the relationship and show
support. Support following suicide would appear to be less apparent and more
problematic.
Lev and McCorkle (1998) also report that those who have lost a family
member to cancer learn to find a new identity and new meaning in life. Again,
this would appear similar to the posttraumatic growth and healing reported in
the current review (Kalischuk & Hayes, 2003; Smith et al., 2011) following sui-
cide. However, Lev and McCorkle (1998) suggest that the ability to find new
meaning represents the final phase in a linear bereavement process. The litera-
ture in the current review suggests that the bereavement process is more complex
and nonlinear (Begley & Quayle, 2007).

Future Research
Based on the findings of the current review, there are a number of important
areas which could be explored using both qualitative and quantitative methods.
The current review suggests that the ways in which those bereaved by suicide
450 OMEGA—Journal of Death and Dying 74(4)

find meaning in the event have implications for their ability to move forward.
Research could explore particular ways in which the bereaved find meaning and
the different factors that aid them in their journey forward. It is hypothesized
that social support plays a crucial role in this meaning making journey, and the
needs of those bereaved concerning support could be further explored in future
research. It might also be a worthwhile endeavour to research the current per-
ceptions within the wider community concerning suicide and possible barriers to
providing support for those bereaved by suicide. Within the current age of social
networking websites, it may also be of interest to explore the ways in which
suicide is considered and discussed within these sites. This communication via
social networking sites has the potential to either help or hinder the meaning-
making process discussed in the current article and is something that requires
further research.

Clinical Implications
The current review has identified three broad areas that appear to be important
for those bereaved by suicide. While presented separately, it is crucial to remem-
ber that these areas also interact in a number of important ways. One important
such interaction is that between the painful feelings related to suicide and the
ability to make meaning of the event. Therefore, services available for those
bereaved by suicide should focus on ways of helping the bereaved to find a
meaning behind the suicide. One way of facilitating this process may be by
providing mechanisms whereby those bereaved by suicide could interact with
each other, perhaps through support groups specifically for those bereaved by
suicide. This would provide the bereaved with means of finding out how others
bereaved by suicide may have been able to make meaning of the event and allow
them to drop their public mask (Smith et al., 2011).
However, while such support groups may offer potential benefits, it is legit-
imate to question the efficacy of these groups without some professional input. It
may also be important that those bereaved by suicide participate in such groups
only after the initial rawness of the emotions associated with bereavement by
suicide has passed. It may be beneficial to utilize such groups within the context
of a support package that includes individual support from trained profes-
sionals, if needed.
It will also be remembered that those bereaved by suicide and members of the
wider community struggle to find ways of interacting with each other in bene-
ficial ways (Dunn & Morrish-Vidners, 1987). Therefore, some form of psychoe-
ducation could be provided to help those bereaved by suicide to learn what to
expect following their bereavement. For example, the importance of finding
ways to talk about the experience in order to find meaning in it could be
highlighted (Baddeley & Singer, 2009) and possible support organizations sign-
posted. Some method of increasing the awareness of the wider public might also
Shields et al. 451

be of benefit, perhaps through more widely available psychoeducational mater-

ials. Those bereaved by suicide may also benefit from information related to
coping with the possible reactions of others following suicide. Indeed, Begley
and Quayle (2007) suggest that the impact of losing social support following a
suicide was reduced when the bereaved were made aware that people would
avoid them in advance.
Information concerning the three broad areas outlined within this article
related to the feelings of bereavement, the meaning of suicide bereavement,
and the social context could be utilized to help develop suicide-specific measure-
ment tools. Such tools could be able to explore the interaction between the
various areas outlined and identify the possible need for intervention and
could add valuable information to the clinician’s assessment.
Generally, the notion that a greater knowledge and awareness of the grief
process following suicide could ensure that those professionals working with
those who have been bereaved by suicide do so with empathy and understanding
is compelling. Indeed, providing a space for the bereaved to talk about and share
their experience openly and honestly in an understanding and non-judgemental
environment may, in itself, help them through the process of being bereaved by
suicide.

Limitations
While none of the articles included in the current review were excluded based on
quality criteria, there are a number of factors related to the quality of the articles
which should be considered when drawing conclusions from the current article.
The majority of articles used a self-selecting sample, and it is possible that those
who volunteered to take part in the research were qualitatively different than
those who did not. A number of studies also recruited participants through
support organizations, and it is possible that those who had received support
had different experiences from those who had not. Therefore, caution is needed
when considering the transferability of the findings of the current article.
A number of studies within the current review also provided limited infor-
mation concerning reflexivity and an audit trail. Thus, judgments concerning the
trustworthiness of the findings of these studies are difficult to make. Studies
outlined within the current review contained participants who had been
bereaved for varying lengths of time. For example, Fielden (2003) included
participants who had been bereaved for between 2 and 9 years, and in the
Kalischuk and Hayes (2003) study participants had been bereaved from between
6 months and 12 years previously. Therefore, it is difficult to ascertain whether
feelings changed over time since bereavement or the role of time since the
bereavement in the process of making meaning.
The studies outlined in the current article were limited to adult family mem-
bers who had been bereaved by suicide. This excluded children, adolescents,
452 OMEGA—Journal of Death and Dying 74(4)

nonfamily members, and professionals working with those bereaved by suicide.

Future research may be aimed at exploring the bereavement processes for these
different populations.

Conclusion
Qualitative studies that explore the bereavement process of family members who
have been bereaved by suicide identify three broad areas of importance for the
bereaved. These areas are the feeling of being bereaved, the meaning-making
process following bereavement, and the social context. These three areas are
intertwined with the feelings of bereavement being impacted by the ways in
which the bereaved find meaning of the event—a process driven by an attempt
to find an explanation for the suicide. This is itself impacted by the social context
in which it occurs with both the bereaved and members of the wider community
struggling to find ways to act and relate to others. The challenge for services
working with those bereaved by suicide is to understand these complex inter-
actions and provide services that most benefit those bereaved by suicide.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

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

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Author Biographies
Chris Shields is a Clinical Psychologist working in the area of adult mental
health in Northern Ireland. Chris’ research within the area of suicide was influ-
enced by the death of his nephew by suicide and the impact that this had on the
family and wider social circle. Chris is a father of two young boys and a keen
runner.

Michele Kavanagh is a Consultant Clinical Psychologist who specialises in the

area of self-harm with young people and families within the social care system.
She is also a Trainer on the Clinical Psychology Training Programme for
Northern Ireland based at Queens University Belfast where she has responsibil-
ities for personal and professional development.

Kate Russo is an Assistant Course Director on the Doctorate of Clinical

Psychology programme at Queen’s University Belfast. She is also an
Independent Consultant Clinical Psychologist, specialising in the self manage-
ment of chronic and life-limited medical conditions. She has a particular interest
is using phenomenological research to improve people’s lives. She is also an
Author and Eclipse Chaser.