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Sense-Making in Suicide Survivorship: AQualitative Study of the Effect of Grief

Support Group Participation

KATHERINE P. SUPIANOCollege of Nursing, University of Utah, Salt Lake City, Utah, USA

The death of a family member or close friend to suicide is a devastat-ing life event. While research has suggested that suicide survivors maybenefit from participation in support groups, little has been done toidentify those elements of the experience of suicide survivorship thatare impacted by grief support groups. This phenomenological inquiryof suicide survivors’ experience explored the impact of group partici-pation on changes in self-reported grief distress and the participants’process of finding meaning in the loss. Four themes were elucidated:attribution of suicide causation, personal impact and response,wanting to die=wanting to live, and ways of coping. These themeswere examined in the context of group support, interaction withothers, personal=spiritual awareness, and meaning-making.

The person who commits suicide puts his psychological skeleton in thesurvivor’s emotional closet.

—Edwin Schneidman

An estimated 33,000 persons commit suicide in the United States every year,and for every completed suicide, four to six persons, family members orfriends, are impacted (Centers for Disease Control and Prevention, 2009).1

The loss of a family member or close friend to suicide is a devastating lifeevent. Survivors of suicide are commonly more depressed than persons

Received 25 July 2011; accepted 18 October 2011.The author expresses appreciation to the Ben B. and Iris M. Margolis Foundation for

support in this study.Address correspondence to Katherine P. Supiano, College of Nursing, University of Utah,

10 South 2000 East, Room 114, Salt Lake City, UT 84112, USA. E-mail: katherine.supiano@hsc.utah.edu

Journal of Loss and Trauma, 17:489–507, 2012Copyright # Taylor & Francis Group, LLCISSN: 1532-5024 print=1532-5032 onlineDOI: 10.1080/15325024.2012.665298

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experiencing other forms of bereavement, and the risk for depression isheightened among those whose relationship with the decedent was close(Latham & Prigerson, 2004; Mitchell, Sakraida, Kim, Bullian, & Chiappetta,2009).

In addition to depression risk, there is a strong association between theexperience of loss by suicide and complicated grief (Mitchell, Kim, Prigerson,& Mortimer, 2005). Complicated grief is a state of chronic mourning (Zhang,El-Jawahri, & Prigerson, 2006). The hallmark symptom of complicated grief ispersistent yearning for the deceased (Prigerson et al., 1996; Prigerson et al.,2009). Prigerson and colleagues have characterized this as ‘‘a psychologicalprotest against the reality of loss and a general reluctance to make adapta-tions to life in the absence of the loved one’’ (Prigerson et al., 2008,p. 170). Persons experiencing complicated grief frequently present withrecurrent intrusive thoughts of the person who died, preoccupation withsorrow including ruminative thoughts, excessive bitterness, alienation fromprevious social relationships, difficulty accepting the death, and perceivedpurposelessness of life. This symptom disturbance contributes to profoundsocial, occupational, and functional disturbance. Further, individuals whoexperience complicated grief are themselves at greater risk for suicidal idea-tion and attempts (Mitchell et al., 2005; Runeson & Asberg, 2003; Zhang et al.,2006).

These risk sequelae of suicide survivorship suggest that suicide survivorsmay face unique suffering in their grief in comparison to other forms of loss.Human suffering in all of its forms compels the suffering person to attemptto understand the reasons and meaning of the event. Frankl (2006), expandingon his own experience in Nazi concentration camps to that of a broaderhumanity, writes, ‘‘If there is a meaning in life at all, then there must be a mean-ing in suffering. Suffering is an ineradicable part of life, even as fate and death.Without suffering and death human life cannot be complete’’ (p. 67).

In their examination of bereavement following loss by traumatic death,Currier, Holland, and Neimeyer (2006) examined a constructivist model ofgrief that proposed sense-making, the capacity to construct an understandingof the loss experience, as a mediator between the associations of violentdeath and complicated grief symptomology.

Briefly, the elements of sense-making and meaning reconstructionfollowing a death include the capability of grievers to come to terms withthe loss, to realize growth or benefit that the experience of loss may havebrought them, and to reorganize personal identity in the context of loss.Findings reported by Currier and colleagues suggested that failure to findmeaning in violent death was the explanatory pathway between loss byviolent death and complications in grieving.

An additional element of meaning-making may be the manner in whichsuicide survivors construct and attribute the cause of the death. Heider’s(1958) attribution theory posits that one may ascribe the behavior of another

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to intrinsic factors within the personality of the other, to external factors in thelife situation of the other, or to factors beyond the individual and environment(i.e., random events, acts of God).

While not a grief theory, Doka’s (1989, 2008) examination of disenfran-chised grief, the unsupported bereavement experience in persons whose lossmay be outside social and cultural norms, has bearing on suicide survivor-ship. Doka defines disenfranchised grief as ‘‘grief that results when a personexperiences a significant loss and the resultant grief is not openly acknowl-edged, socially validated or publicly mourned’’ (2008, p. 224). The grieverhas no social permission to grieve, nor subsequent entitlement to social sup-port or benefit. Doka studied this phenomenon in bereaved homosexualpartners, in ex-spouses, and in survivors of suicide or homicide. The experi-ence of disenfranchised grief has applications across many interpersonalrelationships and may be relevant in the meaning-making of suicide survi-vors and their risk for complicated grief.

Constantino, Sekula, and Rubinstein (2001) have reported that suicidesurvivors benefit from participation in grief support groups if those groupsare specifically designed to address this loss. Jordan (2001) elaborated onthis benefit, arguing that care of those bereaved by suicide should focuson the thematic content of grief, the social processes of survivors, andthe impact on family systems, recommending homogeneous supportgroups with psychoeducational content and attention to family and socialnetworks. Still, little research has been done to identify those elementsof the experience of suicide survivorship that are impacted by grief supportgroups, suggesting that survivors’ perceptions of support groups meritstudy (Cerel, Padgett, Conwell, & Reed, 2009; Cerel, Padgett, & Reed,2009).

The purpose of this study was to explore the impact of participation insuicide loss grief support groups on participants’ sense-making of the lossand changes in self-reported symptoms of grief distress. The interview frame-work was designed and evaluated through the lens of meaning reconstruc-tion theory (Neimeyer, 2002; Neimeyer, Baldwin, & Gillies, 2006). Thenature of causal attribution by suicide survivors is explored and consideredin the context of potential disenfranchised grief. The following researchquestions are addressed in this study:

1. How do participants recall the elements of distress they experienced uponentry to the group? Upon group completion? At this time?

2. How do participants describe the nature and meaning of the suicide?3. How do participants make sense of a death by suicide, particularly in the

context of their relationship to decedents?4. What elements of the suicide loss grief support group do participants

identify as impacting their current distress burden and sense-making withrespect to their grief?

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METHOD

This qualitative study was conducted as a phenomenological inquiry of alived human experience, namely suicide survivorship. Phenomenologicalinquiry is a qualitative method derived from the philosophy of EdmundHusserl (1931), who maintained that the reality of human consciousness isestablished in the interpretation of sensory experiences. As a research meth-odology, phenomenology respects participants’ reality as perceived. Anassumption of phenomenological inquiry is that ‘‘there is a structure andessence to shared experiences that can be narrated’’ (Marshall & Rossman,2006, p. 104) and thus understood. This study is further conceptualized inthe tradition of the hermeneutic phenomenology of Heidegger (1962), inits emphasis on the prior understanding or forestructure of the researcherand minimal reliance on ‘‘bracketing’’ (McConnell-Henry, Chapman, &Francis, 2009). In this approach, the researcher-interviewer actively engagesin entering the participant’s experience and uncovering the meaning of theexperience, as related in the narrative of survivors. This approach lends itselfto exploration of the ontological understandings of the phenomenon ofsuicide survivorship. In particular, it lends itself to examination and interpret-ation of the recalled process of grief and related experience of distress and ofthe impact of the grief group support experience upon grief, sense-making,and personal growth.

Participants

In this study of suicide survivors, nine participants in a suicide loss supportgroup were drawn from a non-probability purposive sampling of personsenrolled in an ongoing study of change in self-reported symptoms of griefdistress who have completed the pre-test, post-test, and 3-month and6-month follow-up. The suicide support groups from which this samplewas drawn are clinician-facilitated 8-week closed groups for communityresidents offered in a university setting. Participants were at least 1 yearpost-loss and had completed the group at least 6 months prior to enrollmentin this qualitative study.

The selected participants voiced key symptoms associated with compli-cated grief at group onset including yearning, difficulty accepting the realityof the death, distressing=ruminative thoughts, and=or alienation from pre-vious social relationships (Prigerson et al., 2009). Each participant had oneor all of these symptoms but did not need to have more than one symptomto be considered for inclusion. Within the pool of potential participants, sam-pling was further stratified across the two suicide survivor groups thatoccurred in this time frame to minimize the effect of facilitator style. The prin-cipal investigator was not the group facilitator of either of these two suicidesurvivor support groups. Enrollment in this study was nine participants, of

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whom four were male and five female. Eight participants survived the deathof an adult child; the ninth participant survived spousal death. Sampling andinterviewing closed when thoughts and themes expressed by participantsrecurred and I concluded that theoretical saturation (Guest, Bunce, &Johnson, 2006) was realized for the research questions.

Ethical Issues

Permission to conduct the study was obtained from the University of UtahInstitutional Review Board. Prior to beginning the interviews, informedconsent was obtained. The potential participants in this study had previouslyagreed to participate in the original study, but as this study required additionalpersonal disclosure about sensitive content, participants were reconsented.

Data Collection

Interviews were open-ended, semistructured, and in-depth dialogues ofapproximately 90–180 minutes’ duration. Interviews were conducted accord-ing to the interview guide but allowed opportunity for maximum discussionand disclosure. Interviews were conducted in the participants’ home or in theoffice of the interviewer=principal investigator, whichever was the preferredsetting of each participant. I made every effort to ensure that the interviewswere as humanistic and interactive as possible while respecting the contextof the experience under study, particularly the context of loss and suffering.In each interview, care was taken to remain attentive to both the spokenword and to silences. I attended to the affect of participants and respondedwith acceptance of emotions as conveyed while remaining aware of my owncognitive and emotional responses.

I audio-recorded the interview sessions, and they were professionallytranscribed. To maintain confidentiality and protect privacy, pseudonymswere used, and identifying personal content was removed or modified fromthe transcripts. Tapes, transcriptions, and journals were numerically coded asin the primary study to protect the identity of individual participants yet allowfor data cross-referencing to the primary study. I have maintained a studyjournal of observations and personal reflections; these notes were madeimmediately following each interview and later reviewed and memoed.Tapes, transcripts, and journal entries are kept in locked files.

Data Analysis

An essential component of phenomenological interviewing is the role of theinterviewer-researcher in synthesis and interpretation of narrative content(McConnell-Henry et al., 2009). This analysis includes my reflection on thecontent of the narrative interviews and the journaling process to derive an

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interpretation voiced by the interviewer-researcher, not merely an echo ofthe voices of the participants. These interpretations are supported byverbatim comments of the participants to illuminate themes of grief andsense-making as points in a process of individual and interactive (group)change and growth.

I have listened to the audiotapes extensively. I have read and rereadtranscripts to identify themes, and several of the most relevant sections wereanalyzed line-by-line. Identified themes were grouped into coding categoriesthat were then further analyzed to uncover relationships among and betweenmeanings and perspectives, as well as to explore alternative explanations.Supporting quotations represent instances of patterns of meaning in ident-ified themes (Charmaz, 2007, DeCuir-Gunby, Marshall, & McCulloch, 2011).

Reflexivity and the Use of Self

With respect to reflexivity, I attempted to be mindful of my clinical experi-ence as a psychotherapist and attentive to my own prior experience of sui-cide survivorship in the loss of a client. Although the study was framedwithin the context of hermeneutic phenomenology, I compiled a writtenepoche for the purpose of attending to my personal and professional experi-ences apart from those of the participants prior to conducting interviews.This personal reflection helped me listen scrupulously to and be respectfulof the unique historical narrative of each participant, as well as theparticipants’ still-evolving understanding of events and emergentmeaning-making of the death by suicide of their spouse or child.

FINDINGS

Four overarching themes were derived from the narrative content: attributionof suicide causation, personal impact and response, wanting to die=wantingto live, and ways of coping. These themes will be described, and then com-parisons between themes, the process of grieving, and the impact of thegroup will be discussed in the setting of the participants’ understandingand meaning-making of the suicide.

Attribution of Suicide Causation

As participants recalled their initial awareness of the suicide, the shock anddisbelief that occur when a suicide is discovered or upon notification of sui-cide, an immediate search for causal attribution (‘‘why?’’) began. These attri-butions may be described in several ways: as personal, that is, the survivorcausally ascribes them to what the survivor did or did not do; as external,ascribed by the survivor to another person, the decedent, or another reason

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out of the survivor’s control; as inexplicable, beyond the survivor’sunderstanding; or as destiny, that is, the result of an inevitable circumstance.As survivors described the suicide and their attributions of possible reasonsfor the suicide, most cited more than one factor or a combination of factors.

ATTRIBUTION OF CAUSE: PERSONAL

The disbelief of any unexpected death is met with a search for detail andcausation. This search takes place in the context of the relationship betweenthe decedent and the griever, and is often expressed with self-doubt and per-sonal questioning. Statements such as ‘‘If only I had . . . ’’ or ‘‘Why didn’tI . . . ?’’ are common, even when no objective basis for personal causationexists. The uncertainty and unclear culpability of suicide can increase theintensity of this response in survivors of suicide. One survivor, reflectingon his efforts to support his late wife as she spiraled into depression, stated:

I felt guilty about . . . . I felt like I had too much control of the money, andthat I had responsibility to see that the bills were paid. I see now that Ihad no right, after she lost her job, to take control of the money. We bothdid work, so it wasn’t right for me to be in control of how much moneyshe had . . . . I see that she felt totally out of control . . . . Instead of helping,I took more control. I made her feel more out of control.

Another survivor described her helplessness: ‘‘He’d [daughter’shusband] be arrested, beat her . . . she could have come home, but didn’t tellus. What if I [had known]?’’ One mother despaired of not identifying the mag-nitude of her child’s depression soon enough: ‘‘[He] wasn’t his usual happy,perky, energetic—you know, light in his eyes kind of thing . . . . His smile justdidn’t get into his eyes anymore.’’ A strong sense of personal failure perme-ates these comments, and, in many, led to protracted rumination anddisturbing thoughts.

ATTRIBUTION OF CAUSE: EXTERNAL=OTHER

Other narrative comments ascribe causation beyond the ability of the sur-vivor to intervene. These other factors include another person or the deced-ent and often the relationship between the decedent and another person.

‘‘Because the start of the end was when she married him . . . everyweakness she had [her husband] exploited . . . . We lost her month by month,year by year.’’

Another survivor reflected on his wife’s life before they married: ‘‘All Iknow is what she told me. From what I know, in her early life [she] wasmolested by her [name]. Can you ever be convinced that you are loved [afterthat]?’’

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As the issue of attribution was discussed, some participants broadenedtheir description of causation beyond themselves to include multiple, ofteninteractive relationships and situations that contributed to the suicide.

When I saw [son], I thought, ‘‘I failed him’’ . . .hours of [thinking] that. Yet,[he] looked so peaceful. Later, I thought it was because [his girlfriend]cheated on him . . .but he was looking forward to [upcoming event] . . . itcan’t be just one thing.

ATTRIBUTION OF CAUSE: THE DECEDENT

Seven of the participants endorsed a strong understanding of the contri-bution of mental illness to the act of suicide. One parent remarked, ‘‘[He]loved his children, they were his life. The [depression] was so overwhelming,it convinced him that his own children would be better off without him.’’ Afather remarked:

The mood swings were more than he could handle. He’d call and say,‘‘I’m going insane, I’m going crazy,’’ but even then, he was so articulate,he didn’t sound crazy. But I think when you take those moods andcombine it with his personality as a perfectionist, it really, well, maybeit was more than he could bear.

ATTRIBUTION OF CAUSE: INEXPLICABLE

One mother, describing the nuances of her daughter’s erratic personalityover her lifetime, shared her struggle to understand her daughter’s situation:

And they told us, bipolar disease, and I never knew what that was . . . .And she seemed brighter without the [medication], and that never madesense to me . . . . In the fall, she took things [gifts, money], but [she also]gave things away; I didn’t interfere, because it didn’t make sense.

ATTRIBUTION OF CAUSE: DESTINY

In narrative discussions of attribution, participants alluded to circumstancesor combinations of circumstances that overwhelmed the decedent,sometimes framing this as an event that could not have been prevented:

Yes . . . I don’t think, well, I understood, because I don’t think I could everhave lived with [son-in-law]. I think she was just pushed against a wall.[But] I know she took it, the medication, and it could be she meant it[to be a suicide]. Maybe she meant it. But I don’t feel like she would haveleft her sons.

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Others framing this as an event that, if not ‘‘meant to be,’’ was in someway part of a larger ‘‘purpose’’ alluded to positive outcomes of the death.

[Commenting on spiritual experience] so, I felt this spiritual awareness, ahealing power at the end of the light that told me . . .maybe not a voice,that this was [son’s] time. He was too [crying] unprepared for the world.After [the first days—this participant wanted to die], I got stronger andstronger . . . . I could [help] my [list of family members]. Where could thatstrength come from? Only from [son]. I have to live to finish his life.

Personal Impact and Immediate Response

A second theme that emerged from the interviews was recollections of theearliest responses to the suicide. These included anger, disbelief, shame,and doubt. These responses represent the starting point in grief and precedethe subsequent themes of the tension between wanting to die or live andways of coping.

I have never been an angry person. I’m a professional. [But] I was over-whelmed by anger . . . it went on and on . . . I couldn’t start the [next]group and waited. The anger shut me down. I couldn’t work, eat, sleep.Until the anger had a place to go [writing, joining the group] . . . I wentfrom furious to immobilized.

A surviving mother tells of the shock and disbelief that lasted for weeks:‘‘My daughter, my very lovely daughter . . . I could not believe it. I walked andwalked everywhere . . . I just knew if I kept looking, I would find her.’’

A surviving spouse recalls his initial explanations of his wife’s death toothers: ‘‘Shame. I remember telling the bank teller. She asked how [wife]died . . . and I said, ‘breast cancer.’ ’’

A father describes the self-doubt as he realizes the family responsibilitiesthat would follow the suicide: ‘‘[I felt] the [weight of] the world on me. Howwould I tell [my family] . . . how would I be strong enough?’’

These recalled early reactions to the suicide were reconstructed andtransformed by participants in the grief recollections they shared and willbe examined further in the discussion.

Wanting to Die=Wanting to Live

A desire to die after the death of a family member or close friend is acommon response in early grief, and it is reported frequently in conjugalbereavement and, with the greatest frequency, following the death of achild. The unique perception of ‘‘a death out of sequence’’ that is associa-ted with loss of a child is reflected in statements such as ‘‘I should havegone first.’’ In the case of suicide loss, a stated desire to die can be framed

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as the death should be one’s own death instead of the decedent’s, a desirefor death to join the decedent, or death as self-punishment for the suicide.The tension between wanting to die and wanting to live is associated withsuicidal ideation in suicide survivors. Moreover, the desire to die,particularly as a function of yearning, is highly associated with complicatedgrief.

For example, a surviving spouse struggled to want to keep living: ‘‘Ithought about it; this is the one person in the whole world worth livingfor. I’m not able to keep living. [Without] this one, the one person, thesoul-mate, like I said.’’ A mother, commenting on her daughter’s suicidefollowed by the subsequent death of her elderly mother, said, ‘‘I feel like Igot skipped. It shouldn’t have been [daughter], it should have been me.’’Beyond merely wanting to be dead, other survivors actively contemplatedsuicide:

I cut him down. I knew he was dead. I lay with him. I was just with him. Ihad him to myself . . . . I put [the rope] around my neck. What was this likefor him? What would this be like [for me]?

These perceptions, that one cannot live without the decedent or should havedied instead of the decedent, characterize the immediate and sometimes per-sistent thinking that is suggestive of suicidality in conjugal and filial suicidesurvivorship.

Ways of Coping

As the days and weeks of grieving go on, most grieving individuals, exclud-ing those with levels of complicated grief that drastically impair function, findways of coping with the loss. For these suicide survivors, the theme of copingin the narratives was revealed as taking care of oneself, reaching out toothers, and doing things in different ways.

Some examples of self-care were returning to church, immersing oneselfin a job perceived as validating and rewarding, or actively exercising. Oneparticipant spoke of reclaiming a love of music:

Well, I got a small approach. I have to take baby steps. I took . . . I got anaudition to sing the national anthem . . . she was so eager to see me sing.So I’m in to give it a try; she would want that.

Another approach to coping with the suicide was to reach out to otherpeople. For some, this meant giving support to others:

It has always been incredibly sad, but being that sad, it makes it some-thing you have to connect with and be open with to understand it, you

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know. And share with my kids and to make sure that we stay connec-ted through this. I know for a long time, during that same winter, wewould meet each other, like ‘‘so how are you doing?’’ And it is like,you know what, after doing that for a while, this was so much bullshit;so, no, this is not all right [I thought]. So then, I started openingup . . . and then I could say . . . ‘‘no, I want to know how you are, thisis how I am.’’

Others reported intentionally seeking the support of others. Onesurvivor, recalling how she felt on her daughter’s birthday, said, ‘‘I talkedabout it, I thought about it, with a woman I work with, my boss. She hasbeen through her stuff. I couldn’t have been in a better place [to work] forall of her support.’’

Both of these coping strategies, giving support and seeking support,were important elements in the grief support groups and will be exploredbelow.

Suicide survivors also tried new things and learned new ways of coping.One survivor began a journal upon a recommendation from the groupfacilitator:

And I was confused with all of the other losses . . . and . . . some of themwere huge. I talked with [the facilitator] and he knew I was kind ofoverwhelmed and he said, ‘‘why don’t you start by writing about yourson-in-law? I think you’ll get past this ‘block’ if you do.’’ . . . So I didand I sat down. It was about 2 hours straight, in the middle of thenight.

Another commented on reading books on grief to cope:

I read several books [about grief] when I was down there [with herdying mother], while talking about discontinuing life support on mymother. There was a nurse taking care of her, she told me about avery close friend [of hers] that committed suicide and she recom-mended books [for me] to read. They were helpful. I read whateverthey suggested.

DISCUSSION

As I reflected on the four themes of attribution, personal impact andresponse, wanting to die or live, and ways of coping, patterns between thesethemes revealed the survivors’ evolving process of grieving. The journey ofgrief in suicide survivorship included not only the painful, gradual movementtoward recovery, but also startling inflection points of insight and growth. Iwill discuss these two different processes, gradual and abrupt, in the contexts

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of the group experience, interaction with others, and personal=spiritualawareness. These two different but interactive processes will then beconsidered with respect to their congruence with or departure from the the-ories of meaning-making and disenfranchised grief.

The Slow, Hard Work of Healing

In the best of circumstances, grief takes time. With the intensity and uncer-tainty associated with suicide, grieving may be more protracted and fraughtwith disparate feelings, thoughts, and changes in interpersonal relationships.Suicide survivors described an arduous process of small steps forward, inevi-table steps backward, and a slow, painful but eventual forward momentumtoward resuming life. This progress is affected, usually in supportive ways,by the grief groups, in interactions with caring others, and in the interiorwork of personal growth.

HEALING IN THE GRIEF SUPPORT GROUP

The therapeutic purpose of the grief support groups is to enable grievingpersons to gain support from others having a similar loss, to reduce iso-lation, to challenge assumptions about grief and loss, and to provide anopportunity for grieving persons to give support to others by sharing theirexperiences. The duration of the groups encourages steady movementtoward these goals. The experience of the participant whose group facilita-tor encouraged journaling illustrates this: ‘‘To write, to vent, it helped. Butto hear what [group members] said [about what she’d written] helpedmost.’’ For another survivor, to observe the experience of other groupmembers helped him recognize his own growth: ‘‘It had been the longest[time since the suicide] for me. And when I saw what [the members] weregoing through, and remembered I had [felt that], I thought, I must bemaking progress.’’

INTERACTING WITH OTHERS

In their suffering, participants did reach out to others for care and guidance.The perception of comfort and acceptance of support contributed to ahealing grief:

[Later] at the hospital, I asked the pastor, ‘‘how sure are you of what youbelieve in? This Jesus Christ?’’ The pastor told me at this point now ofwhat he believed in . . . . ‘‘Life after death,’’ [he said.] ‘‘How sure [areyou]?’’ . . . . Because, I was thinking you know, with a suicide? . . . . Iwanted to see her after in a better place. And all I remember doing is justreaching out to this pastor, and wrapping my arms around him, saying‘‘she just left us like that . . . she just died.’’ There was silence and I just

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said, ‘‘give me hope.’’ So he gave me some hope [about her beingaccepted in heaven] . . . . Even when I knew she was dead, I was holdingon to hope. That’s why I asked him that.

In contrast, some experiences survivors had with other people wereunsupportive, and other experiences were perceived as hurtful:

[My brother] drove all night . . . to be with me. It didn’t help, and as muchas he wanted to help, my brother, because as bad as my brother felt forme, the way he deals with it is with humor, you know. But because it[was a suicide death], it was out of line. It kills me.

Many found the grief support group to be a safe place to discuss thedisappointing interactions they had with other people in the setting of sui-cide bereavement. One mother remarked about meeting another motherfrom her late daughter’s high school and perceiving that the woman blamedher for her daughter’s death: ‘‘When I hear what [supposed friends] say, Iknow I will never judge another again . . . . That’s the conclusion we all[group members] came to.’’

Participants developed a deeper understanding of the nature ofsuicidality in the context of mutual support from group members and thefacilitator. One participant recalled being assured by the facilitator in the firstsession:

And when [facilitator] said, ‘‘look around the room and feel the tangiblepain here. If you can imagine . . . your loved one as feeling hundreds oftimes worse than this, then maybe we can begin to understand moreabout their experience as they contemplated ending their lives,’’ well, Ibegan to open myself to other explanations.

PERSONAL AND=OR SPIRITUAL GROWTH

Survivors described a gradual awareness that they would continue livingwithout the decedent, and that they could make choices about how theywould live. These recollections, as shared by survivors, had the quality ofquiet reflection, as in this mother’s comment:

I did make a decision not to shut down. Because you can’t live your life ifyou are shut down. I have been that depressed. I know that despair[daughter] was living with. I have worked not to go there.

These moments of growth are characterized by intention and, whiledifficult, seem empowering to the griever. One survivor described amoment when he made a selfless effort to help another person rather than

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yielding to his own self-interest: ‘‘spiritually, at that moment . . . to choosethe spiritual over the material, and then [to see] that light . . . .and neveranother panic attack.’’ He attributed his relief from anxiety to his choiceto be compassionate, and in making this choice, he gained perspectiveon his own suffering.

Inflection Points in Grief

The gradual process of healing, with its characteristic trajectory of small stepsforward, backward, and forward again, was punctuated for some survivorswith breakthrough episodes. I interpret these inflection points in grief as‘‘aha’’ moments. Some survivors had experiences of intense insight, oftendescribed as ‘‘life-changing.’’

HEALING IN THE GRIEF SUPPORT GROUP

In the safe and accepting environment of the support group, assumptionsabout suicide causation and the feelings and thoughts associated with thesuicide can be challenged. One survivor recalled how his perception of beingresponsible for the suicide was impacted: ‘‘Well, and everyone else is in thesame boat . . . saying, talking about their guilt, anger, mostly guilt. I stillbelieve [at that time] it’s my fault, but I’m having to think . . . is it my fault?Does it have to be anybody’s, anyone’s fault?’’ The group facilitator fosteredthis transformed understanding of perceived causation, catalyzing newawareness in this parent: ‘‘When [the facilitator] described bipolar disorder,it was as though she was explaining my son’s entire adult life, and I thought,he couldn’t help it, he never wanted to be that way.’’

Another participant described relinquishing blame:

What made [the anger] unbearable was the wild raging of it . . .mad at[son-in-law] for being a—druggie, mad at [my husband,] he believedher stories, mad at myself, ‘‘why did I let her marry him?’’ mad at [daugh-ter] . . . she took her husband’s methadone! After I wrote and read it [in thegroup] I understood anger has [to have] a place . . .needs a target. Thetarget doesn’t have to be a person.

INTERACTING WITH OTHERS

One survivor related doubt and uncertainty in trying to help other familymembers while being consumed by his own grief, believing his grief was astumbling block in his ability to care for others. In attempting to supportothers, he described realizing, in an instant, that those he was hoping to helpneeded to see his grief as well.

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Yes, but at the same time there is like [my] grief. You have to grieve inorder to have healing, you have to healing before you can reachout . . . effectively, I mean. They go hand in hand; you are weaker, youare stronger, you are weaker. You have to have healing so when youget to that place you have to recognize it. That is difficult, to openlyadmit it.

PERSONAL AND=OR SPIRITUAL GROWTH

Of the inflection points shared by survivors, most of the bursts of insightwere in the realm of personal or spiritual awareness. One survivor relatedhis transition from suicidal intention to safety as a split-second reversal ofcourse:

Yes, [I intended] to have relief from all of it. It was a funny thing, thoughtsthat came on quick. I mean there was not really any planning, or prep-aration for it. I had the sensation of ‘‘this is over,’’ or ‘‘I’m doing it.’’ I’mgoing downstairs to [son’s room—to take his own life]. And this is howit [went] down; instead of going downstairs, I went outside. Yes, it waslike, as soon as I was outside, it was like ‘‘wow.’’ . . . Immediately, I knew,I would never consider that again.

This same survivor described an intensely spiritual encounter with hisson many months later:

It’s midnight and I spoke with [son]. And I welcomed him. And hewelcomed me. And we had our moment . . . . It was a moment that I knewwas going to happen. And I’m just like, all I can do is just wake up andget out of my own way, because that to me . . . just letting it happen, is theright response [to this]. I mean, this is not a coincidence . . . this doesn’t[just] happen.

Relationship of Phenomenological Interpretation to ExistingGrief Theories

Each of the survivor-participants in this study conveyed an intense, lovingrelationship with the decedent. Survivors described a powerful sense of disbe-lief at the suicide, and all miss their deceased family member deeply. All butone of the participants recalled shame and guilt; two struggled with profoundanger. Shame was ascribed by survivors to personal failure, and was some-times reinforced in social recrimination or absence of support. Guilt was pre-sented as self-blame and persisted in the absence of social acceptance. Angerwas attributed variously to the decedent, to the self, to others, or to social sys-tems. The experience of suicide grief, at least as expressed by thoughts andfeelings of survivors, is consistent with Heider’s theory of attribution.

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The narrated experience of suicide survivorship well supports Doka’s(1989, 2008) conceptualization of disenfranchised grief. The sense ofdisenfranchisement was mitigated by perceived acceptance in thegrief support groups, by caring others, and by intellectual or spiritualinsight.

When viewed through the lens of meaning reconstruction, the efforts ofsurvivors to come to terms with the suicide seem extraordinary andcourageous. Sense-making, the transformation from initial shock and disbe-lief to an attained meaning-finding in the face of loss by suicide, is character-ized by arduous and tentative steps of acceptance, forgiveness, andengagement with others, punctuated for some with flashes of insight andgrowth. Each survivor is at a different place in this journey, and their com-ments about other group members affirm their awareness of this. None ofthese survivors would describe themselves as ‘‘done’’ with grief. Yet, in each,the process of meaning-making was apparent to me. Through differentinsights and encounters, each was working to make sense of the deathand come to terms with the reality of suicide. Each survivor could relatetransforming moments of positive change and growth. At varying levels, eachcould identify value in what was learned from the death. Not one of thesesurvivors relinquished the role they had with the decedent, as parent orspouse, yet each was developing a new identity, not without but beyondthe relationship with the decedent. While pain was still very present in theirlives, each survivor was looking forward, and with hope. Recalling Frankl(2006), who observed that ‘‘it is a peculiarity of man that he can only liveby looking to the future’’ (p. 73), we can endorse his position that onewho discerns a ‘‘ ‘why’ for his existence . . .will be able to bear almost any‘how’ ’’ (p. 81).

A moving example of this is conveyed in a father’s perception of his lateson’s continuing active role in his life, and the sense he makes of a possiblegood that came from his son’s death:

So I call it healing. [My son] had more healing power than anybody I’veever met . . . this desire to repair things in him, it was huge . . . . Thehealing power of it and who he is was really unbelievable. I see it andso, I mean, we’ve had a little reversal of roles, and he is now stronger.I’m here and I’m still his father, but I’m looking to him to, say, letme know what is going on. I have had several occasions of [his]guidance.

I find it very compelling that making sense of, or finding meaning in, death isnot the same thing as understanding why the death occurred. The mostreconciled of these survivors will tell you they don’t understand why thismuch-loved person took his or her own life, and further they recognize thatthey may never understand why. In my estimation, those closest to peace

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appear most capable of accepting multiple contributions to causation, andhave found a way to live with mystery.

Study Limitations

While generalizability is not an assumption of qualitative research, the sizeand composition of the study sample does limit the transferability of findings.The sample was small, only included one example of loss of a spouse tosuicide, and cannot be considered representative beyond the communityfrom which it was drawn. Further, it represents only those individuals whosought help from a suicide survivor support group, doubtless the minorityof survivors. The study represents an initial attempt to understandmeaning-making as interpreted phenomenologically from the narratives ofsurvivors’ lived experiences and the use of support groups to facilitate theprocess of suicide grief.

CONCLUSION

Suicide is a catastrophic event that inherently has the power to devastatemany lives. Those closest to the suicide completer may be more at risk forthe worst grief outcomes. The capacity of suicide survivors to grieve deeply,fully, and with resolution is mediated by their ability to make sense of thedeath in a way that actualizes personal and spiritual growth and achieves apersonal identity of self-acceptance. This meaning-making is facilitated bysupportive interpersonal relationships, among which grief support groupsmay be extremely valuable.

NOTE

1. By way of clarification, family and close friends of people who have committed suicide are referred

to as ‘‘survivors of suicide,’’ and this term is uniquely limited to this context. Persons who have attempted

suicide and survived the attempt are referred to as ‘‘attempters’’; those who have accomplished suicide are

referred to as ‘‘completers.’’

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Katherine P. Supiano is an assistant professor (clinical) and director of Caring Con-nections: A Hope and Comfort in Grief Program, College of Nursing, University of Utah.She has been a practicing clinical social worker and psychotherapist for over 30 years.Her clinical practice has included care of older adults with depression and multiplechronic health concerns, family therapy, end-of-life care, and bereavement care.

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