Initial-Stage Suicide Bereavement Experiences : A Case Study

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Initial-Stage Suicide Bereavement Experiences : A Case Study © 2022 the Authors Published version Chen, Yan; Laitila, Aarno Chen, Y., & Laitila, A. (2022). Initial-Stage Suicide Bereavement Experiences : A Case Study. Omega : Journal of Death and Dying, OnlineFirst. https://doi.org/10.1177/00302228221095905 2022 Original Manuscript OMEGA—Journal of Death and Dying 2022, Vol. 0(0) 1–21 © The Author(s) 2022 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/00302228221095905 journals.sagepub.com/home/ome Initial-Stage Suicide Bereavement Experiences: A Case Study Yan Chen 1 , and Aarno Laitila 1 Abstract This study aimed to shed light on the initial-stage bereavement experiences of an individual bereaved by suicide, at three months from the loss of his spouse to suicide. A semi-structured in-depth interview was conducted with the individual, a man in his thirties. The data were analyzed using qualitative assimilation analysis, based on the Assimilation Model and the Assimilation of Problematic Experiences Scale (APES). The APES ratings of the interview revealed that the individual’s bereavement was associated with the earlier stages of APES (all scoring under 3.5). In addition, the swift and frequent fluctuations in the APES ratings gave indications that the bereavement was unstable and complicated. It is suggested that mental health professionals could use APES to evaluate suicide bereavement and take note of the APES evaluations in clinical interventions. Keywords suicide bereavement, initial stage, case study, Assimilation Analysis, Assimilation Model Introduction Surviving the death of a family member is challenging, especially when the death is due to suicide. Shneidman (1973) claimed that in cases of suicides the greatest public health issue is mitigation of the impact of the loss on those bereaved. Estimations of the numbers of persons bereaved per suicidal death have varied from six (Shneidman, 1972)toten 1 Department of Psychology, University of Jyv¨ askyl¨ a, Jyvaskyla, Finland Corresponding Author: Yan Chen, Department of Psychology, University of Jyv¨ askyl¨ a, P.O. Box 35, FI-40014 Jyv¨ askyl¨ a, Jyv¨ askyl¨ aFI40014, Finland. Email: [email protected].fi (Wrobleski, 1991), while the latest estimate of those exposed per suicide has risen to 135 (Cerel et al., 2019). It should be noted that among those left behind by suicide, there is significant variation in the aftermath of the loss, since it encompasses those exposed to suicide, those affected by suicide, and those bereaved by suicide (Andriessen, 2009; Andriessen & Krysinska, 2012;Berman, 2011;Cerel et al., 2014;Crosby & Sacks, 2002). The present study focused on the subset of persons most greatly impacted by suicide, namely those bereaved by suicide. Note that in this paper several synonymous terms are used: “persons bereaved by suicide,”“the suicide bereaved,”and the simplified forms “those bereaved”and “the bereaved.” The need to study individuals’lived experiences of suicide bereavement is based on the impact of the loss (Chakraborty & Halder, 2018;Spillane et al., 2017), the large number of those bereaved (Cerel et al., 2019), and the risk of additional suicides and of various mental health disorders among the bereaved (Runeson & ˚ Asberg, 2003;Zhang et al., 2005). According to the framework proposed by Jordan and McIntosh (2011), bereavement following suicide shares some common characteristics with bereavement after all types of loss, including elements of bereavement after unexpected deaths and violent deaths. However, beyond these shared reactions, suicide bereavement has various qualitatively unique and complex characteristics that distinguish it from bereavement following nonsuicidal deaths (Jordan, 2001). These will be summarized below. Initially, shock, accompanied by numbness and disbelief, may occur due to the unexpected nature of the suicide (Andriessen & Krysinska, 2012), although those who have experienced an intensive “suicide watch”may feel a sense of relief (Sveen & Walby, 2008). In addition, persons bereaved by suicide tend to experience a number of negative feelings towards themselves; these can include heightened feelings of guilt, self-blame, and perceived responsibility for the loss (Bailley et al., 1999;Chapple et al., 2015;Kõlves et al., 2019). At the same time, they may also feel adverse emotions emanating from the loved one, involving feelings of rejection (Chakraborty & Halder, 2018) and a sense of desertion by the deceased (Andriessen & Krysinska, 2012). This can generate intense anger toward the deceased, as well as deep feelings of unworthiness regarding oneself (Chakraborty & Halder, 2018;Jordan, 2008;Kõlves et al., 2019). A unique element of suicide bereavement is a search for answers, and a pondering on unanswered questions, mainly consisting of reasons for the suicidal death, and involving sense-making and meaning-making regarding the death (Castelli Dransart, 2013;2017;Cerel et al., 2013). This may very well lead to dramatic changes in one’s belief system, encompassing life, the self, others, and the world (Bell et al., 2012;Janoff-Bulman, 1992). Suicidally bereaved individuals are faced with a higher possibility of suffering from mental problems, and may go through an extremely long and complicated bereavement process (Cerel et al., 2013;Cvinar, 2005;Peters et al., 2016). The manifestations consist of a variety of mental difficulties and disorders (de Groot et al., 2006;Hibberd et al., 2010;Jordan, 2008;Mckinnon & Mckinnon, 2014;Nam, 2016). In addition, grieving family members may also encounter negative experiences in their social network, 2OMEGA—Journal of Death and Dying 0(0) including stigma, shame, embarrassment, withdrawal, avoidance, loneliness, and isolation (Bell et al., 2012). At the same time, the surviving families are also likely to experience a series of changes at the family level. Disenfranchised grief may restrict openness in communication and in perception within the family (Bell et al., 2012). This may progress to distortion or closure of communication, and to occurrences of family secrecy (Cerel et al., 2008;Nelson & Frantz, 1996). The guilt, anger, and blame that family members feel toward each other and toward themselves can contribute to silence, maintained in order to cover potentially terrible accusations (Lukas & Seiden, 2007). Some dysfunctional families in which suicide has occurred can experience the same or even a higher risk of dysfunction following their suicidal loss (Jordan, 2001). Moreover, suicide itself has the possibility to distort family patterns, and develop dysfunctional family dynamics (Jordan, 2001). Findings on the distinctive features of suicide bereavement, as experienced by individuals and families, have focused on the bereavement process (Gaffney & Hannigan, 2010), certain aspects of suicide bereavement (Castelli Dransart, 2013; Cvinar, 2005;Mitchell et al., 2004;Nam, 2016;Talseth & Gilje, 2017;Wood et al., 2012), and the lived experiences of suicide bereavement (Begley & Quayle, 2007). However, in these studies there has been little focus on suicide bereavement experiences at the initial stage, though these have been touched on in several other studies (Kõlves et al., 2019;Mitchell et al., 2004;Ross et al., 2018). In addition, no systematic, methodologically robust tools have been applied to characterize the complicated inner world of the suicide bereaved at the initial stage of their bereavement. An understanding of the concrete features of the initial stage of suicide bereavement could assist professionals in providing tailored help to the bereaved. To achieve this aim, in this study we chose qualitative assimilation analysis (Stiles et al., 2004;Tikkanen et al., 2013; Tikkanen & Leiman, 2014) as a tool for data analysis, since it has proved to offer particular advantages for microanalytic research (Stiles et al., 1990). Assimilation analysis is based on the Assimilation Model (AM) and the Assimilation of Problematic Experiences Scale (APES). AM was first utilized to study the changes occurring within psychotherapies (Honos-Webb et al., 1998;Osatuke & Stiles, 2006;Penttinen et al., 2017). Subsequently, the scope of AM developed to new contexts, including gathering data from non-therapeutic interviews (Henry et al., 2009; Moore et al., 2014;Osatuke et al., 2011). The present study represents a further extension of AM, i.e., towards suicide bereavement. The data were drawn from a nontherapeutic interview, the aim being to demonstrate an individual’s lived experiences of suicide bereavement at the initial stage. The AM method considers problematic experiences as separate, active voices within the person. The self is seen as consisting of a community of voices (Mair, 1977). The voices are formed from traces of associated experiences, and are connected by meaning bridges (Honos-Webb & Stiles, 1998). The community smoothly assimilates voices of unproblematic experience; by contrast, the self may avoid voices composed of problematic experiences, leaving them to form nondominant voices (Brinegar et al., 2006; Chen and Laitila 3 Honos-Webb et al., 2003). The self becomes stronger and more intact as it incorporates more of a person’s problematic experience. Assimilation involves the building of a meaning bridge that combines an unaccepted, nondominant voice with an established self/community of voices, which is represented by a dominant voice (Honos-Webb et al., 1999). The sequence of the assimilation levels (APES) reflects a varying association between a dominant voice and a nondominant voice (Honos-Webb & Stiles, 1998). Two basic entities—topic and theme—are included in the AM. A topic refers to an expressed attitude toward an object (which can be a person, thing, event, or situation), whereas a theme is defined as an attitude revealed recurrently, possibly regarding several objects (Stiles et al., 1991). In the process of assimilation, the community of voices accommodates the problematic voices through a process that can be divided into eight predictable stages, from stage 0 to stage 7. These can be summarized in terms of the Assimilation of Problematic Experiences Scale (APES) (Stiles et al., 2004). The eight-stage process includes both cognitive and affective features. At stage 0, the problematic voices are denied or avoided; the affect may be minimal (Stiles et al., 2004). At stage 1, the preference is for problematic voices not to be mentioned; hence they are suppressed or avoided, coming to light only when stimulated by external circumstances, and accompanied by strongly unpleasant but intermittent affect. At stage 2, the problematic voices enter prolonged awareness, but without formulation of the problem, and with acutely painful affect. At stage 3, the problems are clarified, and the opposing voices are distinguished; the affect is unpleasant but exists within the individual’s control, not in a state of panic. It is only at stage 4 that understandings between the separate voices are reached, with problematic experiences being formulated and understood to some extent, along with mixed affect encompassing negative and positive experiences. At stage 5, the understandings are applied to solve problems, while the voices collaborate to find solutions to problems in daily living, with pleasant and optimistic affect. At stage 6, the voices can be utilized with flexibility; the affective tone is pleasant and satisfied. At stage 7, the voices are completely assimilated, growing into resources for dealing with new situations, accompanied by positive or neutral affect. In our study, AM made it possible to identify particular problematic experiences related to a family member’s suicide. Wilson (2011) used AM to evaluate bereavement counseling. Differing somewhat from his research, our study focused on the use of assimilation analysis to analyze specifically suicide bereavement, in the context of nontherapeutic research interviews. In seeking to underpin our qualitative research approach, we specifically applied a case study approach as having the capacity to delineate real-life situations and substantial details (Flyvbjerg, 2006). This is in line with most published research on AM (Basto et al., 2018;Laitila & Aaltonen, 1998;Osatuke et al., 2011;Penttinen et al., 2017). AM has been used as a tool for qualitative research, especially when a case study approach has been applied to theory-building (McLeod, 2010;Stiles, 2007). In the present study we used a single case involving only one person who was bereaved by 4OMEGA—Journal of Death and Dying 0(0) suicide, recruited in China (People’s Republic of China). Our aims centered around the following questions: What is the nature of suicide bereavement experiences at the initial stage? How is AM applicable to the analysis of suicide bereavement experiences? Method Participant This case study formed part of a larger research project concentrating on the suicide bereavement experiences of persons bereaved in China. Participant W (a pseudonym) had lost his wife to suicide three months prior to the interview. In manifesting the shortest time interval after suicide, W was unique in the entire data corpus within the project. He was interviewed four times, i.e., at around 3 months, 7 months, 10 months, and 18 months from the loss. The first interview is included within this article, since it fulfilled the goal of clarifying suicide bereavement experiences at the initial stage (which has scarcely been studied previously). In addition, W’sfirst interview was adequately informative. His ways of expressing the situation as he experienced it were vivid and detailed, and the richness of his descriptions made the interview a good basis for an intensive case study—always bearing in mind the need for sensitivity and for a strictly ethical approach (see below). In terms of personal background W was a man in his thirties. He had received a higher education. He had been married for 4–5 years. The marriage was the first for both W and his late wife, and they did not have children. Research Ethics The fieldwork of the research project commenced after ethical approval was obtained from the affiliated university’s ethics committee. Suicide is such a sensitive topic that ethical issues were clearly of paramount importance in research of this kind. Before the interview, the first author—who was also the interviewer, and who is a Chinese female clinical psychology doctoral student and certified psychological counselor— introduced to W the purpose and procedures of the interview. She mentioned both the potential benefit and risks pertaining to the research, with an emphasis on the voluntary and anonymous nature of the participation. She informed W of his right to withdraw from the interview at any time, and the resources available if he experienced negative emotions aroused by the interview. Questions raised by W were answered. Immediately before the interview began, a written informed consent form was signed. Great emphasis was placed on caring for W’s feelings and well-being during the entire interview, and also for his mental well-being after the interview. The stance of the interviewer, and the process of the interview, were greatly influenced by the belief that researchers must learn from the suicide bereaved and enter the field with a “notknowing”attitude (see Dyregrov, 2011). Throughout the interview, the interviewer mostly followed W’s focus on his bereavement experiences, giving him the initiative Chen and Laitila 5 and freedom to decide what to express. In this way it was intended that the interviewee could gain more control regarding the autonomous management of his own emotions, and of the pace of the narration during the interview. After the interview, the interviewer undertook follow-up inquiries on the participant’s mental well-being so that support could be offered when needed. Procedures Entering the Field—Recruitment of the Participant. W was recruited through a suicide bereavement support group in an economically developed city in China. First of all, the interviewer contacted and met the group leader, an experienced psychologist working in a psychiatric hospital. After discussion of the research project and hearing the opinions of the group members, it was agreed that the interviewer could take part in the group meetings on several occasions, as a volunteer and as a researcher. The group had regular monthly meetings in which the interviewer participated on two occasions. It was during these that the interviewer got to know W. During the interaction between the interviewer and W within the group meetings, W was willing to openly talk about his bereavement experiences with the interviewer, and he showed great interest in the research. After discussing W’s emotional stability with the group leader and getting an affirmative answer, the interviewer invited W to participate in the study. Data Collection—Interview. A face-to-face, semi-structured in-depth interview was conducted with W. The interview focused on his bereavement experiences and his bereavement process, and further on his emotional reactions, perception, changes, and ways of coping at different times. The interview occurred in a quiet and private venue, with the aim of making W feel safe and uninterrupted. The 144-minute interview was recorded and subsequently transcribed verbatim. Analysis of the Interview. The first author conducted the interview in China. She subsequently transcribed the interview from an audio recording to a verbatim transcript, and translated the transcript into English. Initially, she conducted the assimilation analysis through listening to the audio recording, and through reading the Chinese transcript. The audio recording was a good basis for perception of W’s emotions, as prosodic features such as volume, tone, pauses, sighing, and trembling in the voice could be vividly heard, and hence taken into account in the analysis. Meanwhile, the second author, a Finnish psychologist with extensive experience in clinical psychology research, went through the translated transcript and conducted the assimilation analysis. After the independent and concurrent assimilation analysis conducted by the first and second author, the two authors performed collaborative data analysis within regular data sessions (face-to-face meetings and online video meetings). The analytical procedure used was adapted from a four-step assimilation analysis previously used to analyze psychotherapy sessions (Brinegar et al., 2006;Stiles & Angus, 2001). At every 6OMEGA—Journal of Death and Dying 0(0) step, the independent data analyses alternated with collaborative data sessions. Each step was iterative until consensus was achieved. Step 1: Familiarization and Cataloguing. Through listening to the audio recording and reading the Chinese transcript (with the second author reading the translated transcript), W’s thoughts and feelings regarding his wife’s suicide were noted, and a list was made of the problematic topics. Step 2: Identifying Problematic Voices and the Community of Voices. From the list of topics extracted in Step 1, one central theme, namely W’s wife’s suicide, was identified. Within this theme, seven voices, including four dominant voices and three nondominant voices, were distinguished on the basis of their content and emotion. Step 3: Excerpting Passages. Passages representing the seven voices were located and excerpted. After this step, 21 passages representing the voices were selected. Step 4: Describing the Process of Assimilation Represented in the Passages. APES ratings were assigned to each of the 21 passages screened in Step 3, and the reasoning for the ratings was clarified. The development of specific voices was noted, as were interactions and conflicts between voices. Results Overview: W’s Community of Voices and Nondominant Voices The main product of the four-step data analysis is summarized in Table 1 below. We identified one central theme from the interview, i.e., W’s wife’s suicide. There were two pairs of conflicting voices, as listed in Table 1. These consisted of (1) the self-regulation voice as opposed to uncontrollable emotions, and (2) normalcy of life as opposed to accidental death/suicidal death. The occurrence and the changes in the APES ratings of the voices are presented in Figure 1. In the following sections we shall elaborate how these voices developed in the interview. The rationalizing voice was manifested when W wandered among various scientific and philosophical topics accompanied by negative but comparatively calm emotions Table 1. Voices within W’s Self. Reference by letters a–d(see Figure 1) Community of voices Problematic voices cRationalizing dSelf-observation aSelf-regulation Uncontrollable emotions bNormalcy of life Accidental death (b1) Suicidal death (b2) Chen and Laitila 7 (APES 0.8). From Figure 1 it can be observed that the rationalizing voice (represented by line cin Figure 1) was the only voice present in the first 63 min after the interview began, and in the last 21 min before the end of the interview, with intermittent occurrences also from 79:03 to 90:50 min, where it was accompanied by other voices. With the rationalizing voice, W seemed to involve himself in rational thinking, and to temporarily avoid talking about his wife’s suicide. Within this phase, W was mostly close to the stage of “active avoidance,”i.e., APES 0.8. However, one exception appears at 88:24, when the APES rating of the rationalizing voice reaches 2.0. The excerpt below presents one example of W’srationalizing voice. Excerpt 1: (61:16–61:36) W: Then, in fact, from junior high school, I began to have an interest in philosophy though I didn’t know it was philosophy back then, but after I read it, I felt it rather suited my preference...... The emergence of W’sself-observation voice implied less avoidance than before (hence representing APES 0.9). From around the 63 rd minute, with the self-observation voice, W’s narratives moved in such a way as to be more internally related to himself, as compared to the external topics taken up previously. Excerpt 2: (63:09–65:14) Figure 1. Occurrence of Voices, and Changes in the APES Ratings over the Entire Interview. 8OMEGA—Journal of Death and Dying 0(0) bereavement. We anticipate that relevant comparisons will be made in subsequent analyses within the current research project. Our analysis revealed that W showed certain distinctive features in processing his suicidal loss. Indeed, every individual who has been bereaved through suicide may have qualitatively distinct paths through bereavement (Hall, 2014). W’s alternation in narration between various scientific/philosophical topics and his loss-related experiences could have formed his own efficient way of maintaining a balance between his restless emotions and his ongoing life demands. In addition, one can see that at some points W’s emotions were detached from self-regulation, which was dominated by his rationality. In this regard, Gaffney and Hannigan (2010) explained the detachment of emotions at the initial stage of bereavement as acting as a self-defensive strategy, minimizing the traumatic impact of the suicidal loss on the bereaved person. The fact of the loss may initially be so overpowering that bereaved persons need to become detached in order to manage their everyday functioning (Gaffney & Hannigan, 2010). Strengths and Limitations For the sake of credibility of the study, the research setting, the participants, and the data analysis have been presented here through “thick”description, giving as much detail as space allows (Creswell & Miller, 2000). Furthermore, close collaboration between the two authors was seen as providing a further guarantee of the credibility of the data analysis. Nevertheless, one must be aware that the possibilities of generalizing from this study are limited, given that it involves one single case exhibiting (one may assume) distinct characteristics as regards bereavement experiences. Moreover, because of the low accessibility of suicide bereaved individuals in China, sampling was based on convenience, meaning that we cannot exclude the possibilities of selection bias. Another limitation is that our data do not allow us to make any valid cultural interpretations regarding suicide bereavement. Some cultural features may indeed have been present in the interview, but our research procedures involved a focus rather on the private and individual processes of suicide bereavement. Despite the limitations above, it can be claimed that our single case study illustrated the research participant’s initial stage of bereavement experiences in depth and in detail. It provides a unique portrait of the internal process of adapting to suicidal loss, and a comprehensive overview of the dynamic interaction between the voices within the process. The combination of AM with suicide bereavement research made the nuances of the internal processes visible. Hence, our study seems well placed to extend the (so far) limited knowledge on the bereavement experiences of the suicide bereaved, and especially knowledge on the initial stage of suicide bereavement, bearing in mind that very few previous studies have focused on this phase. It can be claimed that the researcher-participant relationship in this study exhibits both strengths and limitations. The interviewer took part in the bereavement support group’s regular meetings on two occasions. This appeared to leave W enough time to Chen and Laitila 15 consider his participation; in addition, familiarity with the interviewer before the interview was favorable in creating a sense of safety such that W could volunteer to participate. This helped to build rapport, allowing the interviewer access to crucial narratives in W’s experiences, with richer and more authentic data. However, in such a case, the interviewer and interviewee might well develop unconscious preconceived opinions about each other. Hence, W’s interview could well have had features different from those carried out with people outside the group, in terms of the interview process and the content of the data. Clinical Implications On the basis of this study, it can be claimed that health professionals could usefully apply forms of assimilation analysis to gain a clear portrait of the internal process of adapting to suicidal loss, with possibilities for more specific guidance on the intervention. Moreover, as indicated by this and by other studies, professionals may bear in mind that instability, complexity, and (very possibly) ambivalence can accompany the bereaved through their initial bereavement. Helping bereaved persons to cope with instability, complexity, and ambivalence merits a strong initial emphasis in clinical intervention, and can be expected to form one of the main standards in assessing the psychosocial support provided at this stage. Conclusion The application of AM shed light on initial suicide bereavement experiences. In terms of AM, the research participant was still at the initial stage of his bereavement process, and had a considerable way to go before fully assimilating his suicidal loss. Professionals should aim to establish a rapport with bereaved persons that will allow them to consider their distinct characteristics, and by applying assimilation analysis professionals may gain a clearer understanding of the inner conflicts of the bereaved. Knowledge of suicide bereavement at the initial stage (and specifically, suicidal loss at three months post-death) can contribute to determining the most appropriate ways to alleviate the negative impacts of the complicated and unstable psychological states experienced, with possibilities for improving the mental health status of bereaved family members. Acknowledgments We would like to sincerely thank the research participant included in this article for generously sharing his lived bereavement experiences with us. 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. 16 OMEGA—Journal of Death and Dying 0(0) Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was supported in part by dissertation grants from the Faculty of Education and Psychology, University of Jyv¨ askyl¨ a. ORCID iD Yan Chen https://orcid.org/0000-0002-8322-1954 Aarno Laitila https://orcid.org/0000-0002-0865-520X References Andriessen, K. (2009). Can postvention be prevention? Crisis,30(1), 43–47. https://doi.org/10. 1027/0227-5910.30.1.43 Andriessen, K., & Krysinska, K. (2012). Essential questions on suicide bereavement and postvention. International Journal of Environmental Research and Public Health,9(1), 24–32. https://doi.org/10.3390/ijerph9010024 Bailley, S. E., Kral, M. J., & Dunham, K. (1999). Survivors of suicide do grieve differently: Empirical support for a common sense proposition. Suicide & Life-Threatening Behavior, 29(3), 256–271. https://doi.org/10.1111/j.1943-278X.1999.tb00301.x Basto, I., Stiles, W. B., Bento, T., Pinheiro, P., Mendes, I., Rijo, D., & Salgado, J. (2018). Fluctuation in the assimilation of problematic experiences: A case study of dynamic systems analysis. Frontiers in Psychology,9(8), 1–10. https://doi.org/10.3389/fpsyg.2018.01119. Begley, M., & Quayle, E. (2007). The lived experience of adults bereaved by suicide a phenomenological study. Crisis,28(1), 26–34. https://doi.org/10.1027/0227-5910.28.1.26 Bell, J., Stanley, N., Mallon, S., & Manthorpe, J. (2012). Life will never be the same again: Examining grief in survivors bereaved by young suicide. Illness Crisis and Loss,20(1), 49–68. https://doi.org/10.2190/IL.20.1.e Berman, A. L. (2011). Estimating the population of survivors of suicide: Seeking an evidence base. Suicide and Life-Threatening Behavior,41(1), 110–116. https://doi.org/10.1111/j. 1943-278X.2010.00009.x Brinegar, M. G., Salvi, L. M., Stiles, W. B., & Greenberg, L. S. (2006). Building a meaning bridge: Therapeutic progress from problem formulation to understanding. Journal of Counseling Psychology,53(2), 165–180. https://doi.org/10.1037/0022-0167.53.2.165 Castelli Dransart, D. A. (2013). From sense-making to meaning-making: Understanding and supporting survivors of suicide. British Journal of Social Work,43(2), 317–335. https://doi. org/10.1093/bjsw/bct026 Castelli Dransart, D. A. (2017). Reclaiming and reshaping life: Patterns of reconstruction after the suicide of a loved one. Qualitative Health Research,27(7), 994–1005. https://doi.org/10. 1177/1049732316637590 Cerel, J., Brown, M. M., Maple, M., Singleton, M., Venne, J., Moore, M., & Flaherty, C. (2019). How many people are exposed to suicide? Not six. Suicide and Life-Threatening Behavior, 49(2), 529–534. https://doi.org/10.1111/sltb.12450 Chen and Laitila 17 Cerel, J., Jordan, J. R., & Duberstein, P. R. (2008). The impact of suicide on the family. Crisis, 29(1), 38–44. https://doi.org/10.1027/0227-5910.29.1.38 Cerel, J., Maple, M., Aldrich, R., & van de Venne, J. (2013). Exposure to suicide and identification as survivor: Results from a random-digit dial survey. Crisis,34(6), 413–419. https:// doi.org/10.1027/0227-5910/a000220 Cerel, J., McIntosh, J. L., Neimeyer, R. A., Maple, M., & Marshall, D. (2014). The continuum of “survivorship”:Definitional issues in the aftermath of suicide. Suicide and Life-Threatening Behavior,44(6), 591–600. https://doi.org/10.1111/sltb.12093 Chakraborty, S., & Halder, S. (2018). Psychological sequelae in suicide survivors: a brief overview. Indian Journal of Social Psychiatry,34(2), 105–110. https://doi.org/10.4103/ijsp. ijsp Chan, T. M. S., & Cheung, M. (2020). The “men in grief”phenomenon among suicide bereaved Chinese men in Hong Kong. Death Studies.https://doi.org/10.1080/07481187.2020. 1855609. Chapple, A., Ziebland, S., & Hawton, K. (2015). Taboo and the different death? Perceptions of those bereaved by suicide or other traumatic death. Sociology of Health and Illness,37(4), 610–625. https://doi.org/10.1111/1467-9566.12224 Creswell, J. W., & Miller, D. L. (2000). Determining validity in qualitative inquiry. Theory Into Practice,39(3), 124–130. https://doi.org/10.1207/s15430421tip3903_2 Crosby, A. E., & Sacks, J. J. (2002). Exposure to suicide: Incidence and association with suicidal Ideation and behavior: United States, 1994. Suicide and Life-Threatening Behavior,32(3), 321–328. https://doi.org/10.1521/suli.32.3.321.22170 Cvinar, J. G. (2005). Do suicide survivors suffer social stigma: A review of the literature. Perspectives in Psychiatric Care,41(1), 14–21. https://doi.org/10.1111/j.0031-5990.2005. 00004.x de Groot, M. H., de Keijser, J., & Neeleman, J. (2006). Grief shortly after suicide and natural death: A comparative study among spouses and first-degree relatives. Suicide and LifeThreatening Behavior,36(4), 418–431. https://doi.org/10.1521/suli.2006.36.4.418 Dyregrov, K. (2011). What do we know about needs for help after suicide in different parts of the world? A phenomenological perspective. Crisis,32(6), 310–318. https://doi.org/10.1027/ 0227-5910/a000098 Flyvbjerg, B. (2006). Five misunderstandings about case-study research. Qualitative Inquiry, 12(2), 219–245. https://doi.org/10.1177/1077800405284363 Gaffney, M., & Hannigan, B. (2010). Suicide bereavement and coping: A descriptive and interpretative analysis of the coping process. Procedia - Social and Behavioral Sciences,5, 526-535. https://doi.org/10.1016/j.sbspro.2010.07.137. Hall, C. (2014). Bereavement theory: Recent developments in our understanding of grief and bereavement. Bereavement Care,33(1), 7–12. https://doi.org/10.1080/02682621.2014. 902610 Henry, H. M., Stiles, W. B., Biran, M. W., Mosher, J. K., Brinegar, M. G., & Banerjee, P. (2009). Immigrants’continuing bonds with their native culture: Assimilation analysis of three interviews. Transcultural Psychiatry,46(2), 257–284. https://doi.org/10.1177/ 1363461509105816 18 OMEGA—Journal of Death and Dying 0(0) Hibberd, R., Elwood, L. S., & Galovski, T. E. (2010). Risk and protective factors for posttraumatic stress disorder, prolonged grief, and depression in survivors of the violent death of a loved one. Journal of Loss and Trauma,15(5), 426–447. https://doi.org/10.1080/ 15325024.2010.507660 Honos-Webb, L., Greenberg, L. S., & Stiles, W. B. (2003). A method of rating assimilation in psychotherapy based on markers of change. Journal of Counseling Psychology,50(2), 189–198. https://doi.org/10.1037/0022-0167.50.2.189 Honos-Webb, L., Lani, J. A., & Stiles, W. B. (1999). Discovering markers of assimilation stages: The fear-of-losing-control marker. Journal of Clinical Psychology,55(12), 1441–1452. https://doi.org/10.1002/(SICI)1097-4679(199912)55:12<1441::AID-JCLP3>3.0.CO;2-k Honos-Webb, L., & Stiles, W. B. (1998). Reformulation of assimilation analysis in terms of voices. Psychotherapy,35(1), 23–33. https://doi.org/10.1037/h0087682 Honos-Webb, L., Stiles, W. B., Greenberg, L. S., & Goldman, R. (1998). Assimilation analysis of process-experiential psychotherapy: A comparison of two cases. Psychotherapy Research, 8(3), 264–286. https://doi.org/10.1080/10503309812331332387 Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. American Journal of Clinical Hypnosis,36(3), 222-225. https://doi.org/10.1080/00029157. 1994.10403078 Jordan, J. R. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide and Life-Threatening Behavior,31(1), 91–102. https://doi.org/10.1521/suli.31.1.91.21310 Jordan, J. R. (2008). Bereavement after suicide. Psychiatric Annals,38(10), 679–685. https://doi. org/10.3928/00485713-20081001-05 Jordan, J. R., & McIntosh, J. L. (2011). Is suicide bereavement different? A framework for rethinking the question. In J. R. Jordan & J. L. McIntosh (Eds.), Grief after suicide: Understanding the consequences and caring for the survivors (pp. 19–42). Routledge. https://doi.org/https://doi.org/10.4324/9780203886045-12 Kõlves, K., Zhao, Q., Ross, V., Hawgood, J., Spence, S. H., & de Leo, D. (2019). Suicide and other sudden death bereavement of immediate family members: An analysis of grief reactions six-months after death. Journal of Affective Disorders,243(8), 96–102. https://doi. org/10.1016/j.jad.2018.09.018 Laitila, A., & Aaltonen, J. (1998). Application of the assimilation model in the context of family therapy: A case study. Contemporary Family Therapy,20(3), 277–290. https://doi.org/10. 1023/A:1022460711560 Lukas, C., & Seiden, H. M. (2007). In Rev (Ed.), Silent grief : living in the wake of suicide. Jessica Kingsley Publishers Mair, M. (1977). The community of self. In D. Bannister (Ed.), New perspectives in personal construct theory (pp. 125–149). Academic Press Mckinnon, J. M., & Mckinnon, J. M. (2014). Exploring the formal supports used by people bereaved through suicide: A qualitative study. Social Work in Mental Health,12(3), 231–248. https://doi.org/10.1080/15332985.2014.889637 McLeod, J. (2010). Case study research: In counselling and psychotherapy. Sage. https://doi.org/ 10.4135/9781446287897. Chen and Laitila 19 Mitchell, A. M., Kim, Y., Prigerson, H. G., & Mortimer-Stephens, M. K. (2004). Complicated grief in survivors of suicide. Crisis,25(1), 12–18. https://doi.org/10.1027/0227-5910.25.1. 12 Moore, S. C., Osatuke, K., Howe, S. R., Moore, S. C., Osatuke, K., & Veterans, U. S. (2014). Assimilation approach to measuring organizational change from preto post-intervention. World Journal of Psychiatry,4(1), 13–29. https://doi.org/10.5498/wjp.v4.i1.13 Nam, I. (2016). Suicide bereavement and complicated grief: Experiential avoidance as a mediating mechanism. Journal of Loss and Trauma,21(4), 325–334. https://doi.org/10.1080/ 15325024.2015.1067099 Nelson, B. J., & Frantz, T. T. (1996). Family interactions of suicide survivors and survivors of non-Suicidal death. Omega: Journal of Death and Dying,33(2), 131–146. https://doi.org/ 10.2190/3aq4-kuqe-kj4r-8q89 Osatuke, K., Glick, M. J., Stiles, W. B., Greenberg, L. S., Shapiro, D. A., & Barkham, M. (2005). Temporal patterns of improvement in client-centred therapy and cognitive-behaviour therapy. Counselling Psychology Quarterly,18(2), 95–108. https://doi.org/10.1080/ 09515070500136900 Osatuke, K., Reid, M., Stiles, W. B., Kasckow, J. W., Zisook, S., & Mohamed, S. (2011). Narrative evolution and assimilation of problematic experiences in a case of pharmacotherapy for schizophrenia. Psychotherapy Research,21(1), 41–53. https://doi.org/10.1080/ 10503307.2010.508760 Osatuke, K., & Stiles, W. B. (2006). Problematic internal voices in clients with borderline features: An elaboration of the assimilation model. Journal of Constructivist Psychology, 19(4), 287–319. https://doi.org/10.1080/10720530600691699 Penttinen, H., & Wahlstr¨ om, J. (2013). Progress in assimilation of problematic experience in group therapy for social phobia: A subgroup analysis. Journal of Contemporary Psychotherapy,43(2), 123–132. https://doi.org/10.1007/s10879-012-9227-3 Penttinen, H., Wahlstr¨ om, J., & Hartikainen, K. (2017). Assimilation, reflexivity, and therapist responsiveness in group psychotherapy for social phobia: A case study. Psychotherapy Research,27(6), 710–723. https://doi.org/10.1080/10503307.2016.1158430 Peters, K., Cunningham, C., Murphy, G., & Jackson, D. (2016). Helpful and unhelpful responses after suicide: Experiences of bereaved family members. International Journal of Mental Health Nursing,25(5), 418–425. https://doi.org/10.1111/inm.12224 Ross, V., Kõlves, K., Kunde, L., & de Leo, D. (2018). Parents’experiences of suicidebereavement: A qualitative study at 6 and 12 months after loss. International Journal of Environmental Research and Public Health,15(4), 618. https://doi.org/10.3390/ ijerph15040618 Runeson, B., & ˚ Asberg, M. (2003). Family history of suicide among suicide victims. American Journal of Psychiatry,160(8), 1525–1526. https://doi.org/10.1176/appi.ajp.160.8.1525 Shneidman, E. S. (1972). Survivors of suicide. Charles C Thomas Shneidman, E. S. (1973). Deaths of man. Quadrangle Spillane, A., Larkin, C., Corcoran, P., Matvienko-Sikar, K., & Arensman, E. (2017). What are the physical and psychological health effects of suicide bereavement on family members? 20 OMEGA—Journal of Death and Dying 0(0) Protocol for an observational and interview mixed-methods study in Ireland. BMJ Open, 7(3), e014707. https://doi.org/10.1136/bmjopen-2016-014707 Stiles, W. B. (2007). Theory-building case studies of counselling and psychotherapy. Counselling and Psychotherapy Research,7(2), 122–127. https://doi.org/10.1080/14733140701356742 Stiles, W. B., & Angus, L (2001). Qualitative research on clients’assimilation of problematic experiences in psychotherapy. Psychotherapy: Theory, Research, Practice, Training,38(4), 462–465. https://doi.org/10.1037//0033-3204.38.4.462 Stiles, W. B., Elliott, R., Llewelyn, S. P., Firth-Cozens, J. A., Margison, F. R., Shapiro, D. A., & Hardy, G. (1990). Assimilation of problematic experiences by clients in psychotherapy. Psychotherapy,27(3), 411–420. https://doi.org/10.1037/0033-3204.27.3.411 Stiles, W. B., Morrison, L. A., Shapiro, D. A., Firth-cozens, J., Shapiro, D. A., & Firth-Cozens, J. (1991). Longitudinal study of assimilation in exploratory psychotherapy. Psychotherapy Research,28(2), 195–206. https://doi.org/10.1037/0033-3204.28.2.195 Stiles, W. B., Osatuke, K., Glick, M. J., & Mackay, H. C. (2004). Encounters between internal voices generate emotion: An elaboration of the assimilation model. The Dialogical Self in Psychotherapy, 91-107. https://doi.org/10.4324/9780203314616. Sveen, C.-A., & Walby, F. A. (2008). Suicide survivors’mental health and grief reactions: A systematic review of controlled studies. Suicide and Life-Threatening Behavior,38(1), 13–29. https://doi.org/10.1521/suli.2008.38.1.13 Talseth, A. G., & Gilje, F. L. (2017). Liberating burdensomeness of suicide survivorship loss: A critical interpretive synthesis. Journal of Clinical Nursing,26(23–24), 3843–3858. https:// doi.org/10.1111/jocn.13797 Tikkanen, S., & Leiman, M. (2014). Resolution of an impasse at a network meeting: Dialogical sequence analysis of the use of a shared formulation. Counselling Psychology Quarterly, 27(2), 154–173. https://doi.org/10.1080/09515070.2013.873859 Tikkanen, S., Stiles, W. B., & Leiman, M. (2013). Achieving an empathic stance: Dialogical sequence analysis of a change episode. Psychotherapy Research,23(2), 178–189. https:// doi.org/10.1080/10503307.2012.752115 Wilson, J. (2011). The assimilation of problematic experiences sequence: An approach to evidence-based practice in bereavement counseling. Journal of Social Work in End-Of-Life and Palliative Care,7(4), 350–362. https://doi.org/10.1080/15524256.2011.623468 Wood, L., Byram, V., Gosling, A. S., & Stokes, J. (2012). Continuing bonds after suicide bereavement in childhood. Death Studies,36(10), 873–898. https://doi.org/10.1080/ 07481187.2011.584025 Wrobleski, A. (1991). Suicide: Survivors—a guide for those left behind. Afterwords Publishing. Zhang, J., Tong, H., & Zhou, L. (2005). The effect of bereavement due to suicide on survivors’ depression: a study of Chinese samples. OMEGA - Journal of Death and Dying,51(3), 217–227. https://doi.org/ezproxy.jyu.fi/10.2190/496B-Q1WQ-K9TJ-518E Author Biographies Yan Chen and Aarno Laitila are currently at the Department of Psychology, Faculty of Education and Psychology, University of Jyv¨ askyl¨ a, Finland. Chen and Laitila 21