A suicide bereavement model: based on a meta-ethnography of the experiences of adult suicide loss survivors
PMCID: PMC12301309
PMID: 40726943
Abstract
Introduction The annual suicide death rate is c.760,000 therefore, using the widely accepted estimate of 135 people being exposed to each suicide, the worldwide annual exposure rate is over 100 million. While male suicide-loss survivors (SLSs) are equally exposed, the vast majority of suicide bereavement research includes a large majority of female participants. Methods Following the eMERGe and PRISMA guidelines, a meta-ethnography (systematic review of qualitative studies) was carried out to assess historical research into suicide-loss survivorship. Seven data sources were searched, up to 30-Nov-2022, for peer-reviewed studies, written in English, that used identifiable and interpretative qualitative methods, had at least 50% male participation, and offered a valuable contribution to the synthesis. Results Overall, 1,645 records were screened, and 15 reports of included studies assessed. Eight main themes were identified: changed forever, trauma, stigmatization, protector, lost futures, lost in plain sight, societal norms, and dualities. Via line of argument synthesis, and considering the broader literature, a model for suicide bereavement, applicable to all, is proposed that brings together the gamut of pertinent factors into an integrated framework. Discussion The model could be used in practice (clinical, therapy/counseling, education) to enable better understanding of the highly complex and interwoven components of suicide bereavement, thereby facilitating improved and extended services available to SLSs that are more in-tune with their needs. While the model cannot confer full comprehension of suicide bereavement, it can go a long way to assist those looking to assist SLSs by providing a platform for dialogue and empathy.
Full Text
This study was carried out as part of an overall research program investigating postvention (bereavement support) uptake and effectiveness in UK and Ireland adult males bereaved by suicide. The term “suicide loss survivor” (SLS) is utilized in this article as it is being increasingly used for those who have experienced the suicide of a close family member, or a friend, and face persistent, distressing trauma (1). It is thereby differentiated from survivors of suicide attempts. Against a backdrop of c. 760,000 annual suicide deaths globally (2), based on UK (3–5) and Ireland (6) government suicide statistics, annual suicides total approximately 7,500 with male suicide being three to four times more prevalent than female suicide. However, the UK is one of several countries where it has been suggested that the coronial system could result in a 15–50% underestimation of suicide as the officially determined cause of death. This has been associated with SLS pressure on the coroner, the coroner's inherent wish to protect SLS from the associated stigma and, most importantly, coronial reticence to declare deaths as suicide reflective of the legacy of deemed criminality (7). This may have been mitigated, more recently, by the standard of proof for suicide deaths, in England and Wales, being lowered to the civil standard of being on “the balance of probabilities,” from “beyond all reasonable doubt,” in 2018 (8). In the period 2000–2019, Ireland was in keeping with a global trend of declining suicide rates but the numbers for the UK increased, although not statistically significantly (2). The number of people bereaved by suicide annually, across the world, has been estimated at 48 million (9). Using an annual global suicide figure of 700,000 (noted in the same paper) the corresponding annual suicide exposure level, on a ratio basis, would be approximately 480,000 for the UK and Ireland. Using the estimate of 135 people being exposed to each suicide (10), the UK and Ireland annual exposure rate to suicide is 945,000. Results of a UK-wide survey indicated that 77% of participants (including professionals and those that lost friends) were majorly affected by losing a loved one to suicide, with half reporting mental health issues, 38% contemplating suicide, and 8% attempting suicide, directly related to their bereavement by suicide (11). Similarly, a survey conducted in Ireland found that 93% of SLS noted a moderate or major impact on their lives with mental health issues (56%), relationship struggles and alcohol abuse being typical factors, and 35% considering self-harm or suicide (12). A recent systematic review of the psychosocial impact of suicide bereavement on men highlighted their increased risk of suicide and mental health problems, plus issues with relationships and social interactions, over men not bereaved by suicide (13). Furthermore, a systematic review of postvention service models, between 2014 and 2019, found that, generally, studies of suicide bereavement support services had 80–91% female participation (14). However, evidence also suggests that there is no correlation between parental gender (or that of a child lost to suicide) and depression and grief (15). Similarly, no gender differences were found relating to siblings' suicide loss (16) or partner suicide loss, with both genders experiencing reduced life expectancy, higher rates of divorce, children in care, sick leave, and unemployment (17). Yet, despite encountering similar levels of grief and emotional distress to female SLS, male SLS seek help far less frequently. It has also been noted that the impact and management approaches of suicide bereavement interventions vary by gender, with the inadvertent emphasis on the effectiveness of postvention in largely female samples, thereby introducing a major gap in both postvention activities and the literature regarding men (18). In addition to SLS being prone to mental health issues and at increased risk of suicide themselves (19), understanding psychosocial influences, with appropriate interventions, has also been shown to be effective in lessening both suicidal behaviors and the likelihood of attempts (20). Therefore, men are typically not receiving much needed, proven, support to help them cope with their losses.
There are several approaches to qualitative evidence synthesis which have been collated, summarized, and “the state of the method” assessed (21). To achieve the intended objectives of this study, a method was required that goes beyond aggregation of themes but, rather, one which is interpretive of the underlying concepts facilitating creation of an overview regarding the fundamental issues faced by adult males bereaved by suicide. This reflects the two essential components of meta-ethnography, in viewing the source information as metaphorical, rather than literal, and translation of studies into each other during the synthesis (22). This approach allows for a derivation of commonality and the development of constructs that represent the dataset, as a whole, but may not individually be apparent in any of the studies included (23).
The search strategy involved retrieving records that describe the lived experience of adult males bereaved by suicide. The purpose of the search terms was to capture records covering suicidality, aspects of grief or bereavement, relationships to those lost, male involvement, and various types of qualitative study. Wildcards were used to capture linguistic variations, for example “grie*” allowing retrieval of records that describe grief or grieving. The search strategy was honed via multiple searches of the Academic Elite database. In conjunction with the research team and the [University of West London] specialist librarian, the following data sources were searched: Academic Search Elite, CINAHL Complete (Cumulated Index to Nursing and Allied Health Literature), Medline, PsycARTICLES, PsycINFO, ProQuest, and Google Scholar. These were selected as they are frequently used in psychological research and provide a broad coverage of relevant publishers. Each data source was searched independently, as they are indexed differently, and the search strategy was refined based on the initial output generated from the individual sources (see Supplementary material A for the complete search strategy).
The searching of ProQuest was constrained by two of the primary terms, relating to suicidality and bereavement, plus limited to abstracts and the Google Scholar searches were of article titles only. Both measures were necessary to eliminate many thousands of extraneous hits and home in on the target records. The searches were set to return only English language records, to avoid interpretation bias, but no timeframe was set other than a publication date up to and including the end of November 2022. There was no exclusion based on geography. All the studies included in this meta-ethnography had a significant level of male participation (50% or above) and similar aims, in terms of looking to elucidate how the experiences related to suicide-loss shape those left behind (see Supplementary material A for the complete search criteria).
The overall approach adopted is compliant with that advocated by the “STARLITE” guidance which calls for the clear definition of the “sampling strategy, type of study, approaches, range of years, limits, inclusion and exclusions, terms used, electronic sources,” reflecting the mnemonic and intended to provide a standard for reporting literature searches (24).
To mitigate any inherent bias, in their consideration, the studies included in this meta-ethnography have been presented alphabetically by author [save for Ross et al. (25), which is embedded under Entilli et al. (26), as it is an earlier report of the same study]. The comparison of papers was then initiated by using the first study with each of the following studies being assessed against all those preceding (27). The analysis was conducted by Author #1 and cross-validated by Authors #2 and #3. All authors agreed that the themes and interpretative framework were embedded in the data and provided a meaningful interpretation of SLS's experiences.
Studies were included that offered a valuable contribution to the synthesis. This is a subjective appraisal but is in keeping with meta-ethnographic practice (28). When conducting a meta-ethnography, it is common for the quality of the included studies not to be a basis for exclusion prior to the synthesis (27) and this was the case herein. There is no defined standard for assessing the quality of studies included in a meta-ethnography (29). For the purposes of this meta-ethnography, the CASP Qualitative Studies Checklist (30) was employed which consists of 10 questions. Application of these questions facilitated evaluation of studies based on key parameters, including methods, congruity of method with the aims and analysis, ethics, comprehensibility, and value in terms of adding to existing knowledge. Questions reflect three aspects of the quality review with items one to six focused on validity, seven to nine on the results, and 10 on the study value. This framework has been effectively used in other meta-ethnographies (27) where each study is assessed against nine questions, for specific aspects of quality, with ratings of “yes,” “can't tell,” or “no,” plus observations on the value of the research undertaken and overall comments. The studies were all assessed by Author #1 with the other two members of the team each reviewing a random sample. Any divergence of opinion was resolved through dialogue.
Meta-ethnography is a method for synthesis of purely qualitative studies, but it allows for a range of study designs to be included. Its systematic approach facilitates generation of insights into experiences and derivation of impressions and models that can inform both future research and real-world policy and practice (31). While meta-ethnography is an intricate method, and time-consuming, it is well suited for application to primary studies that contain rich data and are highly interpretative (31).
This meta-ethnography adhered to the PRISMA 2020 guidelines for systematic reviews (32). All data and research materials (including our manual coding scheme) are available upon request. This review was not preregistered. Historically, meta-ethnographies have often lacked an audit trail, but standards, such as the eMERGe reporting guidance (33) employed herein, providing structure and aimed to enhance quality, robustness, and reliability, address that potential limitation (21).
Figure 1 depicts the full screening process in line with the current PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guideline (32). It is based on the 2020 version of the PRISMA Flow Diagram template. One report retrieved (26) describes a longitudinal study of parents bereaved by suicide assessed at 6, 12 and 24 months after their losses. A prior report (25) is based on the same study but only covered the 6- and 12-month assessments. Both studies met the inclusion criteria set for the review but, following the latest PRISMA guidance on how this should be reported on the flow diagram, this represents a single included study and increases the “Reports of included studies” by one (34). Overall, based on consensus reached by the review team, 13 papers were included in the meta-ethnography arising from the database searches and two from the manual searches.
The quality assessment of the 14 studies indicated that, despite minor issues, all of them can be relied upon as valid data sources.
All the included studies were conducted since 2010, with most (10/14) being from 2017 onwards. A summary of the key characteristics, from each included study, is presented in Table 1. Together, the two articles mapping to a single study are one of three Australian papers (#6 plus #7, and #1). Other geographies represented are Africa (1: Nigeria (#13)), Asia (4: China (#5), Hong Kong (#4), South Korea (#11), and Pakistan (#2)), Europe (4: England (#12), Germany (#3), Ireland (#9), and Poland (#15)) and North America (2: Canada (#8 and #14)). Cultures vary across these regions and/or sub-populations within them and, of the countries represented, suicide remains illegal in two countries (Nigeria and Pakistan). Eight of the 14 studies (#1, #2, #6 plus #7, #9, #12, #13, and #15) had both male and female participants while the remainder (#3, #4, #5, #8, #10, #11, and #14) included only men, with four of them based on a single participant (#3, #5, #10, and #11). The ages of participants were not supplied for three of the studies (#2, #5, and #12). Where ages were provided, many (6/14) included middle-aged to older participants (#3, #6 plus #7, #8, #11) with some (#4, #9, #13, #14, and #15) including a broad range of ages (4/14), and only two having exclusively younger participation (#1, and #10). Socio-economic background was not provided in most studies, but some did include specific information on the participant(s). In one (#10), it was noted that the individual was part of a family that had immigrated from a non-English speaking country and that they had experienced domestic violence, with a backdrop of financial difficulties. In the Nigerian study (#13) it was recorded that population, from which the sample was drawn, had strong literacy and religiosity, with employment primarily across agriculture, commerce, and the civil service. In the study conducted in China (#5), it was recorded that the participant was recruited from a bereavement support group in a city which is economically developed.
*Ross et al. (25) is a report of an included study (PRISMA) with respect to Entilli et al. (26).
Most studies (#1, #2, #4, #5, #6 plus #7, #9, #11, #12, #13, and #15) collected data via semi-structured interviews (10/14). Data collection for one (#9) was unclear but an examination of the larger study of which it is a component (but not part of this meta-ethnography) implies that this was also via semi-structured interviews (35). Two studies (#8 and #14) employed photovoice interviews, and one was based on the psychotherapy notes for an individual (#3). The procedure, for the psychotherapy study (#3), also notes that the verbatim transcript was translated into English but no issues with this were mentioned. The authors of the study conducted in Poland (#15) noted that the participant quotes were translated from Polish into English and that some fidelity may have been lost due to the resulting text losing a degree of coherence, in some instances.
The outcome of the translation process, involving iterative review of all the studies to assess for concepts consistent across them (reciprocal) or those that differ or are conflicting (refutational) and the subsequent interpretation to create novel themes (line of argument), is encapsulated in Table 2, in which, after a synopsis of each individual study, the cumulative concepts are listed. This reflects the research program's aim of understanding the broad impacts of suicide bereavement. Importantly, this table is not merely a list of themes, but attempts to portray the underlying, cohesive concepts arising from each study, and an amalgamation thereof.
*Ross et al. (25) is a report of an included study (PRISMA) with respect to Entilli et al. (26).
When considering how studies are related to each other, originally characterized as metaphors to capture derived meaning across studies (28), more recently, such amalgamations have been described as storylines, which can help identify sub-sets, commonalities, and conflicts (22). No concepts, across the 15 papers, were found to refute each other. Concepts shared across papers were mostly reciprocal. A line of argument (28), or framework for interpretation was developed which is described below.
Following a method described elsewhere (27, 36), the 14 studies were tabulated to facilitate comparisons of the main concepts identified in each one (Table 3). For ease of review, only the main themes from each study have been included in the table and their descriptions abbreviated and/or paraphrased for fit. However, the full articles, including detailed analyses, findings and discussions, were examined during the translation process. With the proviso that, by their very nature, published studies included a selected set of quotations intended to represent the participants' experiences, such reflections in meta-ethnography are considered first-order constructs, and are typically located in the analysis or results sections of the articles. How participants' perceptions were interpreted by the study authors, are considered as second-order constructs, and usually described in the discussion sections. New concepts, synthesized from first and second order constructs, are deemed third-order constructs (37) and derived as part of the meta-ethnography analysis. From first, second and third order constructs, a line of argument can be generated: a framework of interpretation. Generation of a line of argument comprises an expanded comprehension of the underlying constructs to produce an extended or novel concept (22, 36). To illustrate the analysis, participants' quotations (first-order constructs) are presented in italics using quotations marks, whilst the authors' interpretations (second-order construct) are displayed using quotations marks only:
Table 3 reflects the reciprocal translations of the 14 contributing studies (15 papers). The first- and second-order constructs, included in the table, are representative and not exhaustive. The analysis identified eight concepts (third-order constructs), derived from eight themes (second-order constructs) which were used to generate an all-encompassing new “Suicide Bereavement Model” (line of argument). These concepts (themes) are: changed forever (impact), trauma (distress), stigmatization (blame), protector (responsibility), lost futures (memorialization), lost in plain sight (healthcare and support), societal norms (culture), and dualities (inner conflicts). The model demonstrates how these concepts interplay to reflect a shared core, inherent continuum of devastation mediated, and moderated, by external elements and competing drivers and factors such as relationships (to those lost and fellow SLS), culture, and timeframe (Figure 2). Other research has modeled aspects of the grief associated with suicide loss, from the perspectives of meaning-making and relationships to the deceased, the self and others (39) but the authors are not aware of any model that has holistically encompassed the multitude of factors associated with suicide bereavement.
The far-reaching, and long-standing, impacts of suicide bereavement with, at its core, the permanency of its life-changing implications, are the basis of the model (line of argument) constructed to describe, and contextualize, the synthesis of concepts gleaned from the 14 studies. This is encapsulated visually in Figure 2, and is proposed to be transferable, fitting suicide bereavement regardless of gender, demographics, relationship to the person lost, timeframe and culture. The proposed model is intended to represent the factors that influence adult SLS' cognitive and behavioral changes when experiencing bereavement by suicide, based on the 14 studies assessed. The deep-seated and fundamental modification to SLS' world view is manifestly impacted by key factors that pervade their lives. There is the emotional shock, often exacerbated by underlying issues and/or prior events, and entrenched grief, intensified by blame (externally and/or internally generated) which frequently results in stigmatization. While SLS struggle to cope with their losses, they may also constantly yearn for futures they can never attain with an associated sense of failure, regarding the safety of those lost, and foreboding, regarding others close to them, which can lead to a constant self-doubt of their capabilities to shield those they love. Surrounding all these very strong reactions, SLS may not get appropriate support, or acknowledgment of the impacts on their health, and feel constrained to outwardly project a level of normality, in their everyday lives, that masks their real, and deep-rooted, psychological state. This is driven by factors including culture, religion, and what they perceive to be expected of them by society, as a whole, or components thereof, such as family members, the workplace and community leaders. The combined pressure of all of these factors, bearing on them in unison, can result in SLS experiencing constantly competing perspectives regarding the circumstances of their bereavements.
The aim of this meta-ethnography was to identify prior qualitative research which summarizes current knowledge on how adult males cope with, and adapt to, bereavement by suicide. Overall, the findings suggested that men coped by both extracting meaningfulness and protecting themselves by emotionally separating from the event. While these studies suggest recognized “masculine-style” of grieving, such as stoicism, fatalism, anger, and over-working, they did not get to the essence of what makes men deal with suicide differently from a “conventional-style” of grieving, typified by women, whereby grievers more openly share their feelings and, consequently, received greater support (40). The Suicide Bereavement Model, described herein, is proposed as being applicable to all adults due to the translation synthesis, core to the meta-ethnography, indicating that the included studies support a pertinent line of argument, from which the model is derived, regardless of gender. Of the papers where participation was limited to men (#3, #4, #5, #8, #10, #11, and #14) the focus was on individuals or narrowly targeted groups. Of the studies including males and females (with at least 50% male participation), very little was noted as specifically attributable to men, and the nature of thematic illumination lends itself to inclusion of participants quotes that best exemplify each theme, often masking whether, or at least not amplifying, any trends in gender alignment with the aspects under review. Overall, based on the information gleaned from the 14 studies that fell into the meta-ethnography, despite some instances of male survivors demonstrating stoicism and assuming the role of protector, it was considered that the syntheses and line of argument are equally applicable to men and woman, as some papers indicated the similar traits emerged in female participants. Therefore, the discussion, and associated Suicide Bereavement Model, is proposed to be applicable regardless of gender.
The review findings reveal that suicide bereavement is complex and has many interwoven facets. These wax and wane, interact, and can have differing individual or collective impacts on SLS' capabilities to adapt and cope, in the immediate term after their loss, but also for many years to come, as they struggle to derive any meaning. In that, the overall impact of bereavement by suicide changes SLS' view of the world, and is interwoven into their belief system, attitudes, and daily behaviors, it can be regarded as a form of embodied biographical disruption (41). The complexity regarding SLS' drives and needs, with respect to making meaning out of their losses, has been noted elsewhere (42). That said, even as those bereaved by suicide process their losses and re-shape their lives, the evidence, herein and in the literature, suggests how they handle their grief is far from linear (43, 44). Rather grief intensity can fluctuate and be reactivated by both internal and external stimuli. While some SLS demonstrate personal growth, partly characterized by strengthening existing relationships and facilitating forging new ones (45), over time, some are often fundamentally lonely (46) and locked into negative patterns of “prolonged grief” (47)—now recognized as a mental health condition, evolving from what was previously described as “complicated grief” (48). Indeed, the combined shifts in SLS' perceptions, experiences, and personal reassessments of every aspect of their lives, are very common resulting in their lives being changed forever.
Following suicide bereavement, typically “acute grief” manifests as powerful and disturbing trauma. Psychological shock can be protective, in the short to mid-term, and prevent an individual from being overwhelmed with gloom and desolation. This can allow them to deal with the administrative aspects of death such as registrars, funeral directors, travel, and finances (49). While it has been suggested the difference between suicide bereavement and other types is negligible (50), others have argued that it is very much different, supporting that those bereaved by suicide experience psychological distress above and beyond that associated with other types of loss (19, 51). Men's expression of grief may be delayed, with respect to that of women (52). SLS can feel as if they also lost part of themselves when their loved ones took their own lives (53, 54). In keeping with some of the studies that form part of this meta-ethnography (Papers #3, #10, and #12), it has been observed that other traumas, in the lives of the those bereaved, can significantly impact how they deal with a loss to suicide (55). The trauma, related to suicide, is not limited to individuals but plays out within, and across, family and social constructs (56, 57). However, the majority of studies on suicide focus on specific relationships to those lost (58). Little is known regarding the overall dynamics and how suicide loss impacts generationally (59). Suicide-related trauma can be exacerbated by the bereaved feeling isolated individually (60) or as a family (61) and can be compounded by pre-existing trauma (62). Bereavement by suicide can lead some SLS to question their own existence and undermine their prior value systems (43, 63).
The stigma associated with suicide is widely recognized as an issue for SLS (64). Where decedents had known mental health issues and/or prior suicide attempts, stigmatization can be prevalent even before their losses (65). SLS sense that, generally, people do not perceive suicide as something that can happen in their families, and the families where it does occur are somehow blighted (66). The bereaved can be viewed as sullied by their loved one's suicide, with outsiders assuming mental illness pervades the family, and that it must be prone to suicidality (67). In some cultures, stigmatization of SLS can arise, and be very strong, within families and communities, as noted in a couple of the studies included is this meta-ethnography (Papers #2 and #13) and elsewhere (61, 68). The potential sequelae of suicide bereavement can further lead to stigmatization, as noted for sufferers of prolonged grief disorder (69). Not only are SLS subject to external stigma, but they may also internalize the unempathetic and judgmental opinions of others (70), thereby attributing to themselves blame, and subsequently shame; such self-stigmatization can lead to SLS adopting non-adaptive thinking and behavior (67). Perceived blame can intensify the negative connotations of suicide loss and magnify the suffering of SLS (71, 72). All facets of blame, in combination, can be exacerbated by inaccurate and inconsiderate media coverage (73).
As noted in the findings of several of the 14 included studies, SLS often berate themselves for failing to protect their decedents (Papers #3, #4, #8 and #10). This has also been reported elsewhere (74). The assumption of the role as protector, to other SLS, was also noted (Papers #1, #4, #6, #9, #10, #12, and #13) and has been observed more broadly, including female SLS “directing from the shadows” (75) and SLS looking to rescue others in potential suicidal stress (76). With respect to parents that had lost a child, one paper (#6) reported that fathers assumed the role of protector, with respect to their partners, as they perceived the latter requiring support above and beyond their own needs. Elsewhere, men have also been noted to assume the role of carer, toward their female SLS partners and families (13). Where striving for such safeguarding results in SLS becoming hypervigilant, or overprotective, there is an increased emotional burden to bear, on top of individual's own grief (56).
While SLS grieve intensely, related to the loss of a loved one to suicide, and its aftermath, they also speculate on what might have been in terms of their decedent's potential achievements, time and activities they could have shared, and the children they will never have (53, 54). These aspects can also cause an extension and prolongation to their grief (43). SLS often have a strong desire to keep the memories of those they have lost alive and close to them. While generally beneficial, this has been found to add distress where they could not maintain a cohesive bond, due to loss of mementos, waning memories, or a sense that they have lost control of how their relationship to their decedent is manifested (77). Increasingly, memorialization of those lost to suicide is via social media and online platforms (44). While this aspect of grief management is relatively new, there has been research suggesting mixed effects, with indications that SLS can both find an outlet for their emotions and maintain a virtual relationship with the loved one lost via dynamic media (78), but that commemorative internet sites can exacerbate anguish due to a resulting exacerbation of emotional stress (79).
Somewhat as a result of the persistent taboo around suicide, SLS tend to adopt a façade of normality hiding, or even denying, their true feelings (54) with men being more prone to, or even primed for, emotional concealment (80). Such a persona may be maintained in public, but the mask sometimes drops in the context of peer support (81). SLS can be overwhelmed and struggle to relate their level of devastation to those not in the same situation (82) and maintenance of a pretense of not needing help, or a lack of trust in the provider, may result in those bereaved lacking much needed support (83). Men are often unwilling to consult professionals for fear of being perceived as ineffectual and incapable (52). Also, due to suicide not being openly discussed, SLS may be unaware of its prevalence thereby missing the opportunity of support from others similarly afflicted (84). Men are generally assumed to be outwardly more stoic and are noted to use avoidance, such as a focus on work (85) or increased alcohol consumption (86), as part of their grieving pattern. This, though, can be the perpetuation of a gender stereotype and lead to them perceiving that their needs are being ignored (52). Overall, the lack of attention to SLS' needs can create a scenario where they live “under the radar” as they continue to be faced with significant turmoil, in relation to both themselves and those around them, encompassing their role as a protector, the potential futures lost to them by the suicide, stigmatization, and on-going trauma. SLS are prone a variety of mental health issues that have been found to vary by gender, with men being less likely to seek help (87) and their needs not being identified in healthcare policy setting (80). Research has also identified an increased risk of physical ailments in SLS (88) however, they may be less likely to engage with healthcare services if they perceive that those providers did not meet the needs of those lost to suicide (38, 89). In some cases, organizations can lack empathy (46) and be misaligned with the requirements of the bereaved, with healthcare professionals demonstrating a lack of thought and awareness (90) or frustrating SLS by not providing much needed information (91).
The model depicting the multi-faceted negative experiences of SLS, presented herein, does strongly disagree with the notion of a linear nature to grief and bereavement, and other studies have also indicated that suicide bereavement is very much non-linear (92), despite SLS being pressurized, by external expectations to adhere to a broadly accepted sequence of stages exemplified by linear grief models (93). A recent systematic review of male suicide bereavement studies noted that men often experience marked grief responses but are constrained by the accepted customs and anticipated masculine behaviors in society (13). Several of the 14 included studies noted contextual social and cultural taboos, regarding openness and acknowledgment of suicide, with some highlighting deeply rooted negativity and denial (Papers #4 and #13). The level of repudiation seemed to reflect cultural hostility toward suicide, and SLS, and encompassed religiosity. Taboos can be faced at a family level, where members refuse to engage in a dialogue regarding a suicide (71), or can be at a cultural level, driven by the fear of repercussions and/or religious dogma (68, 94). The latter is exacerbated with suicide remaining an illegal act in many countries (95). Losing someone to suicide has been found to both enhance religious beliefs and diminish them, depending on the individual (96). Lack of empathy toward SLS, as a broad cohort, can lead to disenfranchised grief (44) and the judgement by others may be part of an overall stereotyping of bereaved families as being somehow broken or dysfunctional (61, 67). The need for better education, and a shift in societal attitudes, has been noted as necessary for SLS to receive both compassion and meaningful support (97).
Some of the papers assessed (Papers #2, #6, #8 and #9) suggested their findings exemplified the Dual Process Model of Bereavement's oscillation between factors associated with loss and those that help restore the bereaved to a level of normality (98). The model herein is not in conflict with it, as the “dualities” described here could reflect the “oscillations,” between “loss-oriented” and “restoration-oriented” behaviors, portrayed in the Dual Process Model. That said, the proposed model suggests that the experience may in fact be more intricate, in that SLS may not necessarily find themselves gravitating to either pole, at any given point in time, but may experience both concurrently. For example, they may intellectually accept that they did not have prior knowledge of their loved ones' struggles but, at the same time, still carry guilt because they cannot escape the feeling that they should have known. Whilst not wishing anyone else to experience the trauma of suicide bereavement, at the same time SLS frequently feel that they are not understood (81) or recognized (99). One of the included studies (#4) contains multiple examples of this type of conflicting emotions/experiences, such as emotional regulation vs. uncontrollable emotional responses, which fight for dominance. So, instead of merely oscillating between aspects of bereavement, the proposed model supports that SLS often experience both faces of the dualities at the same time, that is, they co-exist in perpetual contention. Elsewhere, such opposing drivers have been described as leaving SLS in a perpetual liminal state (100).
The 14 primary studies are all relatively recent (2010 and after), demonstrating modern approaches, and adopted recognized qualitative research methods. Adopting the eMERGe project guidance (33) provided structure and rigor to the process of conducting this meta-ethnography. A simplistic (alphabetical by author) approach for synthesizing the studies was adopted to mitigate any potential bias regarding the study locations, demographics, methods, and findings. Throughout its development, the team focused on a clear rationale, distillation of appropriate insights and extrapolation of concepts, a pragmatic and critical assessment of findings, and the creation of a clear model, that describes the output, to achieve high quality at each process stage, and overall (29). There was a strong accord within the research team throughout the stages of the meta-ethnography and the derivation of the model that describes suicide bereavement holistically. The model proposed is novel, with its generally applicability bolstered by the inclusion of studies with a high proportion of male participation, and it seems to resonate with the broader literature on the impacts of suicide bereavement.
Sections
"[{\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B1\", \"B2\", \"B3\", \"B5\", \"B6\", \"B7\", \"B8\", \"B2\", \"B9\", \"B10\", \"B11\", \"B12\", \"B13\", \"B14\", \"B15\", \"B16\", \"B17\", \"B18\", \"B19\", \"B20\"], \"section\": \"Introduction\", \"text\": \"This study was carried out as part of an overall research program investigating postvention (bereavement support) uptake and effectiveness in UK and Ireland adult males bereaved by suicide. The term \\u201csuicide loss survivor\\u201d (SLS) is utilized in this article as it is being increasingly used for those who have experienced the suicide of a close family member, or a friend, and face persistent, distressing trauma (1). It is thereby differentiated from survivors of suicide attempts. Against a backdrop of c. 760,000 annual suicide deaths globally (2), based on UK (3\\u20135) and Ireland (6) government suicide statistics, annual suicides total approximately 7,500 with male suicide being three to four times more prevalent than female suicide. However, the UK is one of several countries where it has been suggested that the coronial system could result in a 15\\u201350% underestimation of suicide as the officially determined cause of death. This has been associated with SLS pressure on the coroner, the coroner's inherent wish to protect SLS from the associated stigma and, most importantly, coronial reticence to declare deaths as suicide reflective of the legacy of deemed criminality (7). This may have been mitigated, more recently, by the standard of proof for suicide deaths, in England and Wales, being lowered to the civil standard of being on \\u201cthe balance of probabilities,\\u201d from \\u201cbeyond all reasonable doubt,\\u201d in 2018 (8). In the period 2000\\u20132019, Ireland was in keeping with a global trend of declining suicide rates but the numbers for the UK increased, although not statistically significantly (2). The number of people bereaved by suicide annually, across the world, has been estimated at 48 million (9). Using an annual global suicide figure of 700,000 (noted in the same paper) the corresponding annual suicide exposure level, on a ratio basis, would be approximately 480,000 for the UK and Ireland. Using the estimate of 135 people being exposed to each suicide (10), the UK and Ireland annual exposure rate to suicide is 945,000. Results of a UK-wide survey indicated that 77% of participants (including professionals and those that lost friends) were majorly affected by losing a loved one to suicide, with half reporting mental health issues, 38% contemplating suicide, and 8% attempting suicide, directly related to their bereavement by suicide (11). Similarly, a survey conducted in Ireland found that 93% of SLS noted a moderate or major impact on their lives with mental health issues (56%), relationship struggles and alcohol abuse being typical factors, and 35% considering self-harm or suicide (12). A recent systematic review of the psychosocial impact of suicide bereavement on men highlighted their increased risk of suicide and mental health problems, plus issues with relationships and social interactions, over men not bereaved by suicide (13). Furthermore, a systematic review of postvention service models, between 2014 and 2019, found that, generally, studies of suicide bereavement support services had 80\\u201391% female participation (14). However, evidence also suggests that there is no correlation between parental gender (or that of a child lost to suicide) and depression and grief (15). Similarly, no gender differences were found relating to siblings' suicide loss (16) or partner suicide loss, with both genders experiencing reduced life expectancy, higher rates of divorce, children in care, sick leave, and unemployment (17). Yet, despite encountering similar levels of grief and emotional distress to female SLS, male SLS seek help far less frequently. It has also been noted that the impact and management approaches of suicide bereavement interventions vary by gender, with the inadvertent emphasis on the effectiveness of postvention in largely female samples, thereby introducing a major gap in both postvention activities and the literature regarding men (18). In addition to SLS being prone to mental health issues and at increased risk of suicide themselves (19), understanding psychosocial influences, with appropriate interventions, has also been shown to be effective in lessening both suicidal behaviors and the likelihood of attempts (20). Therefore, men are typically not receiving much needed, proven, support to help them cope with their losses.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B21\", \"B22\", \"B23\"], \"section\": \"Introduction\", \"text\": \"There are several approaches to qualitative evidence synthesis which have been collated, summarized, and \\u201cthe state of the method\\u201d assessed (21). To achieve the intended objectives of this study, a method was required that goes beyond aggregation of themes but, rather, one which is interpretive of the underlying concepts facilitating creation of an overview regarding the fundamental issues faced by adult males bereaved by suicide. This reflects the two essential components of meta-ethnography, in viewing the source information as metaphorical, rather than literal, and translation of studies into each other during the synthesis (22). This approach allows for a derivation of commonality and the development of constructs that represent the dataset, as a whole, but may not individually be apparent in any of the studies included (23).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"SM1\"], \"section\": \"Search strategy\", \"text\": \"The search strategy involved retrieving records that describe the lived experience of adult males bereaved by suicide. The purpose of the search terms was to capture records covering suicidality, aspects of grief or bereavement, relationships to those lost, male involvement, and various types of qualitative study. Wildcards were used to capture linguistic variations, for example \\u201cgrie*\\u201d allowing retrieval of records that describe grief or grieving. The search strategy was honed via multiple searches of the Academic Elite database. In conjunction with the research team and the [University of West London] specialist librarian, the following data sources were searched: Academic Search Elite, CINAHL Complete (Cumulated Index to Nursing and Allied Health Literature), Medline, PsycARTICLES, PsycINFO, ProQuest, and Google Scholar. These were selected as they are frequently used in psychological research and provide a broad coverage of relevant publishers. Each data source was searched independently, as they are indexed differently, and the search strategy was refined based on the initial output generated from the individual sources (see Supplementary material A for the complete search strategy).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"fn0001\", \"SM1\"], \"section\": \"Search criteria\", \"text\": \"The searching of ProQuest was constrained by two of the primary terms, relating to suicidality and bereavement, plus limited to abstracts and the Google Scholar searches were of article titles only. Both measures were necessary to eliminate many thousands of extraneous hits and home in on the target records. The searches were set to return only English language records, to avoid interpretation bias, but no timeframe was set other than a publication date up to and including the end of November 2022. There was no exclusion based on geography. All the studies included in this meta-ethnography had a significant level of male participation (50% or above) and similar aims, in terms of looking to elucidate how the experiences related to suicide-loss shape those left behind (see Supplementary material A for the complete search criteria).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B24\"], \"section\": \"Approach\", \"text\": \"The overall approach adopted is compliant with that advocated by the \\u201cSTARLITE\\u201d guidance which calls for the clear definition of the \\u201csampling strategy, type of study, approaches, range of years, limits, inclusion and exclusions, terms used, electronic sources,\\u201d reflecting the mnemonic and intended to provide a standard for reporting literature searches (24).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B25\", \"B26\", \"B27\", \"fn0002\"], \"section\": \"Approach\", \"text\": \"To mitigate any inherent bias, in their consideration, the studies included in this meta-ethnography have been presented alphabetically by author [save for Ross et al. (25), which is embedded under Entilli et al. (26), as it is an earlier report of the same study]. The comparison of papers was then initiated by using the first study with each of the following studies being assessed against all those preceding (27). The analysis was conducted by Author #1 and cross-validated by Authors #2 and #3. All authors agreed that the themes and interpretative framework were embedded in the data and provided a meaningful interpretation of SLS's experiences.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B28\", \"B27\", \"B29\", \"B30\", \"B27\"], \"section\": \"Approach\", \"text\": \"Studies were included that offered a valuable contribution to the synthesis. This is a subjective appraisal but is in keeping with meta-ethnographic practice (28). When conducting a meta-ethnography, it is common for the quality of the included studies not to be a basis for exclusion prior to the synthesis (27) and this was the case herein. There is no defined standard for assessing the quality of studies included in a meta-ethnography (29). For the purposes of this meta-ethnography, the CASP Qualitative Studies Checklist (30) was employed which consists of 10 questions. Application of these questions facilitated evaluation of studies based on key parameters, including methods, congruity of method with the aims and analysis, ethics, comprehensibility, and value in terms of adding to existing knowledge. Questions reflect three aspects of the quality review with items one to six focused on validity, seven to nine on the results, and 10 on the study value. This framework has been effectively used in other meta-ethnographies (27) where each study is assessed against nine questions, for specific aspects of quality, with ratings of \\u201cyes,\\u201d \\u201ccan't tell,\\u201d or \\u201cno,\\u201d plus observations on the value of the research undertaken and overall comments. The studies were all assessed by Author #1 with the other two members of the team each reviewing a random sample. Any divergence of opinion was resolved through dialogue.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B31\", \"B31\"], \"section\": \"Approach\", \"text\": \"Meta-ethnography is a method for synthesis of purely qualitative studies, but it allows for a range of study designs to be included. Its systematic approach facilitates generation of insights into experiences and derivation of impressions and models that can inform both future research and real-world policy and practice (31). While meta-ethnography is an intricate method, and time-consuming, it is well suited for application to primary studies that contain rich data and are highly interpretative (31).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B32\", \"B33\", \"B21\"], \"section\": \"Transparency and openness\", \"text\": \"This meta-ethnography adhered to the PRISMA 2020 guidelines for systematic reviews (32). All data and research materials (including our manual coding scheme) are available upon request. This review was not preregistered. Historically, meta-ethnographies have often lacked an audit trail, but standards, such as the eMERGe reporting guidance (33) employed herein, providing structure and aimed to enhance quality, robustness, and reliability, address that potential limitation (21).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"F1\", \"B32\", \"B26\", \"B25\", \"B34\"], \"section\": \"Findings\", \"text\": \"Figure 1 depicts the full screening process in line with the current PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guideline (32). It is based on the 2020 version of the PRISMA Flow Diagram template. One report retrieved (26) describes a longitudinal study of parents bereaved by suicide assessed at 6, 12 and 24 months after their losses. A prior report (25) is based on the same study but only covered the 6- and 12-month assessments. Both studies met the inclusion criteria set for the review but, following the latest PRISMA guidance on how this should be reported on the flow diagram, this represents a single included study and increases the \\u201cReports of included studies\\u201d by one (34). Overall, based on consensus reached by the review team, 13 papers were included in the meta-ethnography arising from the database searches and two from the manual searches.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"fn0003\"], \"section\": \"Findings\", \"text\": \"The quality assessment of the 14 studies indicated that, despite minor issues, all of them can be relied upon as valid data sources.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"T1\"], \"section\": \"Study characteristics\", \"text\": \"All the included studies were conducted since 2010, with most (10/14) being from 2017 onwards. A summary of the key characteristics, from each included study, is presented in Table 1. Together, the two articles mapping to a single study are one of three Australian papers (#6 plus #7, and #1). Other geographies represented are Africa (1: Nigeria (#13)), Asia (4: China (#5), Hong Kong (#4), South Korea (#11), and Pakistan (#2)), Europe (4: England (#12), Germany (#3), Ireland (#9), and Poland (#15)) and North America (2: Canada (#8 and #14)). Cultures vary across these regions and/or sub-populations within them and, of the countries represented, suicide remains illegal in two countries (Nigeria and Pakistan). Eight of the 14 studies (#1, #2, #6 plus #7, #9, #12, #13, and #15) had both male and female participants while the remainder (#3, #4, #5, #8, #10, #11, and #14) included only men, with four of them based on a single participant (#3, #5, #10, and #11). The ages of participants were not supplied for three of the studies (#2, #5, and #12). Where ages were provided, many (6/14) included middle-aged to older participants (#3, #6 plus #7, #8, #11) with some (#4, #9, #13, #14, and #15) including a broad range of ages (4/14), and only two having exclusively younger participation (#1, and #10). Socio-economic background was not provided in most studies, but some did include specific information on the participant(s). In one (#10), it was noted that the individual was part of a family that had immigrated from a non-English speaking country and that they had experienced domestic violence, with a backdrop of financial difficulties. In the Nigerian study (#13) it was recorded that population, from which the sample was drawn, had strong literacy and religiosity, with employment primarily across agriculture, commerce, and the civil service. In the study conducted in China (#5), it was recorded that the participant was recruited from a bereavement support group in a city which is economically developed.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B25\", \"B26\"], \"section\": \"\", \"text\": \"*Ross et al. (25) is a report of an included study (PRISMA) with respect to Entilli et al. (26).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B35\"], \"section\": \"Study characteristics\", \"text\": \"Most studies (#1, #2, #4, #5, #6 plus #7, #9, #11, #12, #13, and #15) collected data via semi-structured interviews (10/14). Data collection for one (#9) was unclear but an examination of the larger study of which it is a component (but not part of this meta-ethnography) implies that this was also via semi-structured interviews (35). Two studies (#8 and #14) employed photovoice interviews, and one was based on the psychotherapy notes for an individual (#3). The procedure, for the psychotherapy study (#3), also notes that the verbatim transcript was translated into English but no issues with this were mentioned. The authors of the study conducted in Poland (#15) noted that the participant quotes were translated from Polish into English and that some fidelity may have been lost due to the resulting text losing a degree of coherence, in some instances.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"T2\"], \"section\": \"Analysis\", \"text\": \"The outcome of the translation process, involving iterative review of all the studies to assess for concepts consistent across them (reciprocal) or those that differ or are conflicting (refutational) and the subsequent interpretation to create novel themes (line of argument), is encapsulated in Table 2, in which, after a synopsis of each individual study, the cumulative concepts are listed. This reflects the research program's aim of understanding the broad impacts of suicide bereavement. Importantly, this table is not merely a list of themes, but attempts to portray the underlying, cohesive concepts arising from each study, and an amalgamation thereof.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B25\", \"B26\"], \"section\": \"\", \"text\": \"*Ross et al. (25) is a report of an included study (PRISMA) with respect to Entilli et al. (26).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B28\", \"B22\", \"B28\"], \"section\": \"Analysis\", \"text\": \"When considering how studies are related to each other, originally characterized as metaphors to capture derived meaning across studies (28), more recently, such amalgamations have been described as storylines, which can help identify sub-sets, commonalities, and conflicts (22). No concepts, across the 15 papers, were found to refute each other. Concepts shared across papers were mostly reciprocal. A line of argument (28), or framework for interpretation was developed which is described below.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B27\", \"B36\", \"T3\", \"B37\", \"B22\", \"B36\"], \"section\": \"Analysis\", \"text\": \"Following a method described elsewhere (27, 36), the 14 studies were tabulated to facilitate comparisons of the main concepts identified in each one (Table 3). For ease of review, only the main themes from each study have been included in the table and their descriptions abbreviated and/or paraphrased for fit. However, the full articles, including detailed analyses, findings and discussions, were examined during the translation process. With the proviso that, by their very nature, published studies included a selected set of quotations intended to represent the participants' experiences, such reflections in meta-ethnography are considered first-order constructs, and are typically located in the analysis or results sections of the articles. How participants' perceptions were interpreted by the study authors, are considered as second-order constructs, and usually described in the discussion sections. New concepts, synthesized from first and second order constructs, are deemed third-order constructs (37) and derived as part of the meta-ethnography analysis. From first, second and third order constructs, a line of argument can be generated: a framework of interpretation. Generation of a line of argument comprises an expanded comprehension of the underlying constructs to produce an extended or novel concept (22, 36). To illustrate the analysis, participants' quotations (first-order constructs) are presented in italics using quotations marks, whilst the authors' interpretations (second-order construct) are displayed using quotations marks only:\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"T3\", \"F2\", \"B39\"], \"section\": \"Analysis\", \"text\": \"Table 3 reflects the reciprocal translations of the 14 contributing studies (15 papers). The first- and second-order constructs, included in the table, are representative and not exhaustive. The analysis identified eight concepts (third-order constructs), derived from eight themes (second-order constructs) which were used to generate an all-encompassing new \\u201cSuicide Bereavement Model\\u201d (line of argument). These concepts (themes) are: changed forever (impact), trauma (distress), stigmatization (blame), protector (responsibility), lost futures (memorialization), lost in plain sight (healthcare and support), societal norms (culture), and dualities (inner conflicts). The model demonstrates how these concepts interplay to reflect a shared core, inherent continuum of devastation mediated, and moderated, by external elements and competing drivers and factors such as relationships (to those lost and fellow SLS), culture, and timeframe (Figure 2). Other research has modeled aspects of the grief associated with suicide loss, from the perspectives of meaning-making and relationships to the deceased, the self and others (39) but the authors are not aware of any model that has holistically encompassed the multitude of factors associated with suicide bereavement.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"F2\"], \"section\": \"Summary\\u2014A novel model for suicide bereavement\", \"text\": \"The far-reaching, and long-standing, impacts of suicide bereavement with, at its core, the permanency of its life-changing implications, are the basis of the model (line of argument) constructed to describe, and contextualize, the synthesis of concepts gleaned from the 14 studies. This is encapsulated visually in Figure 2, and is proposed to be transferable, fitting suicide bereavement regardless of gender, demographics, relationship to the person lost, timeframe and culture. The proposed model is intended to represent the factors that influence adult SLS' cognitive and behavioral changes when experiencing bereavement by suicide, based on the 14 studies assessed. The deep-seated and fundamental modification to SLS' world view is manifestly impacted by key factors that pervade their lives. There is the emotional shock, often exacerbated by underlying issues and/or prior events, and entrenched grief, intensified by blame (externally and/or internally generated) which frequently results in stigmatization. While SLS struggle to cope with their losses, they may also constantly yearn for futures they can never attain with an associated sense of failure, regarding the safety of those lost, and foreboding, regarding others close to them, which can lead to a constant self-doubt of their capabilities to shield those they love. Surrounding all these very strong reactions, SLS may not get appropriate support, or acknowledgment of the impacts on their health, and feel constrained to outwardly project a level of normality, in their everyday lives, that masks their real, and deep-rooted, psychological state. This is driven by factors including culture, religion, and what they perceive to be expected of them by society, as a whole, or components thereof, such as family members, the workplace and community leaders. The combined pressure of all of these factors, bearing on them in unison, can result in SLS experiencing constantly competing perspectives regarding the circumstances of their bereavements.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B40\"], \"section\": \"Discussion\", \"text\": \"The aim of this meta-ethnography was to identify prior qualitative research which summarizes current knowledge on how adult males cope with, and adapt to, bereavement by suicide. Overall, the findings suggested that men coped by both extracting meaningfulness and protecting themselves by emotionally separating from the event. While these studies suggest recognized \\u201cmasculine-style\\u201d of grieving, such as stoicism, fatalism, anger, and over-working, they did not get to the essence of what makes men deal with suicide differently from a \\u201cconventional-style\\u201d of grieving, typified by women, whereby grievers more openly share their feelings and, consequently, received greater support (40). The Suicide Bereavement Model, described herein, is proposed as being applicable to all adults due to the translation synthesis, core to the meta-ethnography, indicating that the included studies support a pertinent line of argument, from which the model is derived, regardless of gender. Of the papers where participation was limited to men (#3, #4, #5, #8, #10, #11, and #14) the focus was on individuals or narrowly targeted groups. Of the studies including males and females (with at least 50% male participation), very little was noted as specifically attributable to men, and the nature of thematic illumination lends itself to inclusion of participants quotes that best exemplify each theme, often masking whether, or at least not amplifying, any trends in gender alignment with the aspects under review. Overall, based on the information gleaned from the 14 studies that fell into the meta-ethnography, despite some instances of male survivors demonstrating stoicism and assuming the role of protector, it was considered that the syntheses and line of argument are equally applicable to men and woman, as some papers indicated the similar traits emerged in female participants. Therefore, the discussion, and associated Suicide Bereavement Model, is proposed to be applicable regardless of gender.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B41\", \"B42\", \"B43\", \"B44\", \"B45\", \"B46\", \"B47\", \"B48\"], \"section\": \"Changed forever\", \"text\": \"The review findings reveal that suicide bereavement is complex and has many interwoven facets. These wax and wane, interact, and can have differing individual or collective impacts on SLS' capabilities to adapt and cope, in the immediate term after their loss, but also for many years to come, as they struggle to derive any meaning. In that, the overall impact of bereavement by suicide changes SLS' view of the world, and is interwoven into their belief system, attitudes, and daily behaviors, it can be regarded as a form of embodied biographical disruption (41). The complexity regarding SLS' drives and needs, with respect to making meaning out of their losses, has been noted elsewhere (42). That said, even as those bereaved by suicide process their losses and re-shape their lives, the evidence, herein and in the literature, suggests how they handle their grief is far from linear (43, 44). Rather grief intensity can fluctuate and be reactivated by both internal and external stimuli. While some SLS demonstrate personal growth, partly characterized by strengthening existing relationships and facilitating forging new ones (45), over time, some are often fundamentally lonely (46) and locked into negative patterns of \\u201cprolonged grief\\u201d (47)\\u2014now recognized as a mental health condition, evolving from what was previously described as \\u201ccomplicated grief\\u201d (48). Indeed, the combined shifts in SLS' perceptions, experiences, and personal reassessments of every aspect of their lives, are very common resulting in their lives being changed forever.\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B49\", \"B50\", \"B19\", \"B51\", \"B52\", \"B53\", \"B54\", \"B55\", \"B56\", \"B57\", \"B58\", \"B59\", \"B60\", \"B61\", \"B62\", \"B43\", \"B63\"], \"section\": \"Trauma\", \"text\": \"Following suicide bereavement, typically \\u201cacute grief\\u201d manifests as powerful and disturbing trauma. Psychological shock can be protective, in the short to mid-term, and prevent an individual from being overwhelmed with gloom and desolation. This can allow them to deal with the administrative aspects of death such as registrars, funeral directors, travel, and finances (49). While it has been suggested the difference between suicide bereavement and other types is negligible (50), others have argued that it is very much different, supporting that those bereaved by suicide experience psychological distress above and beyond that associated with other types of loss (19, 51). Men's expression of grief may be delayed, with respect to that of women (52). SLS can feel as if they also lost part of themselves when their loved ones took their own lives (53, 54). In keeping with some of the studies that form part of this meta-ethnography (Papers #3, #10, and #12), it has been observed that other traumas, in the lives of the those bereaved, can significantly impact how they deal with a loss to suicide (55). The trauma, related to suicide, is not limited to individuals but plays out within, and across, family and social constructs (56, 57). However, the majority of studies on suicide focus on specific relationships to those lost (58). Little is known regarding the overall dynamics and how suicide loss impacts generationally (59). Suicide-related trauma can be exacerbated by the bereaved feeling isolated individually (60) or as a family (61) and can be compounded by pre-existing trauma (62). Bereavement by suicide can lead some SLS to question their own existence and undermine their prior value systems (43, 63).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B64\", \"B65\", \"B66\", \"B67\", \"B61\", \"B68\", \"B69\", \"B70\", \"B67\", \"B71\", \"B72\", \"B73\"], \"section\": \"Stigmatization\", \"text\": \"The stigma associated with suicide is widely recognized as an issue for SLS (64). Where decedents had known mental health issues and/or prior suicide attempts, stigmatization can be prevalent even before their losses (65). SLS sense that, generally, people do not perceive suicide as something that can happen in their families, and the families where it does occur are somehow blighted (66). The bereaved can be viewed as sullied by their loved one's suicide, with outsiders assuming mental illness pervades the family, and that it must be prone to suicidality (67). In some cultures, stigmatization of SLS can arise, and be very strong, within families and communities, as noted in a couple of the studies included is this meta-ethnography (Papers #2 and #13) and elsewhere (61, 68). The potential sequelae of suicide bereavement can further lead to stigmatization, as noted for sufferers of prolonged grief disorder (69). Not only are SLS subject to external stigma, but they may also internalize the unempathetic and judgmental opinions of others (70), thereby attributing to themselves blame, and subsequently shame; such self-stigmatization can lead to SLS adopting non-adaptive thinking and behavior (67). Perceived blame can intensify the negative connotations of suicide loss and magnify the suffering of SLS (71, 72). All facets of blame, in combination, can be exacerbated by inaccurate and inconsiderate media coverage (73).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B74\", \"B75\", \"B76\", \"B13\", \"B56\"], \"section\": \"Protector\", \"text\": \"As noted in the findings of several of the 14 included studies, SLS often berate themselves for failing to protect their decedents (Papers #3, #4, #8 and #10). This has also been reported elsewhere (74). The assumption of the role as protector, to other SLS, was also noted (Papers #1, #4, #6, #9, #10, #12, and #13) and has been observed more broadly, including female SLS \\u201cdirecting from the shadows\\u201d (75) and SLS looking to rescue others in potential suicidal stress (76). With respect to parents that had lost a child, one paper (#6) reported that fathers assumed the role of protector, with respect to their partners, as they perceived the latter requiring support above and beyond their own needs. Elsewhere, men have also been noted to assume the role of carer, toward their female SLS partners and families (13). Where striving for such safeguarding results in SLS becoming hypervigilant, or overprotective, there is an increased emotional burden to bear, on top of individual's own grief (56).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B53\", \"B54\", \"B43\", \"B77\", \"B44\", \"B78\", \"B79\"], \"section\": \"Lost futures\", \"text\": \"While SLS grieve intensely, related to the loss of a loved one to suicide, and its aftermath, they also speculate on what might have been in terms of their decedent's potential achievements, time and activities they could have shared, and the children they will never have (53, 54). These aspects can also cause an extension and prolongation to their grief (43). SLS often have a strong desire to keep the memories of those they have lost alive and close to them. While generally beneficial, this has been found to add distress where they could not maintain a cohesive bond, due to loss of mementos, waning memories, or a sense that they have lost control of how their relationship to their decedent is manifested (77). Increasingly, memorialization of those lost to suicide is via social media and online platforms (44). While this aspect of grief management is relatively new, there has been research suggesting mixed effects, with indications that SLS can both find an outlet for their emotions and maintain a virtual relationship with the loved one lost via dynamic media (78), but that commemorative internet sites can exacerbate anguish due to a resulting exacerbation of emotional stress (79).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B54\", \"B80\", \"B81\", \"B82\", \"B83\", \"B52\", \"B84\", \"B85\", \"B86\", \"B52\", \"B87\", \"B80\", \"B88\", \"B38\", \"B89\", \"B46\", \"B90\", \"B91\"], \"section\": \"Lost in plain sight\", \"text\": \"Somewhat as a result of the persistent taboo around suicide, SLS tend to adopt a fa\\u00e7ade of normality hiding, or even denying, their true feelings (54) with men being more prone to, or even primed for, emotional concealment (80). Such a persona may be maintained in public, but the mask sometimes drops in the context of peer support (81). SLS can be overwhelmed and struggle to relate their level of devastation to those not in the same situation (82) and maintenance of a pretense of not needing help, or a lack of trust in the provider, may result in those bereaved lacking much needed support (83). Men are often unwilling to consult professionals for fear of being perceived as ineffectual and incapable (52). Also, due to suicide not being openly discussed, SLS may be unaware of its prevalence thereby missing the opportunity of support from others similarly afflicted (84). Men are generally assumed to be outwardly more stoic and are noted to use avoidance, such as a focus on work (85) or increased alcohol consumption (86), as part of their grieving pattern. This, though, can be the perpetuation of a gender stereotype and lead to them perceiving that their needs are being ignored (52). Overall, the lack of attention to SLS' needs can create a scenario where they live \\u201cunder the radar\\u201d as they continue to be faced with significant turmoil, in relation to both themselves and those around them, encompassing their role as a protector, the potential futures lost to them by the suicide, stigmatization, and on-going trauma. SLS are prone a variety of mental health issues that have been found to vary by gender, with men being less likely to seek help (87) and their needs not being identified in healthcare policy setting (80). Research has also identified an increased risk of physical ailments in SLS (88) however, they may be less likely to engage with healthcare services if they perceive that those providers did not meet the needs of those lost to suicide (38, 89). In some cases, organizations can lack empathy (46) and be misaligned with the requirements of the bereaved, with healthcare professionals demonstrating a lack of thought and awareness (90) or frustrating SLS by not providing much needed information (91).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B92\", \"B93\", \"B13\", \"B71\", \"B68\", \"B94\", \"B95\", \"B96\", \"B44\", \"B61\", \"B67\", \"B97\"], \"section\": \"Societal norms\", \"text\": \"The model depicting the multi-faceted negative experiences of SLS, presented herein, does strongly disagree with the notion of a linear nature to grief and bereavement, and other studies have also indicated that suicide bereavement is very much non-linear (92), despite SLS being pressurized, by external expectations to adhere to a broadly accepted sequence of stages exemplified by linear grief models (93). A recent systematic review of male suicide bereavement studies noted that men often experience marked grief responses but are constrained by the accepted customs and anticipated masculine behaviors in society (13). Several of the 14 included studies noted contextual social and cultural taboos, regarding openness and acknowledgment of suicide, with some highlighting deeply rooted negativity and denial (Papers #4 and #13). The level of repudiation seemed to reflect cultural hostility toward suicide, and SLS, and encompassed religiosity. Taboos can be faced at a family level, where members refuse to engage in a dialogue regarding a suicide (71), or can be at a cultural level, driven by the fear of repercussions and/or religious dogma (68, 94). The latter is exacerbated with suicide remaining an illegal act in many countries (95). Losing someone to suicide has been found to both enhance religious beliefs and diminish them, depending on the individual (96). Lack of empathy toward SLS, as a broad cohort, can lead to disenfranchised grief (44) and the judgement by others may be part of an overall stereotyping of bereaved families as being somehow broken or dysfunctional (61, 67). The need for better education, and a shift in societal attitudes, has been noted as necessary for SLS to receive both compassion and meaningful support (97).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B98\", \"B81\", \"B99\", \"B100\"], \"section\": \"Dualities\", \"text\": \"Some of the papers assessed (Papers #2, #6, #8 and #9) suggested their findings exemplified the Dual Process Model of Bereavement's oscillation between factors associated with loss and those that help restore the bereaved to a level of normality (98). The model herein is not in conflict with it, as the \\u201cdualities\\u201d described here could reflect the \\u201coscillations,\\u201d between \\u201closs-oriented\\u201d and \\u201crestoration-oriented\\u201d behaviors, portrayed in the Dual Process Model. That said, the proposed model suggests that the experience may in fact be more intricate, in that SLS may not necessarily find themselves gravitating to either pole, at any given point in time, but may experience both concurrently. For example, they may intellectually accept that they did not have prior knowledge of their loved ones' struggles but, at the same time, still carry guilt because they cannot escape the feeling that they should have known. Whilst not wishing anyone else to experience the trauma of suicide bereavement, at the same time SLS frequently feel that they are not understood (81) or recognized (99). One of the included studies (#4) contains multiple examples of this type of conflicting emotions/experiences, such as emotional regulation vs. uncontrollable emotional responses, which fight for dominance. So, instead of merely oscillating between aspects of bereavement, the proposed model supports that SLS often experience both faces of the dualities at the same time, that is, they co-exist in perpetual contention. Elsewhere, such opposing drivers have been described as leaving SLS in a perpetual liminal state (100).\"}, {\"pmc\": \"PMC12301309\", \"pmid\": \"40726943\", \"reference_ids\": [\"B33\", \"B29\"], \"section\": \"Strengths, limitations, and reflexivity\", \"text\": \"The 14 primary studies are all relatively recent (2010 and after), demonstrating modern approaches, and adopted recognized qualitative research methods. Adopting the eMERGe project guidance (33) provided structure and rigor to the process of conducting this meta-ethnography. A simplistic (alphabetical by author) approach for synthesizing the studies was adopted to mitigate any potential bias regarding the study locations, demographics, methods, and findings. Throughout its development, the team focused on a clear rationale, distillation of appropriate insights and extrapolation of concepts, a pragmatic and critical assessment of findings, and the creation of a clear model, that describes the output, to achieve high quality at each process stage, and overall (29). There was a strong accord within the research team throughout the stages of the meta-ethnography and the derivation of the model that describes suicide bereavement holistically. The model proposed is novel, with its generally applicability bolstered by the inclusion of studies with a high proportion of male participation, and it seems to resonate with the broader literature on the impacts of suicide bereavement.\"}]"
Metadata
"{\"section-at-acceptance\": \"Public Mental Health\"}"