The Clinical Utility of Spirituality and Religion in Meaning-Making Theory for Suicide Loss Survivors: A Scoping Review

Abstract

In the case of violent/traumatic loss due to a completed suicide, there can be an overwhelming and complicated grief reaction followed by a spiritual need for the process of sense making and finding meaning. Some emerging literature on suicide loss survivors (SLSs) denotes that suicide loss is more similar to other forms of bereavement but is uniquely characterized by high levels of shame, guilt, self-blame, and stigma. This article examines themes within the current literature on the bereavement process, meaning-making theory, religion, and spirituality. The aim of this scoping review was to consider the question concerning the clinical utility of accompanying meaning-making interventions with a spiritually informed approach for SLS. The research was conducted through a scoping review. Records were identified through database searches of ProQuest (N = 93); OMNI (N = 184); and EBSCO (N = 63). Through a process involving identification, screening, and eligibility guided by inclusion and exclusion criteria, a total of 25 (N = 25) articles were used. These articles were analyzed in-depth for commonalities. Grief experiences, religious and spiritual experiences and meaning-making were three themes that emerged from the literature. In conclusion, this review elevates the importance of an integrated clinical counselling approach that encourages meaning-making within the context of spirituality to promote positive psychotherapy outcomes and growth for SLSs.

1. Introduction

Suicide is a critical public health problem characterized by the fatal outcome of an act that ends an individual’s life (Durkheim 1951) that is characterized as a traumatic loss. The World Health Organization (2021) has estimated that more than 700,000 people die by suicide annually worldwide. With each completed suicide, family members, friends, and communities are left behind to grieve and make sense of the loss long after their loved one’s death. It has been stated that for every completed suicide, there are six suicide loss survivors (SLSs) left to grieve (Shneidman 1969). Yet, this frequently quoted number was not empirically verified and appeared to be a conservative estimate representing only kin relationships (Cerel and Sanford 2018; Hunt et al. 2019).

Historically, those bereaved by suicide were referred to as suicide survivors. However, the term recently changed to suicide loss survivor (SLS) which encompasses “someone who experiences a high level of self-perceived psychological, physical, and/or social distress for a considerable length of time after exposure to the suicide of another person” (Jordan and McIntosh 2011, p. 7). This definition expands SLSs beyond kinship to include family, friends, coworkers, clinicians, and others who may also be impacted by a completed suicide. It also exemplifies the distressing symptoms and longevity of grief experiences a SLSs may endure.

Meaning-making theory has embodied many theoretical perspectives and is studied under various terms, including benefit-finding, stress-related growth, and posttraumatic growth (PTG) (Lewis Hall and Hill 2019). Meaning-making has proven particularly important when processing and challenging highly stressful life experiences (Park 2010). Meaning-making is rooted in the belief that something good or meaningful can arise from the most challenging times, and PTG is the “diverse positive changes in the aftermath of a traumatic event” (Lee et al. 2019, p. 415). Also, when considering long-term outcomes, Park (2005) indicated that religion and spirituality (R/S) may have an influential positive impact given that it fosters and encourages meaning-making deriving from adverse events.

Some emergent literature on SLSs has denoted that suicide loss is more similar to other forms of bereavement but is uniquely characterized by high levels of shame, guilt, self-blame, and stigma. These feelings can further complicate the bereavement process (Begley and Quayle 2007; Peters et al. 2016). In contrast, other literature has conveyed that SLSs experience greater difficulty assimilating and navigating the challenges of grief and bereavement (Cerel et al. 2008), coupled with more significant evidence of psychopathological challenges (Cerel et al. 2009). The conflicting views within the literature on the grief and bereavement process for SLSs predominantly espouse that bereavement by suicide is complex, negatively impacts the lives and functioning of those who are bereaved and is often a highly traumatic event (Levi-Belz et al. 2021). Given the complicated nature of suicide bereavement, it is important to determine how to best support SLSs through their grief experiences and processes. Given the positive outcomes concerning the clinical influence of meaning-making and R/S for those exposed to stressful or traumatic events, its implications for positive outcome and growth for SLSs is worthy of further study.

This scoping review addressed the following research questions. Each question refers to meaning-making theory and the clinical utility of meaning-making theory specific for SLSs.

(1) How is meaning-making theory a practical approach to addressing grief and loss for suicide loss survivors?

(2) How do religion and spirituality contribute to meaning-making for suicide loss survivors?

(3) How can meaning-making theory be utilized as a therapeutic tool to aid in posttraumatic growth for suicide loss survivors?

2. Methodology

2.1. Purpose of Scoping Review

The literature on meaning-making has argued that individuals who experience traumatic events, such as learning about a death of a loved one by suicide, are inherently motivated to find positive accommodation following the traumatic event. In order to discuss the clinical utility of R/S and meaning-making for SLSs, this scoping review included literature that encompassed the bereavement process of SLSs, R/S, meaning-making and posttraumatic growth.

2.2. Value of a Scoping Review

Scoping reviews are a method of knowledge synthesis that are designed to be systematic, transparent, and replicable (Grant and Booth 2009; O’Brien et al. 2016). They are unique in that they integrate all types of literature to generate themes and conclusions. In this way, scoping reviews are a valuable method of knowledge synthesis to investigate broad topics and can inform policymakers and researchers on the need for further research.

This scoping review followed the stages in the framework outlined by Arksey and O’Malley (2005), which include (1) identifying the research question (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarizing and reporting the results.

2.3. Results

2.3.1. Identifying Relevant Studies

The literature deemed relevant to this study was identified through an extensive search in the following databases: Proquest, OMNI, and EBSCO. Techniques and terms used included search tools such as medical subject headings (mesh) and Boolean operators to expand and narrow searches. Single and combined keywords include:

• “Meaning-making” OR meaningmaking OR “meaning-making” OR “post traumatic growth” OR “positive psychology” (any field/ anywhere);
• Grief OR “death and dying” OR bereavement OR mourning OR loss (all subject);
• Suicide OR “suicide survivor” OR “suicide loss survivors” OR “violent death” OR “violent loss” (anywhere);
• Therapy OR counselling OR counseling intervention OR treatment OR “mental health care” OR psychotherapy OR “wellness programs” OR psychiatry OR postvention OR “clinical psychology” (all subject/ Indexing) OR Social work;
• Religion OR religions OR religious OR spirituality OR spiritual OR Christianity OR theology OR faith OR sacred OR prayer (in anywhere).

When the result yielded over 650 Results an additional NOT search criteria was applied to exclude articles that were unrelated to the subject of the scoping review:

• NOT (nursing OR nurse OR nurses OR “school shooting” OR HIV OR abuse OR “chronicpain” OR education OR “COVID-19” OR pandemic OR cancer OR marriage OR divorce OR pregnancy OR incarceration OR earthquake OR tsunami OR “job loss” OR “pet loss” OR “spinal cord injury” OR “weight loss” OR “Kidney disease”) (any field).

Nurses and nursing research were a part of the exclusion criteria as they provide more acute care and support rather than ongoing counselling and support services. Furthermore, the research coming from the nursing field was found to be on those at risk of suicide or those who have attempted suicide, not SLSs. For these reasons, nursing, nurses and nurse were excluded from this scoping review.

The same search strategies and combinations were used in all databases using subject headings and keywords.

2.3.2. Study Selection

342 potentially relevant studies were examined against the set inclusion and exclusion criteria. The search included: English, peer-reviewed journal articles, with dates between 2006 and 2021. Additionally, studies were included if their demographic was 18+ years in age and provided information on meaning-making, post-traumatic growth, and grief and bereavement concerning SLSs. Furthermore, if studies provided information on religion/spirituality and meaning-making for SLSs, or discussed the clinical use or effectiveness of meaning-making theory for SLSs they were also included.

Studies were excluded if their study population were children, adolescents or parents/loved ones of a child/adolescent who completed suicide. Additionally, studies were excluded if they addressed meaning-making as a suicide prevention strategy for those at risk of completing suicide or who have suicidal ideations/tendencies. Furthermore, studies were excluded if they addressed meaning-making and attachment or early maladaptive schemas. As well as studies using meaning-making described through leisure, hobbies, recreation, creative arts, or narrative therapy. Lastly, studies were excluded if suicide was discussed generally through violent or traumatic loss. The reason for these exclusions was that the information would be better presented in independent research.

Once the search terms and inclusion criteria were applied, articles were selected for use in this scoping review based on the relevance of their abstract to the research questions. From there, articles were reviewed in-depth and were only included if they related to meaning-making, religion and spirituality as a mechanism of meaning-making for SLSs. It should be noted that there is one exception to the inclusion criteria that was used. The exception is a master’s dissertation by Henneberry (2010). Although it is not a peer-reviewed paper, this dissertation addresses pertinent themes related to this paper including, grief, meaning-making and R/S. Following the process of identification, screening and eligibility a total of 25 articles were selected (Figure 1: PRISMA flow chart).

3. Findings: Themes in the Literature

In alignment with the Arksey and O’Malley (2005) scoping review framework, this review summarizes research findings for clinicians and practitioners and describes gaps in the existing literature for future research. The following themes were reviewed and analyzed: grief experience, meaning-making and R/S experience. Given that this review bridges literature from different research areas, the content of each article did have slight variations. However, when charting the data, specific themes and sub-themes emerged, providing a congruent analysis on meaning-making theory for SLSs.

4. Grief Experiences of Suicide Loss Survivors

The grief experiences of SLSs are widely discussed within suicide bereavement literature. While there is no clear consensus as to whether or not bereavement by suicide is distinctive or more complicated than other types of bereavement, there is realization that the bereavement process for SLSs is complex and traumatic (Levi-Belz 2021). Accordingly, it is important to explore and identify some of the distinct grief experiences of SLSs.

4.1. Suicide Loss in the Context of Grief and Bereavement

Much of the research on death and dying has discussed the expansive range of general grief reactions and bereavement processes for those who have lost a loved one. SLSs have significant and severe emotional and psychological disturbances that impact their daily lives and functioning (Levi-Belz 2021). One of the most challenging experiences for SLSs is the heightened risk of complicated grief (CG).

Complicated grief is described as grief that remains intense in longevity, significantly impairs functioning and does not decrease with time (Levi-Belz 2020; Levi-Belz and Lev-Ari 2019). It is characterized by increased psychological and psychiatric conditions like anxiety, depression, sleep disturbances, substance misuse, suicidal ideation, and suicide attempts that persist in the absence of treatment (Levi-Belz 2020; Levi-Belz and Lev-Ari 2019). SLSs are at heightened risk of developing CG due to the sudden and traumatic nature of the death and the strong emotions of shame, responsibility, blame, and guilt (Henneberry 2010). Additionally, SLSs may experience CG symptomatology due to difficulties with social interactions and low levels of self-disclosure (Levi-Belz 2020). Suppression of thoughts and a reluctance to disclose feelings and behavior related to one’s grief can become a barrier to positive psychological outcomes. Opportunity for formation of new beliefs and outlooks that emerge through the progression of meaning-making is vital to reframing one’s new worldview.

For SLSs, the completed suicide often becomes “the central and destructive element” (Castelli Dransart 2017, p. 997) in their lives. This feeling results from losing a significant relationship and the violation the completed suicide has on SLSs identity. Gall et al. (2014) found that SLSs discussed the sudden and unexpected nature of the completed suicide and social stigmatization as well as struggles in meaning-making. Other research described how SLSs felt like they were forced to deal with the emotional impact of a traumatic and unwanted change (Shields et al. 2017). These strong emotions and need for control often resulted in negative psychological responses or the use of maladaptive coping behaviours (Begley and Quayle 2007; Hunt et al. 2019). These intense struggles and maladaptive coping behaviours may lead to more complicated bereavement processes, grief symptomatology, and meaning-making difficulty.

Hunt et al. (2019) and Levi-Belz and Lev-Ari (2019) established that SLSs are not only at heightened risk of psychiatric conditions but also of suicidal behaviour. SLSs frequently report being watchful for a suicide contagion effect within their family and social circles (Shields et al. 2017). SLSs occasionally contemplate completing suicide themselves (Lee et al. 2019) due to the immense pain and strong feelings they are experiencing (Hunt et al. 2019). This research has highlighted the need for clinical interventions that included risk assessments, therapeutic relationship support, and navigation through the grieving process.

4.2. Feelings Associated with Suicide Loss

Suicide loss survivors often experience strong emotions and feelings surrounding self-blame and responsibility associated with losing their loved one (Begley and Quayle 2007). Research has revealed that SLS’s experience guilt and self-blame for not preventing the suicide or for missed opportunities to connect and check-in with their loved one before the death, or feeling that they played a role in their loved one’s death (Begley and Quayle 2007; Hunt et al. 2019). This can result in strong unwanted feelings, rumination on the events, behaviours, and emotions of their loved ones and themselves prior to the completed suicide, and often leads to an inability to make meaning of the death (Begley and Quayle 2007; Levi-Belz et al. 2021; Shields et al. 2017). In a systematic review on the bereavement process following suicide, Shields et al. (2017) found that SLSs may place blame on others for the completed suicide to regain control and free themselves from guilt.

While the emotions and feelings mentioned above are commonly cited within the literature, not all SLSs have the same emotional reactions. According to Henneberry (2010) some SLSs have a preconceived idea or an expectation of the completed suicide due to multiple past attempts or openly discussed suicidal ideations. SLSs who anticipated the suicide or those who were left with a semblance of knowledge as to why their loved one completed suicide could conceptually see the importance of distancing themselves from distressing feelings. These SLSs were more likely to see the completed suicide as a choice their loved one made outside of themselves and had an easier time making meaning. However, even though initial distressing symptoms may have been reduced does not mean that all SLSs in this category were free from experiencing strong emotions. Most of these emotions stemmed from stigmatization concerning social and cultural norms. These emotional components are directly connected and woven into experiences associated with social connections. There are a range of social aspects associated with suicide bereavement.

4.3. Social Components of Being a Suicide Loss Survivor

The grief and bereavement literature have illustrated that expressing thoughts and feelings with others is an integral part of grief work. For SLSs, social conversations and support can help address psychosocial difficulties, aid with schema reconstruction, and facilitate meaning-making, leading to PTG (Levi-Belz 2021; Shields et al. 2017). Yet, social interactions often result in inner turmoil for SLSs that modulate the degree or level of social interaction they engage in (Begley and Quayle 2007). The sociocultural norms and the stigmatization of suicide often become internalized emotions of shame, guilt, and blame for SLSs (Lee et al. 2019). The stigma and internalized emotions ultimately lead to a perceived lack of social support and a hesitancy for SLSs to discuss their grief experience with others.

Begley and Quayle (2007) revealed that SLSs sensed when others were uncomfortable around them and felt as though others failed to realize the challenges and painful emotions they were experiencing. The sense of discomfort and unease from others is associated with feelings of blame, guilt, and shame causing avoidance of social activities. SLSs often feel they need permission to talk about the deceased and their grief experience, which is rarely granted (Hunt et al. 2019; Shields et al. 2017). The unmet feeling adds to the decision to withdraw from social circles and avoid social interaction. Unfortunately, these actions reinforce the belief that others feel uneasy around them, which intensifies the SLSs distress and feelings of responsibility (Hunt et al. 2019).

In the study by Lee et al. (2019), participants felt that speaking about their emotions or suicide bereavement experiences with others might make the feelings even more real. Several studies related to social interactions and SLS’s experiences have found that they often feel embarrassed or they worry about feeling judged by others for appearing weak, or for sharing emotions and aspects of the loss, and consider how to manipulate or steer conversations to prevent others from prying in to the cause of death (Hunt et al. 2019; Kasahara-Kiritani et al. 2017; Smith et al. 2011). Smith et al. (2011) referred “the gaze of others” (p. 423) and discussed how SLSs often adopt a public persona that disguises true emotions to give others the impression that they were functioning even if they truly wanted or needed to talk about their grief experience.

Kasahara-Kiritani et al. (2017) highlighted SLSs capacity to discuss the suicide loss with others depended on their personal view of suicide. If the bereaved viewed suicide as a sin or in a negative light, they were more likely to conceal the cause of death from others due to the sinful nature of completed suicide (Kasahara-Kiritani et al. 2017; Shields et al. 2017).

Despite these challenges with social interactions between SLSs and their support systems, the literature has demonstrated that social connection is beneficial and necessary for moving through grief (Hunt et al. 2019; Lee et al. 2019). Social connection to others can influence the meaning-making process by helping revise narratives or to process the grief experience (Lee et al. 2019). Social connection and support can help with positively influencing the assimilation and integration of the completed suicide into global and situational meanings, (Lee et al. 2019; C. L. Park 2005, 2010).

5. Meaning-Making and Suicide Loss Survivors

A death by suicide causes a long, non-linear, and complex meaning-making process for SLSs which cannot be categorized in stages. The subsequent section on meaning-making theory for SLSs provides an overview of the intricate processes by which SLSs can make and derive meaning from loss.

5.1. Making Sense of the Suicide

Making sense of loss involves searching for an understanding as to why the death occurred. Begley and Quayle (2007) argued that SLSs are in constant oscillation and reappraisal between stories of the deceased and the completed suicide to make sense of loss and find meaning. For some SLSs, it can take years of evaluating and reviewing the pre-death life of their loved one in hopes of knowing why they completed suicide. However, Henneberry (2010) and Shields et al. (2017) attested that SLSs seldomly find satisfactory answers despite the significant amount of energy they use to search for an explanation in an attempt to make sense of he suicide.

SLSs spend a substantial amount of time ruminating and re-establishing the circumstances that surrounded the completed suicide. For example, they may evaluate predeath interpersonal relationships of the deceased, replay the events and behaviours of the deceased in the months and weeks leading up to the completed suicide, and assess their perceived role in the suicide (Begley and Quayle 2007; Castelli Dransart 2017). Re-establishing the circumstances surrounding the completed suicide often leads to a ruminative and obsessive search for answers to why, what if, and how come questions (Armour 2007; Henneberry 2010). This rumination and obsessive search for answers often leaves SLSs in an endless loop of trying to make sense of the loss.

Through the ruminative process of seeking answers to unanswerable questions, the emotional components of suicide bereavement become interwoven into the meaning-making process (Shields et al. 2017). These findings are further supported in the study by Armour (2007), who noted, “the internalizing symptoms of depression, shame, perceived stigma, and guilt are kept alive by an obsessive search for why. Why did this happen? What did I do to cause this? Was it my fault?” (p. 65). Rumination may be an effort for the bereaved to relieve themselves of guilt and blame in order to regain their sense of control. However, these questions often lead to further feelings of guilt and blame, creating personalization surrounding the reason their loved one completed suicide (Armour 2007; Begley and Quayle 2007). SLSs simultaneously search for the answers to “why” while ruminating on the role they played in their loved one’s death.

Gall et al. (2014) expressed that bereaved individuals would benefit from efforts to work through and process feelings of guilt, such as missing possible signs of distress, or questioning one’s parenting. While the process of rumination may be initially helpful for SLS, it can also lead to maladaptive coping strategies and CG symptomatology (Levi-Belz et al. 2021). Castelli Dransart (2013) identified that the SLSs who remained in rumination had a more challenging time relinquishing the search for answers and had difficulty using their thoughts to assimilate or accommodate situational and global meanings. However, it has been found that SLSs who use low to moderate amounts of rumination to sift through the loss’s traumatic nature can find meaning and experience PTG (Begley and Quayle 2007; Levi-Belz 2015). SLSs who successfully negotiate the complex process of meaning-making experience healing of distressing grief symptomatology and positive growth (Shields et al. 2017; Smith et al. 2011). To move forward in meaning-making, SLSs have to understand that the “why” question may never be answered, and place the ultimate responsibility on the deceased without becoming consumed by rumination.

According to Begley and Quayle (2007), meaning-making occurs “in the context of seeking out the story of death, then matching prior beliefs about the person to a possible cause of death while protecting their sense of self in the process.” (p. 30). Low to moderate amounts of rumination can lead to a revision or reconstruction of the death story by incorporating the loss into their situational and global meaning system. Smith et al. (2011) survivors face the question of why someone would take their own life and what life and death meant to them. SLSs can then develop greater awareness of their life and place in the world, and this can ultimately lead to meaning-making and PTG.

5.2. Understanding and Acceptance

Gall et al. (2014) and Henneberry (2010) illustrated that at some point during the search for meaning, many SLSs begin to stop asking the why questions and accept a plausible reason for the completed suicide. Acceptance does not necessarily mean that the SLS has come to accept the act of suicide or that all their questions are answered, but rather it means that the SLS comes to achieve a greater comprehension of the suicide (Henneberry 2010). Through acceptance, Gall et al. (2014) indicated that SLSs begin to challenge their personal feelings of responsibility and guilt in order to engage in a more self-compassionate and gentler realization of their loved one’s completed suicide. However, with time and appropriate support, low to moderate amounts of rumination can lead to understanding and acceptance (Castelli Dransart 2017). Begley and Quayle (2007) explained that some SLSs begin to form a view that the suicide was either an impulsive act or that their loved one was struggling with mental illness. SLSs who were able to assign responsibility to the deceased for the completed suicide were more likely to relinquish feelings of guilt and self-blame.

The literature on meaning-making for SLSs has also highlighted that some survivors do not ruminate on the “why” questions. Henneberry (2010) noted that for these SLSs, either their loved one left a note explaining why they were taking their life, or there was an indication of suicide due to suicidal ideations or past attempts. However, most SLSs are not fortunate enough to know their loved one’s reasons for completing suicide and consequently have difficulty making sense of the completed death. Instead, it is the hope that with time and support, SLSs can make enough sense to satisfy their search for answers so they can get to a place of understanding and acceptance.

5.3. Assigning Meaning: Positive Reappraisal

It can take years to process the grief of a completed suicide, although, many SLSs eventually come to a place of acceptable reappraisal of the suicide and assimilate or accommodate the loss within situational and global meanings. The reappraisal or reframing process of suicide has been deemed as purposeful (Begley and Quayle 2007) and encompasses (a) “letting the death be good” and (b) “using the death as motivation” (Hunt et al. 2019, p. 341). Some SLSs can find a way to reframe the tragic experience of suicide loss into a more nuanced experience (Hunt et al. 2019, p. 341).

In Begley and Quayle’s (2007) study SLSs explained reprioritizing their life’s purpose and priorities and described a “tendency towards helping others who were vulnerable” (p. 31). Using the completed suicide to help others was echoed across studies by Armour (2007), Hunt et al. (2019), and Lee et al. (2019). In these studies, the SLSs were able to keep the memory of their loved ones alive and honour the deceased by helping others through their suicide loss experiences.

Gall et al. (2014) found that another way that SLSs reframed the suicide of their loved ones was through self-care and self-reflective activities while simultaneously monitoring their maladaptive coping behaviours. Many SLSs did not allow the completed suicide to define the deceased’s life. These SLSs found resolution in the love they shared and the belief that there was a purpose to knowing them, even if it was for a short period. SLSs who can make positive changes in their interpersonal relationships are more authentic, kind, and compassionate towards the suffering of others.

Levi-Belz (2021) argued that belongingness in social contexts may provide opportunities for self-disclosure, which would facilitate meaning-making and PTG. They surmised that SLSs who can openly discuss personal feelings with others will likely feel supported, which may soften the emotional distress and pain. This further illuminates the importance and value of SLSs having supportive individuals with whom they can process their grief.

According to Begley and Quayle (2007), some SLSs reported finding meaning or purpose in the completed suicide; however, they did not want to communicate to others that they had moved on. Gall et al. (2014) professed that guilt may be why SLSs had difficulty communicating to others that they were moving forward with their lives. However, given that shame and guilt permeate the lives of SLSs, disclosing feelings and thoughts with safe people is important (Levi-Belz 2015). Sharing thoughts and feelings with others may provide the SLSs with different perspectives about themselves and the suicide event, which would help to facilitate meaning-making and PTG.

Healthy relationships are essential to facilitate meaning-making; although, social connections for SLSs are often very complex. SLSs rarely feel supported and often experience alienation from others. Additionally, supportive individuals occasionally feel like they did not know how to respond appropriately to SLSs emotions or bereavement experiences (Shields et al. 2017). Social connection and validation are critical to facilitate meaning-making and PTG for SLSs (Levi-Belz 2021; Testoni et al. 2022). SLSs who feel like a burden have higher levels of self-blame and self-hate, further amplifying their grief emotions (Levi-Belz 2021). In more recent research Testoni et al. (2022) contended that the meaning-making process should be conceptualized as “a spiritually grounded quest to find significance in the experience” (p. 12) that is best achieved through dialogue within supportive relationships.

6. Religious and Spiritual Experiences of Suicide Loss Survivors

Despite the limited research and complicated subject matter of R/S in relation to suicide loss, it is important to discuss the role R/S may have on bereavement and meaning-making processes (Henneberry 2010; Jahn and Spencer-Thomas 2018). SLSs across several studies described adaptive and maladaptive aspects of R/S and how R/S impacted their bereavement and meaning-making process (Castelli Dransart 2018; Gall et al. 2015; Henneberry 2010; Jahn and Spencer-Thomas 2018). Castelli Dransart (2018) conveyed that some SLSs experienced challenges with their pre-existing R/S beliefs after a completed suicide. Conversely, for other SLSs, the completed suicide starts the beginning of a religious and spiritual quest.

Those bereaved by suicide often search for guidance and meaning through R/S, even if they did not consider themselves religious or spiritual before their loss (Castelli Dransart 2018; Čepulienė et al. 2021). The literature depicts how R/S can positively aid in the bereavement process by lowering distress, thus contributing to greater wellbeing (Castelli Dransart 2018; Jahn and Spencer-Thomas 2014; Jahn and Spencer-Thomas 2018). Additionally, R/S helps with assimilating and accommodating the loss of a loved one into situational and global systems and aiding with meaning-making (Jahn and Spencer-Thomas 2018). However, for other SLSs, the death of a loved one can cause R/S challenges contributing to higher levels of distress and maladaptive coping (Castelli Dransart 2018; Jahn and Spencer-Thomas 2014; Jahn and Spencer-Thomas 2018).

Henneberry (2010) noted that SLSs used more spiritual coping mechanisms rather than turning to organized religion. SLSs were found to be more comfortable practicing and utilizing spiritual resources independently rather than engaging in congregating religious practices. SLSs use of spiritual practices over formal religious practices is echoed in the study by Jahn and Spencer-Thomas (2018). Their study found that SLSs use spiritual practices to support their bereavement process through continuing bonds, a sense of presence, the role of God, and an Afterlife. These themes will be further explored as to how they relate to meaning-making for SLSs.

6.1. Continuing Bonds/Sense of Presence

A part of the R/S experience related to meaning-making theory and PTG for SLSs is the notion of continuing bonds and a sense of presence. Early grief and loss theories focused on and promoted emotional detachment and ending bonds with the deceased as the primary goal of healing. However, in more recent decades, the grief paradigm has shifted from detachment to continuing bonds with the deceased (Jahn and Spencer-Thomas 2018, cited in Klass et al. 1996). Klass et al. (1996) theorized that healthy grief is not about detachment or linearly moving through grief according to phases or stages. Instead, healthy grief is about how the bereaved can create a new relationship with the deceased in a meaningful way. Continuing bonds are rooted in attachment, safety, and security, which can be continued through mental and emotional involvement rather than a physical relationship. The idea of a sense of presence is related to continuing bonds and the spiritual understanding of “something that cannot be seen but can be sensed” (Čepulienė et al. 2021, p. 19). Individuals who are bereaved and experiencing a sense of presence often feel as though they receive messages or signs associated with the deceased and tend to believe these are real and true connections or messages from their deceased loved one (Čepulienė et al. 2021). A sense of presence can help SLSs make hopeful connections and derive meaning from the loss, resulting in decreased distress.

Continuing bonds and a sense of presence can occur in multiple ways and often emerge from internal representations or an interactive connection (Jahn and Spencer-Thomas 2018). For those who experience continuing bonds through internal representations, the bond is related to memories, reflections, or dreams. Internal representation of continuing bonds can also be reached through advocacy work. For those who experience continuing bonds through interactive connection, the bereaved may experience the presence of the deceased, or they may ask the deceased for guidance or comfort during challenging moments (Jahn and Spencer-Thomas 2018). Internal and interactive connections are positive examples of continuing bonds that can provide the bereaved with a sense of safety and security which help with the bereavement and grief process. SLSs can use internal and interactive connections to assimilate and accommodate the loss into their situational and global meaning systems (Jahn and Spencer-Thomas 2014; Jahn and Spencer-Thomas 2018). Similarly, Begley and Quayle (2007) reported that SLSs continued to have attachments to the deceased and believed that the deceased continued to play a role in their lives, adding to their sense of peace which aided in meaning-making and PTG.

On the other hand, Gall et al. (2015) and Jahn and Spencer-Thomas (2018) discussed how some SLSs experience strong and unwanted feelings attributing to negative memories and provoking sadness and/or anger toward the deceased. Some SLSs have expressed that they felt their loved one was not at peace (Gall et al. 2015; Jahn and Spencer-Thomas 2018). These feelings and messages can provoke additional distress, complicating the grief bereavement process.

Whether a sense of presence and continuing bonds are perceived as positive or negative experiences often depends on the interpretation of the message or symbolism and one’s spirituality. The lack of positive experiences with continuing bonds can hinder meaning-making and PTG for SLSs. Some empirical studies have also suggested that continuing bonds or a sense of presence are fabricated; however, increasing evidence supports their value (Čepulienė et al. 2021). In fact, there have been several books written on continuing bonds and their importance in bereavement (Klass and Steffan 2018). However, additional research is necessary to further determine how continuing bonds and a sense of presence are related to meaning-making and PTG for SLSs and their bereavement/grief process.

6.2. Role of God/Higher Power

One of the conflicting experiences for SLSs regarding R/S and meaning-making is the role of God or a Higher Power (HP). Across the literature, many SLSs questioned God’s agency and transcendence in their loved one’s completed suicide (Castelli Dransart 2018; Čepulienė et al. 2021; Gall et al. 2015; Henneberry 2010; Jahn and Spencer-Thomas 2018). To explain this further, some SLSs who believed in or sought guidance from God/ HP after the completed suicide had difficulty assimilating how their loved one’s death was a part of God/HP’s will. SLSs questioned how God/HP could take their loved one away and how God/HP did not intervene to prevent the completed suicide (Castelli Dransart 2018; Čepulienė et al. 2021; Gall et al. 2015; Henneberry 2010; Jahn and Spencer-Thomas 2018).

The challenges associated with God/HP included feelings of anger and betrayal which changed and shattered SLSs previously held relationship with the divine (Castelli Dransart 2018; Henneberry 2010; Jahn and Spencer-Thomas 2018). Additionally, Some SLSs who believed in God/HP also had difficulty assimilating R/S into their new global meanings, resulting in changes to their R/S beliefs and faith (Castelli Dransart 2018). For these individuals, meaning-making and the grief process were more difficult as they had to accommodate and change their global meanings to match their new beliefs.

For other SLSs, R/S beliefs changed their relationship with God/HP, but in a more nuanced way. Their R/S beliefs brought on an understanding or acceptance that God’s involvement in human life involved a sense of companionship (Castelli Dransart 2018, p. 15). To further explain, these SLSs believed that “[God] does not get involved in human life in concrete ways” (Castelli Dransart 2018, p. 15) but instead served as a supportive figure. Additionally, some SLSs also used God/HP to communicate with their deceased loved one to find answers/guidance so they could ultimately achieve a sense of peace (Gall et al. 2015). Jahn and Spencer-Thomas (2018) found that SLSs who can come to a place of awareness and acceptance of God/HP’s role in the suicide loss are more likely to use R/S as a source of healing and comfort. SLSs who viewed God/HP’s role as a negative reminder of their loved one had difficulty using R/S as a mechanism of alleviating distress and meaning-making. SLSs views on God/HP’s role in the completed suicide is important in understanding the bereavement and meaning-making experiences of SLSs.

6.3. An Afterlife

SLSs across the literature spoke on themes of an Afterlife (Castelli Dransart 2018; Gall et al. 2015; Jahn and Spencer-Thomas 2018). The concept of an Afterlife is closely related to religious doctrines and beliefs rooted in cultures and traditions about what happens after death (Čepulienė et al. 2021). Some religious doctrines stigmatize completed suicide, causing questions and concerns regarding their loved one’s journey in an Afterlife (Čepulienė et al. 2021). However, for other SLSs, the idea of an Afterlife can provide comfort and peace. It is also important to note that those who are not religiously affiliated, or who deem themselves to be spiritual and not religious, may also have views of an Afterlife and even reincarnation.

Research has demonstrated that adaptive adjustments and meaning-making often result when the SLS believes in an Afterlife where reconnection and reunion seem possible (Čepulienė et al. 2021). Castelli Dransart (2018), delineated both SLSs who were and were not actively practicing R/S spoke about the possibility of life after death or one day being reunited with their loved one. For example, a participant from the study by Castelli Dransart (2018) said, “I still do not believe in God, but at the same time one day I began to say to myself: one day I will see him again” (p. 10). In another study, SLSs interpreted their spiritual experiences as evidence that an Afterlife exists, which provided comfort and understanding that their loved one was safe and at peace (Jahn and Spencer-Thomas 2018). Castelli Dransart (2018) pronounced that the form in which the Afterlife exists remains unclear. Often the description or belief of an Afterlife depends on the religious doctrines and spiritual beliefs of the SLS. For some SLSs, the Afterlife takes on a form that describes Heaven or being in the presence of God (Castelli Dransart 2018, p. 8). For other SLSs, the Afterlife is more of an energy or soul form that continues to exist, while others believe the deceased carried on through reincarnation (Castelli Dransart 2018). Regardless of the form of an Afterlife, these beliefs often give meaning to survivors as they provide a sense that their loved one is protected and no longer suffering. However, there can be negative associations with an Afterlife for other SLSs depending on religious beliefs regarding suicide death.

In many religious practices, suicide can be sinful, resulting in the need for the deceased to be purified after the act before being allowed to enter into an Afterlife (Castelli Dransart 2018). Thoughts of the need for purification can create conflicting feelings for SLSs as they remain unsure if their loved one is protected or free from suffering (Jahn and Spencer-Thomas 2018). Concerns and fears surrounding an Afterlife can hinder the meaning-making process for SLSs. However, these concerns regarding an Afterlife may be alleviated by R/S rituals and practices (Čepulienė et al. 2021). The idea of an Afterlife further adds to the discussion of how a completed suicide can impact SLSs religious beliefs. A more in-depth review and analysis of specific religious doctrines and beliefs of SLSs regarding a completed suicide are needed to draw further conclusions on the role of an Afterlife in SLSs grief and bereavement processes.

7. Discussion: Clinical Utility of Meaning-Making for Suicide Loss Survivors

Many postvention efforts have supported SLSs through the bereavement process, however, a limited amount of research has studied their implications for practice. Additionally, there is insufficient empirical evidence outlining the effectiveness of available interventions on the bereavement process (Castelli Dransart 2013). The lack of research is particularly concerning from a clinical and community postvention practice point of view. Hunt et al. (2019) imparted that less than five percent of academic literature on suicide addresses postvention. However, studies show a need for clinical support to aid SLSs with bereavement (Castelli Dransart 2013; Peters et al. 2016). For SLSs accessing professional bereavement support, many valued the help they received and expressed it was “moderately to highly helpful” (Castelli Dransart 2013, p. 331). While counselling or psychotherapy may be of assistance to a SLS, further research is needed to understand the process and benefits of postvention treatment.

Suicide loss survivors are a vulnerable demographic thus, it is essential to identify therapeutic interventions that may help foster positive changes, such as meaning-making and PTG with SLSs (Levi-Belz et al. 2021). Mental health practitioners (MHPs) who support SLSs need to focus on interventions that foster growth to help find meaning. Levi-Belz et al. (2021) elucidated that the processes that lead to meaning-making and PTG are important. The clinical view of trauma and traumatic grief is beginning to shift from focusing on deficits to a more inclusive view of positive and adaptive aspects of bereavement (Lee et al. 2019). Accordingly, MHPs working with SLSs can help identify and maintain positive changes through meaning-making efforts.

Given the diversity of settings and fields in which MHPs work, there is a strong probability that clinicians will encounter SLSs within their practice. Therefore, MHPs need awareness and understanding of bereavement processes, as well as the depth of grief that SLSs endure, to be better equipped for supporting bereavement and the reconstruction of meaning (Castelli Dransart 2013; Peters et al. 2016). This review has identified broad areas of the grief and bereavement processes and meaning-making, and the following subsections will connect these themes for SLSs to the clinical utility of meaning-making theory.

7.1. Supporting the Grief/Bereavement Experience of Suicide Loss Survivors

Gall et al. (2014) highlighted the importance of the therapeutic helping relationship between MHPs and those bereaved by suicide using a variety of active listening, and rapport building skill to promote engagement, connection, and sense of control within the therapeutic relationship. A systematic review conducted by Shields et al. (2017) supported this notion by indicating that MHPs working with SLSs must practice from a place of empathy and compassion by providing a space for the survivor to discuss and share their experiences in an understanding and supportive environment (Peters et al. 2016). Henneberry (2010) further emphasized the importance of being fully present to the SLS. Jordan and McGann (2017) argued that a therapeutic presence helps SLSs feel understood by the MHP, reducing feelings of isolation by providing a sense of belonging.

In the early stages of suicide bereavement, Gall et al. (2014) clarified that the goal is to aid the SLS in discussing their grief experiences while the MHP acknowledges, validates, and normalizes this process. MHPs may need to help the SLS establish a sense of stability in order for them to begin to process some of the emotions.

The majority of completed suicides are unexpected, as such, many SLSs report initial feelings of shock and disbelief. Jordan and McGann (2017) explicated that the initial clinical support and intervention for SLSs often involves the “retelling of the death narrative” (p. 660), with the recognition that this step requires attention before meaning-making exploration can begin.

7.2. Fostering Meaning-Making with Suicide Loss Survivors

In making sense of loss, the SLS seeks to find a reasonable explanation for why the death occurred and reframe it within their global meanings. Castelli Dransart (2013) described how MHP’s can help by providing a space for SLSs to discuss their grief. experiences. Intentional use of strategies and procedures to support the integration and reappraisal of the grief experience can assist with reconstructing existing narratives that aid in meaning-making (Castelli Dransart 2013; Jordan and McGann 2017).Through the use of clinical strategies, tools, and the helping relationship, MHPs can support SLSs in their rumination on the why, what if, and how come questions in order to help them accept that they may never make complete sense of the suicide (Henneberry 2010; Jordan and McGann 2017). Castelli Dransart (2013) explained that MHPs can “encourage survivors to broaden their attention from the issue of comprehension (why) to one of finding something of personal significance (what for, existential meaning) and to new post-loss meaning structures and purpose” (p. 332). MHPs may aid SLSs with meaning-making by helping them broaden their thoughts to find personal significance rather than trying to narrowly comprehend why their loved one completed suicide, and to reconstruct a more coherent narrative and meaning.

Additionally, MHPs can support meaning-making through supporting and fostering social connections and relations. As noted above, due to stigma SLSs are likely to isolate themselves from others and meaning-making often occurs within a social context. Therefore, MHPs should provide psychoeducation to de-stigmatize suicide, while creating safe space to discuss the suicide loss, offer social validation for the loss, and enhance the communication and interpersonal skills of the SLS, (Castelli Dransart 2013).While it is beyond the scope of this review to address group intervention strategies, MHPs can also support SLSs in attending suicide loss support groups to foster connection with individuals going through similar experiences.

Mental health professionals must recognize the challenge SLSs experience with finding meaning while attending to the meaning-making process. Communication through an empathetic stance concerning the deceased person’s suffering and the choices involved is a way to begin this development. MHPs need to find a balance between exploring meaning with the SLS while remaining vigilant and watching for signs that they are stuck in a ruminative process (Gall et al. 2014). MHPs must respect the needs and goals of SLSs. Meeting SLSs where they are in the bereavement and meaning-making process is essential.

7.3. Supporting Religion and Spirituality in a Clinical Setting with Suicide Loss Survivors

As previously discussed, the death of a loved one can provoke questions and thoughts surrounding religion and spirituality. Numerous researchers have imparted the importance of addressing and discussing R/S with SLSs (Castelli Dransart 2018; Čepulienė et al. 2021; Gall et al. 2015; Henneberry 2010; Jahn and Spencer-Thomas 2014, 2018). Castelli Dransart (2018) stressed that clinicians need to value and be open to discussing the R/S experiences and struggles that SLSs experience. Thus, it is important for MHPs to address R/S in order to support SLSs holistically. Through discussion of R/S, MHPs may be able to support meaning-making leading to PTG. MHPs can provide SLSs with support and guidance surrounding R/S and experiences as part of the meaning reconstruction process According to Castelli Dransart (2018), MHPs should identify the SLSs R/S beliefs surrounding a completed suicide and explore whether those beliefs are a positive or negative source of coping.

Gall et al. (2015) and Henneberry (2010) revealed that MHPs are often open and willing to discuss issues concerning R/S with SLSs. However, MHPs often wait for SLSs to bring up the topic of R/S within the session, even when there are apparent insinuations of its importance in the grief and bereavement process. The hesitancy MHPs have in bringing up R/S is associated with not wanting to instill their R/S beliefs onto their client, and feeling uncomfortable or uncertain discussing R/S (Henneberry 2010). Furthermore, some MHPs believe it is important to adopt a non-denominational or informal approach to discussing R/S within their practice (Gall et al. 2015). These feelings and beliefs can result in the MHP avoiding asking the SLS questions regarding their R/S experiences, hindering a critical aspect of the meaning-making process.

Many MHPs are conscious of the adverse effects that R/S may have on those bereaved by suicide, and are concerned about the timing of broaching such conversations (Gall et al. 2015; Henneberry 2010). While some practitioners in Henneberry’s (2010) study felt that the timing of these discussions was important, Gall et al. (2015) contended it is problematic to leave discussing R/S until later because the bereaved may be experiencing an R/S crisis that can impede adjustment and meaning-making. Therefore, the MHP should ensure appropriate timing to discussing R/S, and not avoid the topic altogether due to personal biases or beliefs.

Henneberry (2010) affirmed that MHPs need to take the initiative in leading conversations about R/S with SLSs as they may feel shame deriving from stigma and avoid discussing R/S. SLSs may feel more holistically supported if MHPs discuss R/S, which would help the meaning-making and grief process. Castelli Dransart (2018) found that SLSs often wished their MHPs would initiate a conversation regarding R/S in their bereavement experiences. R/S discussions with SLSs may include continuing bonds, sense of presence, the role of God/HP, and questions concerning an Afterlife. Furthermore, MHP should address issues and concerns regarding shame and stigma associated with religious doctrines and communities.

SLSs experiencing challenges with R/S may exhibit more distressing grief symptoms, particularly if they cannot share their personal beliefs surrounding a completed suicide. For example, Castelli Dransart (2018) noted that some SLSs believed their loved one was going to hell or that they were stuck in purgatory, which added to the R/S crisis. If MHPs do not adequately address or discuss R/S with SLSs, negative feelings can be further perpetuated. Further, if feelings of shame or anger towards R/S experiences go unaddressed, the bereaved may have a more challenging time working through the grief and making meaning from the loss. MHPs can help SLSs distress and facilitate the assimilation or accommodation of R/S into their situational and global meanings, ultimately leading to positive reappraisal and growth.

The literature on the role of R/S for SLSs proves to be rather complex. For some SLSs, R/S is a source of comfort, and for others it is a source of suffering. Given the complexity in response MHPs need to be mindful of the R/S themes during suicide bereavement and prepared to discuss positive and negative feelings that may arise. Not all SLSs will identify with R/S or want to share their experiences pertaining to R/S with MHPs. However, clinicians should actively ask questions related to R/S to understand SLSs beliefs and values in order to holistically support their bereavement experiences.

8. Limitations/Gaps in Research

This scoping review followed the methodological frameworks outlined by Arksey and O’Malley (2005) and PRISMA guidelines (Tricco et al. 2018). The scoping review proved to be a practical methodological framework for this study as there was limited research on specific topics assessed within this review. However, it should be noted that the articles included within this review were self-screened, and there is the possibility that articles were missed due to human error.

While none of the articles included in this review were excluded based on quality, several factors related to the quality of the articles should be considered when forming conclusions. The articles each used different methodologies and participant screening tools, and as such, the participants in the articles may have different experiences than those not included. Additionally, this scoping review did not include all mental health professionals but instead focused on clinical counsellors and psychotherapists providing ongoing support rather than acute intervention. Future research should address R/S and meaning-making for SLSs while focusing on a more encompassing service provision such as acute intervention. Furthermore, most studies included participants that were dominantly female, and therefore this review may not include a fair depiction of experiences for males, non-binary individuals, or those across the gender continuum.

The studies outlined within this current review were limited to adults 18 years of age and older who are bereaved by suicide and excluded the opinions and values of children and adolescents. Future research should explore the bereavement processes for younger age demographics. Additionally, religion and spirituality were widely addressed within this research paper, but variances within specific religious doctrines were not accounted for. It may be of value for future research to account for the differences in religious doctrines to distinguish their effect on meaning-making. Lastly, the research looked at suicide and bereavement through a Western lens and did not consider specific bereavement rituals and practices within different cultures. Additional research should consider specific religious doctrines and look at meaning-making in bereavement through a culturally inclusive lens.

9. Conclusions

This scoping review has identified findings related to meaning-making theory for suicide loss survivors. The main themes identified include the feelings following bereavement by suicide, the social context of suicide bereavement, meaning-making from the suicide event, and aspects of religion and spirituality following suicide bereavement. This review connected and analyzed the above-mentioned themes within clinical and counselling or psychotherapy sessions to further understand meaning-making as an effective intervention with SLSs. This review adds to the comprehension and effectiveness of religion and spirituality in meaning-making with SLSs through qualitative studies that examine their bereavement processes. To the best of our knowledge, this is the first scoping review examining the bereavement processes following suicide that concerns meaning-making and religion and spirituality which can improve clinical effectiveness.

The findings reveal that those bereaved by suicide are at heightened risk for CG presentations and struggles with meaning-making. SLSs often experience distressing emotions and feelings following a completed suicide. The most common feelings discussed are related to shock, guilt, responsibility, self-, and shame. These feelings can hinder SLSs from making sense of the suicide and the meaning-making process. The feelings arise due to the SLS ruminating on questions of why, how come, and what-if. SLSs may need help from MHPs to process strong emotions to prevent an endless cycle of rumination.

This review established that R/S practices and rituals can play an important role in grief processes and meaning-making for SLSs. However, the SLSs relationship with R/S may be rather complex and could result in positive or negative coping. In terms of dealing with suicide bereavement, R/S may include issues, distress, challenges, and existential questions, or conversely bring comfort through continuing bonds with the deceased and/or a sense of presence to their loved one. The role/belief of God/HP can be important as well as one’s R/S worldview and the belief in an Afterlife. This review demonstrated that R/S practices used by SLSs have profound meaning and are often a source of positive healing and transformation. The role of the MHP is vital to encouraging this reflective and growth process. Opening up dialogue and creating a space for conversation concerning R/S can promote exploration for SLSs and determining goals for practice interventions.

SLSs can spend years revaluating and reappraising the deceased’s life, the suicide event and themselves. Yet, if the SLS can successfully navigate and negotiate the complex meaning-making process, they will experience healing, and this may require MHP support. However, this does not occur linearly, nor is it packaged into stages or phases of grief theories. Additionally, meaning-making may also be an independent process that is paradoxical in that SLSs have to make sense and find meaning out of something deemed senseless. MHPs can support SLSs in the assimilation and accommodation of their grief and bereavement experiences, which can help foster the meaning-making process for SLSs.

The clinical utility of meaning-making theory for SLSs lacks research and empirical evidence on its effectiveness. However, this review shared how MHPs can support SLSs through the process of meaning-making by providing psychoeducational support, fostering safe and healthy social connections, and facilitating the processing of emotions. It was beyond the scope of this review to analyze suicide loss support groups; however, the research has supported the notion that these groups may be another place for SLSs to find and foster meaning. Therefore, it may be essential for future research to look at meaning-making within support groups for SLSs.