*Article* **Attitudes toward Suicide and the Impact of Client Suicide: A Structural Equation Modeling Approach**

**Irene Pisnoli and Ruth Van der Hallen \***

Clinical Psychology, Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands

**\*** Correspondence: vanderhallen@essb.eur.nl

**Abstract:** Previous research has revealed that mental health professionals (MHPs) often experience significant short- and long-term impacts in the aftermath of client suicide. Individual differences are significant, yet what factors explain these differences remain unclear. The current study aimed to investigate to what extent MHPs' attitudes toward (client) suicide could predict the short- and long-term impacts of client suicide. A total of 213 MHPs, aged between 18 and 75, reported on a client suicide and their attitudes toward (client) suicide using self-report questionnaires. The results indicate that MHPs who believe it is one's "rightful choice" to die by suicide report less and MHPs who believe "suicide can and should be prevented" report more impact of client suicide. Predictability and preventability of client suicide proved strongly, positively correlated; yet, neither predicted the impact of client suicide. Taken together, these findings highlight the importance of MHPs' attitudes toward (client) suicide with respect to clients and MHPs (self-)care.

**Keywords:** practitioner; clinician; survivor; patient; PTSS

**Citation:** Pisnoli, I.; Van der Hallen, R. Attitudes toward Suicide and the Impact of Client Suicide: A Structural Equation Modeling Approach. *Int. J. Environ. Res. Public Health* **2022**, *19*, 5481. https://doi.org/10.3390/ ijerph19095481

Academic Editors: Paul B. Tchounwou, Karolina Krysinska, Karl Andriessen and Yossi Levi-Belz

Received: 12 March 2022 Accepted: 29 April 2022 Published: 30 April 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

### **1. Introduction**

Suicide, defined as an intentional, self-destructive, and self-inflicted act that causes death, is a challenging public health dilemma worldwide [1]. Each year, between 0.5 and 1.2 million people globally die by suicide [2]. For every single loss, it has been estimated that about 135 individuals consider themselves significantly affected [3]. These "suicide survivors", i.e., people that shared an emotional connection with a person who died by suicide, include family and friends as well as mental health practitioners (MHPs), whose grief is often disregarded [4]. Considering that mental illness has been argued to play an important role in about 60–98% of all suicides [5,6], high levels of exposure to suicide (loss) in practitioners are not surprising [7]. In fact, practitioners are at the forefront of supporting individuals at risk of suicide, with 30% to 80% of MHPs in Belgium, the U.S., Ireland, and Australia, as well as approximately 98% of MHPs in Slovenia having lost a client to suicide, commonly referred to as "client suicide" [8–10].

The impact of client suicide on MHPs has been a topic of investigation since the early 1980s. Research suggests short-term consequences of client suicide may include emotions of shock, disbelief, confusion, and denial, as well as feelings of distress, depression, and anger at the client/society, guilt, shame, a profound sense of responsibility, failure, and feelings of incompetence [11,12]. Post-traumatic distress symptoms, such as intrusive thoughts, avoidant behavior toward potential suicidal clients, sleep disturbances, irritability, difficulty managing life events, and emotional burnout, have been suggested to affect about 50% of MHPs following client suicide [13,14]. Long-term consequences of client suicide may involve feelings of self-doubt and inadequacy, sensitivity to signs of suicidal risk, vigilance and caution when dealing with at-risk patients, concern over one's competence to treat patients, as well as feelings of anxiety, depression, or helplessness when doing so [14–16]. Individual differences regarding the impact of client suicide on MHPs have been associated with differences in gender, age, previous exposure to suicide, or coping

strategies [10,14,17,18]. Interestingly, however, it remains unclear to what extent MHPs' attitudes toward (client) suicide are associated with the impact of client suicide.

Attitudes toward suicide are defined as multidimensional evaluations of the most critical aspects of suicidal behavior as manifested in emotional, instrumental, and cognitive components and can vary widely between individuals (for a review, see [19]). For instance, suicide attempters and suicide contemplators have been found to be more accepting of suicide than non-attempters or people without a history of suicidal ideation [20,21]. Furthermore, people with more permissive attitudes toward suicide have been associated with greater rates of suicide ideation [22]. More recently, Pitman and colleagues [23] conducted a qualitative study of attitudes toward suicide in 429 young bereaved adults and found that exposure to the suicide of a close friend or relative can influence attitudes to suicide in ways that would influence one's own risk of suicide later in life. The attitudes of medical staff toward suicide have been known to affect the care they provide suicidal patients [24]. Moreover, Samuelsson and colleagues [25] found nurses' willingness to treat and their ability to empathize with suicidal patients depended on their attitudes toward suicide.

MHPs' attitudes toward suicide, such as the attitudes of psychologists, psychotherapists, psychiatrists, or social workers, have not been researched extensively. Werth and Liddle [26] investigated attitudes toward suicide in 186 psychotherapists and found significant individual differences in accepting suicidal ideation as well as actions taken to prevent a suicide depending on why a person had decided to die by suicide. Overall, psychotherapists with more experience were found to be more accepting of suicide and to take less action to prevent suicide than less experienced psychotherapists. Swain and Domino [27] investigated attitudes toward suicide in 1441 mental health professionals. Overall, clergy and general physicians were found to be less accepting of suicide, especially when compared to social workers, who were found to be the most accepting of suicide. Moreover, professionals with personal experience or acquaintance with suicide were found more likely to accept the notion of suicide and better able to recognize signs of suicidal ideation [27–29]. That being said, one can wonder if one's attitude toward suicide might not just dictate how we deal with, treat, assess, or intervene in cases of suicide, but also how we cope or deal when faced with a client's suicide.

Therefore, the current study aims to investigate to what extent MHPs' attitudes toward suicide are associated with the impact of client suicide. In other words, to what extent are MHPs' attitudes toward (client) suicide informative regarding the short- and long-term emotional and professional impacts of client suicide? The results of this study may help broaden our understanding of the effects of a client's suicide as experienced by MHPs, providing insights relevant for training purposes or to reduce professional stigmatization following a client loss.

### **2. Method**

### *2.1. Participants*

This study included data from 213 participants (25% male, 72% female, and 1% nonbinary) aged between 18 and 75 years. All participants had experienced at least one client suicide. The majority of the sample originated from Belgium (47%), Germany (18%), or The Netherlands (15%). A total of 46% of the participants were psychologists, 14% were psychiatric nurses, 13% were psychiatrists, 10% were counselors, and 9% were social workers.

### *2.2. Procedure*

The present study is part of a larger research project looking into the impact of client suicide (for more details, see [17]). All study protocols were in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Erasmus University Rotterdam, The Netherlands (19-007.R1). The study was conducted via an online survey and was aimed at MHPs who had experienced client suicide. Recruitment was set up via social media, professional newsletters, and email. Individual informed consent was obtained from all participants involved in the study prior to participation. Data were collected using a self-administered, online survey available in English, Dutch, and German. All participants completed two questionnaires regarding their attitudes toward (client) suicide as well as three questionnaires related to the impact of client suicide (for more detail, see below). Survey completion took approximately 15–20 min.

### *2.3. Materials*

The ATTS-18 [30] is an abbreviated version of the Questionnaire on Attitudes Toward Suicide [31], a self-report questionnaire developed to assess one's attitudes toward suicide. Example items include: "*people do have the right to take their own lives*" and "*if someone wants to commit suicide it is their business and we should not interfere*". Each item is rated on a 5-point Likert scale, ranging from 1 "*strongly disagree*" to 5 "*strongly agree*". Following EFA/CFA of the ATTS-18, construct reliability was evaluated for our subscales (see Results).

To assess participants' attitudes regarding the predictability or preventability of client suicide, inspired by Alexander and colleagues [15], the following two sets of questions were included. In general, "how predictable is client suicide?", and "how preventable is client suicide?" (labeled as Pred1 and Prev1). In reference to one particular client's suicide, "how predictable was that client's suicide?" and "how preventable was that client's suicide?" (labeled as Pred2 and Prev2). Either item is rated on a 5-point Likert scale, ranging from 1 "*very unpredictable*" to 5 "*very predictable"* or 1 "*very unpreventable*" to 5 "*very preventable*".

The IES-22-R is a revised version of the original IES [32,33], a self-report questionnaire that aims to measure the subjective stress of a particular (traumatic) event in the seven days following. It includes 22 items divided over 3 subscales: (1) intrusion, (2) hyperarousal, and (3) avoidance. Each item is rated on a 5-point Likert scale, ranging from 0 "*not at all*" to 4 "*extremely*". All 22 items are included in a total sum score. Cronbach's alpha as calculated for the current sample was α = 0.95, suggesting excellent scale reliability.

The Long-Term Emotional Impact Scale (LTEIS; [34,35]) is a self-report questionnaire that aims to measure the long-term emotional impact of MHPs who have experienced client suicide. It consists of 10 items focusing on negative emotions that can occur following client suicide. Examples include aspects of therapeutic competence, such as a diminished sense of personal effectiveness, increased anxiety when evaluating suicidal clients, or the evaluation of a greater number of clients as being at risk of suicide. Each item is rated on a 5-point Likert scale, ranging from 1 "*disagree*" to 5 "*agree*". All 10 items are included in a total average score. Cronbach's alpha as calculated for the current sample was α = 0.87, suggesting good scale reliability.

The Professional Practice Impact Scale (PPIS; [34], inspired by [36]) is a self-report questionnaire that aims to measure long-term changes in professional practices in MHPs who have experienced client suicide. It consists of nine items that focus on the changes in professional practice that often follow client suicide, such as the refusal to work with suicidal clients, a greater inclination to consult colleagues, or the consideration of leaving the profession because of client suicide. Each item is rated on a 5-point Likert scale, ranging from 1 "*disagree*" to 5 "*agree*". All nine items are included in a total average score. Cronbach's alpha as calculated for the current sample was α = 0.77, suggesting good scale reliability.

### *2.4. Data Analysis*

Statistical analyses included exploratory factor analysis (EFA) and structural equation modeling (SEM) using IBM SPSS Statistics 27.0 and AMOS 28.0 for Windows. EFA analyses were performed in SPSS using principal axis factoring as an extraction method, with oblimin rotation and Kaiser normalization. To determine the best factor structure, the eigenvalues (>1), factor loadings (≥0.4), scree plot, and conceptual coherence of the individual factors were taken into account [37]. SEM analyses were performed in AMOS using the maximum likelihood estimation method. Global model fit was evaluated using the comparative fit index (CFI; CFI ≥ 0.90) and root mean square error of approximation (RMSEA; 0.05 ≥ RMSEA ≤ 0.08) [38,39].

### **3. Results**

To investigate the extent to which one's attitudes toward suicide, as measured by the ATTS-18, are associated with the short- (IES-R) and long-term (LTEIS and PPIS) impacts of client suicide, EFA and path analysis in SEM were conducted. First, the ATTS-18 was explored using EFA. Factor loadings for the 18 items of the ATTS-18 and their item descriptions are presented in Table 1. EFA analysis identified a two-factor structure accounting for 45.12% of the total variance. Factor 1 was defined as *Rightful Choice* (nine items) and accounted for 32.28% of the variance with an eigenvalue of 5.81. Factor 2 was defined as *Preventability* (six items) and accounted for 12.84% of the variance with an eigenvalue of 2.31. Item 1, Item 8, and Item 17 were removed from the model as they did not load sufficiently on either factor (<0.40). Next, this two-factor structure was confirmed using SEM. To obtain a good model fit, guided by the modification indices and the correlation matrix, Item 12 and Item 13 were removed from the model, and an error correlation between Items 9 and 15 was included. Acceptable model fit, with CFI = 0.91 and RMSEA = 0.08, 90% CI (0.068–0.092), was achieved for a model with two first-order latent variables (i.e., *Rightful Choice*, seven items, and *Preventability*, six items).

**Table 1.** Factor loadings for the 18 items of the ATTS-18.


Extraction method: principal axis factoring. Rotation method: oblimin with Kaiser normalization.

Next, a path analysis in SEM was constructed to evaluate the extent to which the two-factor structure of the ATTS-18 was able to predict the short- and long-term impacts of client suicide (see Figure 1 and Table 2). The two-factor model explained 14% of shortterm, 7% of long-term emotional, and 12% of long-term professional impact variance. Rightful Choice and Preventability were both significantly related to all three impact variables (*p* < 0.05). Specifically, Rightful Choice had a negative significant relationship with short-term (*β* = −0.31, *p* < 0.001), long-term emotional (*β* = −0.22, *p* = 0.017), and longterm professional (*β* = −0.19, *p* = 0.037), whereas Preventability had a positive significant relationship with short-term (*β* = 0.42, *p* < 0.001), long-term emotional (*β* = 0.29, *p* = 0.002), and long-term professional (*β* = 0.40, *p* < 0.001). In other words, to hold the view that it is one's rightful choice to complete suicide is associated with less impact of client suicide, whereas to hold the view that suicide is (and should be) prevented is associated with more impact of client suicide.

impact of client suicide.

client suicide.

Next, a path analysis in SEM was constructed to evaluate the extent to which the twofactor structure of the ATTS-18 was able to predict the short- and long-term impacts of client suicide (see Figure 1 and Table 2). The two-factor model explained 14% of shortterm, 7% of long-term emotional, and 12% of long-term professional impact variance. Rightful Choice and Preventability were both significantly related to all three impact variables (*p* < 0.05). Specifically, Rightful Choice had a negative significant relationship with short-term (*β* = −0.31, *p* < 0.001), long-term emotional (*β* = −0.22, *p* = 0.017), and longterm professional (*β* = −0.19, *p* = 0.037), whereas Preventability had a positive significant relationship with short-term (*β* = 0.42, *p* < 0.001), long-term emotional (*β* = 0.29, *p* = 0.002), and long-term professional (*β* = 0.40, *p* < 0.001). In other words, to hold the view that it is one's rightful choice to complete suicide is associated with less impact of client suicide,

**Figure 1.** Path analysis for the short-term (IES-R), long-term emotional (LTEIS), and long-term professional (PPIS) impacts of client suicide, as predicted by the ATTS-18. **Figure 1.** Path analysis for the short-term (IES-R), long-term emotional (LTEIS), and long-term professional (PPIS) impacts of client suicide, as predicted by the ATTS-18.

**Table 2.** Regression weights for the ATTS-18 predicting short- and long-term outcomes of **Table 2.** Regression weights for the ATTS-18 predicting short- and long-term outcomes of client suicide.


Preventability PPIS 0.290 0.067 0.401 <.001 Note. IES-R: Impact of Event Scale—Revised; LTEIS: Long-Term Emotional Impact Scale; PPIS: Note. IES-R: Impact of Event Scale—Revised; LTEIS: Long-Term Emotional Impact Scale; PPIS: Professional Practice Impact Scale.

> Professional Practice Impact Scale. To investigate the extent to which MHPs' attitudes toward client suicide are associated with the short- (IES-R) and long-term (LTEIS and PPIS) impacts of client suicide, CFA and path analysis were conducted. First, the two-item, two first-order latent variable factor structure (i.e., Predictability and Preventability) was confirmed using SEM. Since both latent variables contain only two indicators, factor loadings were constrained To investigate the extent to which MHPs' attitudes toward client suicide are associated with the short- (IES-R) and long-term (LTEIS and PPIS) impacts of client suicide, CFA and path analysis were conducted. First, the two-item, two first-order latent variable factor structure (i.e., Predictability and Preventability) was confirmed using SEM. Since both latent variables contain only two indicators, factor loadings were constrained to be equal prior to analysis [40]. Good model fit, with CFI = 0.97 and RMSEA = 0.05, was achieved.

> to be equal prior to analysis [40]. Good model fit, with CFI = 0.97 and RMSEA = 0.05, was achieved. Second, a path analysis in SEM was constructed to evaluate the extent to which the two-factor structure was able to predict short- and long-term impacts of client suicide (see Figure 2 and Table 3). The model explained 44% of short-term, 65% of long-term emotional, and 63% of long-term professional impact variance. Predictability and Preventability were highly positively correlated (*r* = 0.97, *p* <0.001), yet neither proved significantly related to any of the three impact variables (*p* > 0.05). Predictability was not significantly related to short-term (*β* = −2.43, *p* = 0.225), long-term emotional (*β* =−3.04, *p* = 0.213), or long-term professional impact (*β* = −2.94, *p* = 0.220). Similarly, Preventability was not significantly related to short-term (*β* = 2.54, *p* = 0.190), long-term emotional (*β* = 3.08, *p* = 0.191), and long-term professional impact (*β* = 3.04, *p* = 0.189). In other words, MHPs' attitudes toward (a particular) client suicide were not associated with the impact of said client suicide.

**Figure 2.** Path analysis for the short-term (IES-R), long-term emotional (LTEIS), and long-term professional (PPIS) impact of client suicide as predicted by Predictability vs. Preventability. **Figure 2.** Path analysis for the short-term (IES-R), long-term emotional (LTEIS), and long-term professional (PPIS) impact of client suicide as predicted by Predictability vs. Preventability.

Second, a path analysis in SEM was constructed to evaluate the extent to which the two-factor structure was able to predict short- and long-term impacts of client suicide (see Figure 2 and Table 3). The model explained 44% of short-term, 65% of long-term emotional, and 63% of long-term professional impact variance. Predictability and Preventability were highly positively correlated (*r* = 0.97, *p* <0.001), yet neither proved significantly related to any of the three impact variables (*p* > 0.05). Predictability was not significantly related to short-term (*β* = −2.43, *p* = 0.225), long-term emotional (*β* =−3.04, *p* = 0.213), or long-term professional impact (*β* = −2.94, *p* = 0.220). Similarly, Preventability was not significantly related to short-term (*β* = 2.54, *p* = 0.190), long-term emotional (*β* = 3.08, *p* = 0.191), and long-term professional impact (*β* = 3.04, *p* = 0.189). In other words, MHPs'

**Table 3.** Regression weights for Predictability and Preventability predicting short- and long-term outcomes of client suicide. **Table 3.** Regression weights for Predictability and Preventability predicting short- and long-term outcomes of client suicide.


Preventability PPIS 7.992 6.089 3.040 .189 Note. IES-R: Impact of Event Scale—Revised; LTEIS: Long-Term Emotional Impact Scale; PPIS: Note. IES-R: Impact of Event Scale—Revised; LTEIS: Long-Term Emotional Impact Scale; PPIS: Professional Practice Impact Scale.

### **4. Discussion**

Professional Practice Impact Scale.

client suicide.

**4. Discussion**  Individual differences regarding the impact of client suicide on MHPs have long been a topic of investigation, for instance, with regard to the difference in gender, age, previous exposure to suicide, or coping strategies [10,e.g., 14]. Interestingly, the extent to which one's attitudes toward (client) suicide might be associated with the impact of client suicide on MHPs had not received a lot of attention. Therefore, the current study aimed to investigate to what extent MHPs' attitudes toward (client) suicide are informative regarding the short- and long-term impacts of client suicide. Looking at attitudes toward suicide, our model explained 14% of short-term, 7% of long-term, and 12% of the longterm professional impact variance. Rightful Choice was associated with less short- and long-term impact, whereas Preventability was associated with more short- and long-term impact. Looking at attitudes toward client suicide, our model explained 44% of the shortterm, 65% of the long-term emotional, and 63% of the long-term professional impact variance. Yet, neither Predictability nor Preventability predicted impact. Implications for Individual differences regarding the impact of client suicide on MHPs have long been a topic of investigation, for instance, with regard to the difference in gender, age, previous exposure to suicide, or coping strategies (e.g., [10,14]). Interestingly, the extent to which one's attitudes toward (client) suicide might be associated with the impact of client suicide on MHPs had not received a lot of attention. Therefore, the current study aimed to investigate to what extent MHPs' attitudes toward (client) suicide are informative regarding the short- and long-term impacts of client suicide. Looking at attitudes toward suicide, our model explained 14% of short-term, 7% of long-term, and 12% of the long-term professional impact variance. Rightful Choice was associated with less short- and long-term impact, whereas Preventability was associated with more short- and long-term impact. Looking at attitudes toward client suicide, our model explained 44% of the short-term, 65% of the long-term emotional, and 63% of the long-term professional impact variance. Yet, neither Predictability nor Preventability predicted impact. Implications for both research and clinical practice are discussed.

both research and clinical practice are discussed. Regarding attitudes toward suicide, our results indicate that generally, one's attitudes toward suicide can indeed play an important role in understanding individual Regarding attitudes toward suicide, our results indicate that generally, one's attitudes toward suicide can indeed play an important role in understanding individual differences in impact following client suicide. Rightful Choice was negatively associated with shortand long-term impact, whereas Preventability was positively associated with short- and long-term impact. In other words, participants who hold the belief that "one has the right to take their own life", "would consider the possibility if ( . . . )", or "can understand that people complete suicide" reported less impact of client suicide, whereas participants who hold the belief that "suicide can be prevented", "it is our human duty to prevent ( . . . )", or "(suicide) is among the worst things to do ( . . . )" reported more impact of client suicide. Whilst novel, overall, these findings seem in line with previous research that suggests that our attitudes toward suicide impact how we perceive suicide-related behavior or intentions. As aforementioned, individuals with a history of suicidal ideation or non-fatal suicide attempts have been found to be more accepting [20,21] and individuals with more permissive attitudes toward suicide have been associated with greater rates of suicide ideation [22]. Moreover, exposure to the suicide of a close friend or relative has been found to influence one's attitudes toward suicide [23], and attitudes of medical staff toward suicide have been known to affect the (willingness to and) care provided to suicidal

patients [24,25]. Last but not least, the belief that "any and every suicide is preventable" has been associated with increased distress in MHPs, as MHPs and their organizations involved in a client suicide may therefore be more inclined to look for a scapegoat or direct blame to one person [41].

Regarding attitudes toward client suicide, our results reveal that the more one considers client suicide predictable, the more preventable one considers it to be, and the other way around; yet, neither stance was significantly associated with the impact of client suicide. Previous research considering attitudes toward client suicide is limited and mostly descriptive. Rothes and colleagues [10] investigated the impact of client suicide in 107 psychiatrists and revealed that 57% of psychiatrists considered their most distressing case of client suicide to be little or not at all preventable and 39% of them thought the event was little or not at all predictable. As such, the predictability and preventability expectations of client suicide seemed to be associated with subsequent distress. Moreover, while Alexander and colleagues [15] reported that publicity in the media and the prospect of litigation exacerbated or modulated the impact of client suicide, attitudes toward client suicide did not. Interestingly, however, the authors did note the importance of said attitude, concluding that "*psychiatrists have to strike a difficult balance in their attitudes to suicide. If they regard suicide as fundamentally unavoidable (* . . . *) such a belief may foster therapeutic nihilism, (* . . . *) if suicide is perceived to be largely preventable and predictable, this may foster a culture of blame."* [15] (p. 1573). Last but not least, previous research suggests that if one can recognize that it is the client, not the MHP, who is ultimately responsible for a client's suicide, this ameliorates the impact of client suicide on the mental health professional [35,42].

Important implications for clinical practice (and supporting research) follow from these results. The current results suggest our attitudes toward (client) suicide do not only influence how we think about client suicide, suicidality, or the care we provide, but also to what extent we are affected or impacted by a client's suicide. Currently, however, (post)graduate training programs for MHPs pay little to no attention to one's attitudes toward suicide [43]. If within these programs suicide is discussed, the emphasis is on understanding suicide, its prevention, and care, and rarely are MHPs asked to reflect on their own ideas or attitudes toward suicide, nor are they stimulated to consider the relevance of such beliefs [44]. Helping MHPs become more aware of the (importance) of their attitudes toward suicide may prove valuable with regard to prevention, (self-)care, and MHPs' understanding of what they may (not) experience in the aftermath of client suicide. Individual differences in how MHPs respond to client suicide are significant and often puzzling to all parties involved. Increased awareness of what factors underlie these individual differences may prevent stigma, maladaptive emotional responses, or feelings of loneliness and isolation. This proposition is in line with previous work by Linke and colleagues [45], who have suggested that MHPs' professional training should foster the idea that suicides are not always preventable. Similarly, Sanders and colleagues [46] have argued in favor of exploring feelings of powerlessness that may arise following a client's suicide and of the notion that not all suicides can be prevented. While the goal would not be (and should not be) to change MHPs' attitudes toward suicide, conversations about the relevance of one's attitudes toward suicide among fellow students or colleagues may prove highly valuable for both patient care as well as self-care regarding suicidality. Moreover, suicide-related training programs should educate MHPs on the likelihood or probabilities of (client) suicide, that suicide is not always preventable, and what the personal and professional impact of a client's suicide might involve. The vast majority of MHPs do not typically receive suicide-related training in assessment, treatment, or risk management, while such programs have been found to positively impact professional practices, clinic policy, and clinicians' confidence and beliefs [47,48].

### *Limitations and Recommendations*

The design of the current study was cross-sectional and employed a convenience sample. Moreover, retrospective self-report data were collected and analyzed. An impli-

cation of this would be that the events, thoughts, feelings, and behaviors reported by the participants could have taken place at any time, even many years previously, and may be subject to self-report bias. Although self-report questionnaires and convenience samples are frequently used in trauma research (e.g., [49–53]), the generalizability of the results may be limited as a result. Moreover, MHPs' attitudes toward suicide were collected when at least one client suicide had already taken place (see inclusion criteria for the current study), rather than before (and after) such event had taken place. The number of client suicides experienced, or the time passed since the event, were not recorded. Previous research, however, suggests that experiencing a client's suicide can alter a clinician's attitudes toward suicide [26,28,29,54]. As such, the current results pertain only to the relationship between MHPs' attitudes toward (client) suicide and the impact of said client suicide as measured after the fact and may not entirely generalize to attitudes toward (client) suicide measured when no such client suicide has taken place (yet). Finally, the ATTS-18 included in the current study was subject to an EFA, resulting in two distinct factors not identified by others previously, potentially limiting the generalizability of the results. Future research is advised to employ a longitudinal design and/or employ a more qualitative approach, assessing attitudes toward (client) suicide in MHPs at the start of their career, allowing for the (re)evaluation of said attitudes over time and, if the situation occurs, following one or more client suicides. That way, research could also further investigate to what extent the number of client suicides one has experienced impacts both MHPs' attitudes toward suicide as well as the impact of client suicide [34]. Moreover, qualitative approaches would allow for a deeper understanding of the experience the MHP has gone through and of the correlated emotions in the MHPs' own words.

### **5. Conclusions**

To conclude, the current study conducted an in-depth investigation of MHPs' attitudes toward (client suicide) in light of the short- and long-term impacts of client suicide. Overall, the results indicate that MHPs who believe it is one's "rightful choice" to complete suicide tend to report less impact of client suicide, whereas MHPs who believe "suicide in general can and should be prevented at all times" tend to report more impact of client suicide. Moreover, the more MHPs consider client suicide as predictable, the more preventable MHPs consider it to be, and the other way around. As such, the current findings highlight the importance of suicide-related training programs and the extent to which such training programs should discuss MHPs' attitudes toward (client) suicide to improve client care as well as MHPs' self-care and mental well-being.

**Author Contributions:** Conceptualization and data curation, R.V.d.H.; formal analysis, I.P. and R.V.d.H.; writing—original draft preparation, I.P.; writing—review and editing, R.V.d.H. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Erasmus University Rotterdam (protocol code 19-007.R1, 21 May 2019).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data that support the findings of this study are available on request from the corresponding author, Ruth Van der Hallen.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


## *Article* **"It's a Living Experience": Bereavement by Suicide in Later Life**

**Trish Hafford-Letchfield 1,\*, Jeffrey Hanna <sup>1</sup> , Evan Grant <sup>1</sup> , Lesley Ryder-Davies <sup>1</sup> , Nicola Cogan <sup>2</sup> , Jolie Goodman <sup>3</sup> , Susan Rasmussen <sup>2</sup> and Sophie Martin <sup>1</sup>**


**Abstract:** Bereavement by suicide for people in later life is significantly under-researched. Research on ageing and suicide has yet to address the experiences of those bereaved by suicide and how such a devastating loss affects the ageing experience. **Objectives**: We explored the substantive issues involved in bereavement by suicide and its impact on later life. **Methods**: This was a co-produced qualitative study. Peer researchers with lived experience conducted in-depth interviews with twentyfour people aged 60–92 years. A phenomenological approach informed the data analysis. **Main Findings:** Themes described included (1) moral injury and trauma; (2) the rippling effect on wider family and networks; (3) transitions and adaptations of bereaved people and how their 'living experience' impacted on ageing. **Conclusions**: It is important to understand how individual experiences of suicide intersect with ageing and the significance of targeted assessment and intervention for those bereaved by suicide in ageing policies and support.

**Keywords:** bereavement; suicide; ageing; later life; suicide prevention; moral injury; trauma; peer support

### **1. Introduction**

Death by suicide is a complex issue of global concern. It is estimated that 700,000 people die from suicide every year [1,2]. In the UK, 8.67% of all deaths are from suicide [3]. This has a significant impact on those bereaved by suicide (commonly defined as someone who has: "lost a significant other (or a loved one) by suicide, and whose life is changed because of the loss" (p. 43) [4]. The interpersonal impact stretches far beyond those closely related to the person [5].

The experiences of suicide bereavement of those aged >60 years old, however, remains a significantly under-researched area. A systematic review of studies found that none fulfilled the inclusion criteria [6]. Hyboldt et al.'s [7] subsequent qualitative empirical study investigated the age-related factors for participants during the post-bereavement restoration process and their re-orientation to life after such a devastating loss. The lack of theoretical and methodological consistency in suicide and ageing research has also been noted [8,9]. Research findings also call for the greater engagement of care professionals [10–12] and consideration of the interpersonal and structural impacts of ageism [13] in order to find answers to the multi-faceted impact of bereavement by suicide. This study sought to explore the experience of being bereaved by suicide on the individual in later life, the implications for help-seeking, support needs and how bereavement by suicide interacts with ageing experiences.

### **2. Materials and Methods**

This study used an in-depth interpretative phenomenological approach (IPA) [14] to explore the substantive issues for people bereaved by suicide in later life. IPA is concerned

**Citation:** Hafford-Letchfield, T.; Hanna, J.; Grant, E.; Ryder-Davies, L.; Cogan, N.; Goodman, J.; Rasmussen, S.; Martin, S. "It's a Living Experience": Bereavement by Suicide in Later Life. *Int. J. Environ. Res. Public Health* **2022**, *19*, 7217. https://doi.org/10.3390/ ijerph19127217

Academic Editors: Karolina Krysinska, Karl Andriessen and Yossi Levi-Belz

Received: 28 April 2022 Accepted: 10 June 2022 Published: 13 June 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

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with the human lived experience, and posits that experience can be understood through exploring the meanings which people impress upon it [15,16]. The research team comprised of academic researchers from social work, psychology, a national mental health charity engaged with ageing empowerment, and two peer researchers (aged 60+ years, with lived experience). Peer research is thought to promote accessibility by grounding data collection in the experiences of those being researched [17,18] and to produce more relevant and practice-oriented knowledge [19,20].

We recruited peer researchers through our charity partner. Peer researchers were remunerated in line with UK guidance for working with experts by experience [20]. This democratisation of the research process required the team to have clear structures to support team members with different expertise and knowledge such as regular briefings and debriefings to mitigate the impact of emotive interviews and practices that more experienced researchers may take for granted [18]. This included providing formal training on qualitative interviewing and data analysis and opportunities for both verbal and written structured dialogue to facilitate mutual and reciprocal learning. The topic guide (see Table 1) was informed by a literature review and scoping of current suicide prevention strategies for potential domains and constructs [21]. While the topic guide had a strong focus on support after loss, it sought to gain broader insights into participants' lived experiences of their loss(es) and their specific relationship to their experiences of ageing.

**Table 1.** Areas covered in the Interview Topic Guide.


The framework underpinning data collection encouraged participants to recount events and the impact of the loss surrounding the person(s) they were talking about by narrating their experience into temporal order and meaning, with a particular emphasis on how this affected their later life. This flexible approach to interviewing encouraged reflective thinking and effort to explain their situation and response to it [22].

The target population were people who were aged 60 years and over, living in the UK, with experience of the loss of a significant other by suicide at least 12 months prior to engaging in the interview. Omerov, Steineck and Dyregrov et al. [23] suggested that meaning-making, recall of experiences and post-traumatic growth are better after this period. The team used purposive and opportunistic sampling to recruit participants using direct mail shot through organisations connected with older people in the UK and via social media. Following screening and informed consent, participants completed a short demographic questionnaire, which captured their individual characteristics, their relationship to the person who died, and the length of time that had passed since the suicide.

One-to-one interviews were conducted virtually on the telephone (*n* = 10) or Zoom (*n* = 14) over 3 months in 2021 coinciding with a period of COVID-19 lockdown in the UK. These were audio-recorded with informed consent and professionally transcribed verbatim. Interviews lasted between 39 and 100 min (mAvg = 58 min). Four members of the team conducted twenty-four individual interviews; and the peer researchers conducted sixteen of these interviews.

As a descriptive, cooperative study, data analysis was inductive. Two researchers read and coded every transcript and met to discuss each transcript as well as identify and reflect upon preliminary themes. These meetings were audio recorded and the transcriptions used to verify and report on the main themes. This method drew on constant comparison [24] to help uncover participants' meanings and furthering interpretive understandings [25]. The team observed data saturation after approximately 17 interviews. In the transcripts, we looked for complex ideas, particularly age-related issues, metaphors and critical moments. We also engaged in a critical reflection of how the qualitative data were interpretated in order to capture any biases and misperceptions during the analytical process. Analyses focused on understanding the breadth of experiences and building a picture of bereavement by suicide, and what this meant for later life grounded in the participants' own narratives.

Ethical approval was provided by the University of Strathclyde Ethnics Committee. Participation was voluntary and followed both verbal and written consent. A key ethical consideration was the impact on researchers and participants from talking about bereavement and suicide [26,27]. The protocol drew on established guidance for working with people bereaved by suicide [28]. Participants were given a structured debriefing and signposted towards support. Participants were followed up one week after the interview to remind them about self-care. Researchers kept a critical incident/reflective diary for their own personal use alongside interviewing. The team adopted guidelines on working with vicarious trauma and had regular debriefings and access to a clinical psychologist. In the spirit of cooperative enquiry, we established clear processes for the peer-research members of the team to ensure that their contributions were valued and provided opportunities for their challenge and leadership [29].

A project advisory group comprised members working in suicide prevention, bereavement support, mental health social work, and a lay older person. This group reviewed the research protocol and tools, and commented on the findings from the interim report.

### **3. Results**

Table 2 provides details on the characteristics of the participant sample (*n* = 24). The participants were predominantly female. Participants were aged 60–94 years old (mAvg = 72.0 years). Their relationship to the person who died by suicide included; being their parent (*n* = 15), spouse/partner (*n* = 4), parent in-law (*n* = 1), grandparent (*n* = 1), aunt/uncle (*n* = 1), and sibling (*n* = 2). The time elapsed between the death was between 1 and 20 (mAvg = 6.8 years).

**Table 2.** Characteristics of the 24 participants included in the study.




Table 3 provides a schematic diagram and description of the three themes and subthemes discussed in this paper. Age-related experiences were integrated across three themes comprising: (1) moral injury; (2) the rippling effect on relationships; and (3) transition and adaptation through a living experience in later life.

**Table 3.** Schematic diagram of key themes from the qualitative data.


### *3.1. Moral Injury and Trauma*

Most participants provided vivid and visceral descriptions of learning about the suicide and its immediate aftermath. These encompassed intense physical and emotional pain with severe shock and numbness. Two people used the metaphor of 'a bomb going off' to convey the immediate and uncontrollable devastation experienced by such a traumatic loss.

A sense of moral injury in the aftermath of experiencing a loss by suicide incorporated an overall sense of failing to prevent, bearing witness to, or learning about the suicide and how this transgressed deeply held moral beliefs and expectations, which compounded the traumatic loss. The distressing psychological, social, behavioural aftermath following the suicide in turn gave rise to moral injury. Negative reactions from people in the bereaved person's network left them feeling isolated and removed from crucial sources of support:

*"Because it was suicide, I could instantly tell by the person's reaction whether to go on with the conversation. A lot of them, kind of, just back away and wouldn't even respond. I remember walking down the town that I used to live in, this lady that I knew really well was walking towards me, she crossed over when she saw me. I'll never forget that."*(female, 69, parent).

This literal crossing of the street to avoid the bereaved person came up regularly. Moral injury stemmed from the lack of insight and discomfort of other people which one participant described as 'sheer callousness'. Self-stigma, guilt, shame and self-blame inevitably gave rise to feelings that they should have been able to prevent this, to have foreseen it, been a better parent or partner, and awareness of the manifest negative judgement and stigma from others:

*"* . . . *it's the guilt that this person* . . . *could do something so awful to themselves. To be so desperate that they'd take their own life. You know,* . . . *I think, the guilt just gets to you, just* . . . *and you feel that everybody's sort of, not judging you, but they must think, gosh, you know, what's happened in this family, that this person could do this to themselves? Why did he not come to you and talk to you?"* (female, 64 years, parent).

Despite some knowing that suicide was a risk and that it could happen, it was still a tremendous shock that made people feel responsible or that they had failed in some way:

*"* . . . *I felt I should have been able to do something to have spotted what was going on* . . . *done something to change the course of events."* (male, 72 years, partner).

Moral injury also occurred where participants were dismissed where they had asked for professional help. They described missed opportunities during the immediate period before the suicide:

*"he'd been threatening with suicide and that day they had the mental health team out, a crisis team and he told them he was wanting to die and they dismissed it, basically and left him in the community. They had convinced me and my daughter that, oh, we were overreacting* . . . *it was only a few hours later he killed himself."* (female, 62 years, grandparent).

### 3.1.1. The Rippling Effect on Relationships and Wider Social Networks

*"I can honestly say it was the most devastating thing that's ever, ever happened to me. I had been bereaved, I'd lost both my parents, I'd lost my friends, I had a miscarriage, I've been divorced. I had gone through major life affecting events but honestly this was* . . . *I just can't tell just how devastating it was."* (female, 72 years, parent).

Participants not only gave testament to the devastating effect on their own lives but this touched significant others (partner, children, friends, wider family) and social networks (acquaintances, work colleagues, neighbours, community) both in the immediate aftermath and longer-term impact. From their later life perspective, some framed these impacts in the context of historical traumatic events and problematic relationships. These affected their coping mechanisms and particularly the family.

The bereaved person's caring role often took precedence over their own immediate needs. One man talked about his mother who deteriorated quickly after the suicide with cognitive decline and died soon after:

*"she was diagnosed with Alzheimer's in February and I truly believe, it was bought on by the shock of my brother's death.* . . . *she went down so quickly, it was shocking"* (female, 62 years, sibling).

Earlier traumatic events involving domestic violence, alcohol issues and the ambivalence from particular family members involved the bereaved person moderating challenging relationships. They were often responsible for all the practical arrangements. Roles became complex where there were blended or reconstituted families. Several participants bereaved as parents, articulated challenges associated with a difficult relationship with an ex-partner or the other parent. They felt unable to comfort each other, remained in dispute about the arrangements for their loved ones such as who could attend the funeral. These experiences contributed to the participants' own lack of self-care and, for some, to extreme post-traumatic stress. Combined with blame and shame, post-suicide family interactions became extremely stressful. Such fractured relationships compounded the person's own loss, and for some, led to a deep sense of betrayal. This extended to their wider friendships:

*"There was one friend actually who I thought was a good friend and she sent flowers and sent a card and then I didn't hear anything from her at all for nine months* . . . *I was absolutely furious, I thought she has not been in touch with me since he died, not once to say are you okay, is there anything I can do, do you want to talk?* . . . *and then nine months later when it's my birthday she just gets in touch and asked me if I wanted to go out for lunch. No mention of [name], no mention of how are you feeling* . . . *And I just said I don't want you to contact me ever again* . . . . . . *she didn't even come to the funeral, she didn't ask when it was, she didn't come, and I was so livid that after 20 years I just cut off all connection with her."* (female, 62 years, grandparent).

These silences were as injurious as insensitive comments. Participants spoke of awkward silences or countered expectations that they '*should have got over it by now*' or *'it was God's will"* (Participant 22, female, 63 years, partner). They longed to be asked how they were coping, to have the person's name spoken and experience other meaningful exchanges about the things most important to them.

Sources of practical support were, however, highly valued:

*"The practical things my daughter is absolutely amazing. She took over everything. I mean, I'm absolute* . . . *I'm at the stage in life, I'm nearly 70, I just couldn't deal with anything anyway, but she is so good* . . . *she thinks of everything, actually. And she still does."* (female, 62 years, grandparent).

From a later life perspective, participants often reflected an appreciative and empathetic understanding of the impact of the suicide on the family. Losing a child in later life conflicted with the expected 'natural order'. Their social standing or position within the family subsequently changed with new responsibilities and dependencies; taking care of grandchildren, siblings and younger family members. They found themselves compensating for the absence of the deceased person, being tentative about their own grief and holding back:

*"She needs me* . . . . . . *and what I did was, I became the* . . . *I, kind of, absorbed everyone's pain. My mum, my niece, my nephew, my sister, so I didn't actually have time to process me. And my aunt actually rang me and said, [name] what about you?"* (female, 62 years, sibling).

Another participant (male, 78 years, partner) was concerned about their daughter, who at the time of losing her mother by suicide, had four girls all under four including twins of three months. Another commented:

*"So, the first few weeks really was me being there for them and cooking and cleaning and doing all the things that she couldn't do. I had to be there and I had to be strong and look after my granddaughter because her mother wasn't capable of doing it at the time, she was in such grief that she couldn't do anything. My daughter couldn't go to work, she was in very, very, deep depression* . . . *"* (female, 68, grandparent).

These intense caring responsibilities sandwiched between ageing parents and their own children, found participants caught in the firing line. For example, one 78-year-old experienced abusive phone calls after the funeral from her daughter-in-law's parents, blaming her for the suicide. Another 69-year-old, after losing her father, described being at the mercy of her 'controlling' mother and being at the receiving end of her anger, which was very hurtful.

### 3.1.2. Transition and Adaptation to Ageing through a Living Experience

The third theme reflected poignant and significant experiences in the personal journey of the bereaved person in later life. This included reflections about their own future, motivation, mortality, and accounts of help seeking. Some described periods of transformation often coinciding with activism and leadership with their peers through shared lived experience. While participants were bereaved at different age-points in their life, they reflected on what their experience meant in terms of ageing:

*"* . . . *I'm 74 and she was my only child* . . . *she was the future and how things are going to be is something very, very important at the moment. I'm giving sort of a lot of thought to it and it's causing me a lot of sadness. So, it's something that, yeah that I need to really* . . . *that I've been thinking of. At one point years ago, in terms of a Will, in terms of what I do with my property and my precious possessions and things, is something that is huge"* (female, 74 years, parent).

This perception of having no-one to look out for you in later life was evident:

*"I think that's the older a person is, when the bereavement happens, the more age does have an impact from isolation point of view, or lack of grand-children, or lack of somebody coming in to do your washing for you, or whatever it might be. The older you are, the less time you've got to sort of get your life back together again in some way or other"* (female, 73 years, parent).

One woman living alone (aged 74) was now using psychotherapy. She reflected on the COVID-19 national lockdown and how she had 'always been locked down' since her daughter's death. This was an important time for reparation and she did a 'lot of (positive) sorting and thinking' about her daughter. She observed the potential for a greater understanding of the impact of death following the huge loss of people during the pandemic as positive. She also used a telephone befriender service which she found helpful and comforting and described herself as "*emerging again like a metamorphosis, like a butterfly, but it's a long, long process".*

Two others commented on the relationship between their grief and the physical and psychological effects of growing older:

*"Well, the first one is, I find sometimes that something's bothering me or upsetting me, or I'm feeling down, I think well is this [Name] or is just getting old?* . . . *am I attributing all of this to the bereavement, when in actual fact, I'd be feeling like this anyway?* . . . *I don't think you can rush grief. But, at the same time, I'm conscious of the fact that if I don't try and at least twin track, I'm not going to finish grieving before I die."* (female, 73 years, parent).

These health concerns triggered greater awareness of the participant's vulnerability and potential dependencies:

*"I had a foot operation, nothing serious, about a year and a half ago and that made me really realise that there's not going to be [name] around to come and be my next of kin. It* *really struck home that sort of feeling that as you approach old age and all the rest of it, you're not going to have your nearest and dearest around. It's something that I've got to manage very much on my own."* (female, 74 years, parent).

Another man's insight was philosophical:

*"We struggle with that somebody has gone, and they're actually gone forever. And again, I put it down in part, to a sort of an arrogance that we feel we're impregnable and immortal, yet we know we're not, and I know now, that as I age more and more"* (Participant 15, male, 72 years. partner).

Participants reflected on the timing of the suicide within their own life course, how they learned to cope and adapt to the loss and its association with other (sometimes cumulative) losses. One woman was 'glad' this happened when she was older, as she had more time with her daughter and in anticipation of living a short while longer would have less pain to endure:

*"Well, I sometimes feel that I've not got the energy for it anymore.* . . . *I feel as if one leg of the table's missing, if you know what I mean. That sounds a bit weird, but there's still a limp if you know what I mean. That's what I'm trying to say, I think. I feel at times kind of broken, yes."* (female, 78 years, parent).

For those retired, they talked about feeling or being very alone, their lack of plans and described temporal and visceral moments that captured these feelings:

*"You feel it, and you'll recognise this I'm sure, [name] yourself. It's mornings and evenings, those early hours, those moments when you put yourself into bed, and there is this, almost deafening silence".* (male, 72 years, partner).

Some bereaved parents remised about lost opportunities for grandchildren. This meant loss of practical support and angst about their future:

*"It feels as if my chest is being torn up".* (female, 63 years, parent).

Participants echoed the importance of disclosure, talking, listening and the validation of experiences following loss through suicide. They described different experiences of seeking help, the type of help offered and taken forward. Some appeared to require initial support that focused on the trauma of the suicide, whilst some accessed therapeutic/counselling services earlier on. They perceived these latter interventions as being more valuable once a significant period had passed. The timing of help seeking and help giving was arbitrary but very important. Those who developed extreme post-traumatic stress were able to connect with appropriate services, whereas many had hit or miss experiences with access and signposting to services:

*"She gave me permission to fall. And I fell hard. I became scared of everything, I didn't like the dark, I became paranoid, I thought people were talking about me. It was the most frightening time of my life. There was no energy, I just slept all day and all night. So, one or two weeks since* . . . *I had to go back to the doctor to renew my prescription and he said, what can I do to help, would you like counselling? And I said, yes please. So, that was my turning point. But those few weeks were the darkest period of my life* . . . *I'm really lucky that I was able to meet with this counsellor, who was my saviour."* (female, 74 years, parent).

Help-seeking was connected to motivation to survive, or having to carry on for others:

*"You've got a very simply choice, you either carry on or you don't. And I did have moments, I think they were, what I would call, poetic moments* . . . *I remember going through a period, I can't remember quite when it was, when [name] had gone, and realising that both my daughters are married, they've both had two children, my mother was still alive, she only died, it's coming up to two years now.. and I remember feeling, nobody needs me anymore. Nobody needs me. My kids don't really need me. They've got their own lives, I'm potentially a complication."* (male, 72 years, partner).

There were references to suicidal thoughts and/or wish for the hastening of the end of life that came and went:

*"I sometimes feel I can drive my car into a wall. I just get fed up with it, I can't take anymore. Aye, I think of suicide a lot. I don't think I'd do it, but I sometimes wish I wasn't here".* (female, 68 years, parent).

One woman whose daughter died 12 years ago reflected on how older people usually hope for a longer life. As someone who was '60 something' at the time, she was comforted by the thought that she would not have to suffer for too long (female, 78 years, parent). Others directly talked about their own mortality and not having enough time to get their life back together. They anticipated a loss of control related to getting older:

*"I think what I worry about is that, that when I do get older, and I get, I mean, I kind of, if I do realise, if I get to that chance to realise my mortality, and you know, I'm reaching the end of my existence. That I'll start to become more mentally challenged* . . . *Because my belief is that if you suppress it, it doesn't go away, it just goes deep, and when you get older, it then begins to come out, in all sorts of ways"* (female, 73 years, partner).

Learning to adapt and live with grief was often articulated as being a mind-set adopted to radically accept the loss and continue living, despite the adverse challenges, barriers and reminders. Adapting to bereavement in different ways meant neither looking for closure but accepting that this was a possibility. One emphasised that it was a living experience:

*"I couldn't put people through what we've all been through basically. Although there have been times and certainly even in lockdown last year, although I do feel most of the time I feel incredibly together, but things* . . . *you do think oh this is a battle. Which is why I think it is a living experience, I don't think it's a lived experience".* (female, 73 years old, parent).

There was some evidence of ageism as one person commented on the research:

*"I'm really pleased that this is* . . . *you know, somebody's doing things that are about suicide, especially at our age, because when you get older, you're not important, in general".*(female, 68 years, parent).

Our participants expressed a strong orientation to the importance of the shared lived experiences with others who had lost a loved one through suicide and learning to adapt to such a significant loss. These comprised of transformational moments through helping others. They described secondary gain from this sense of agency and control in one's own life, through interactions with their peers, actively seeking out others with similar experiences and recognising the wider meaning of their own lives within the context of societal responses to suicide. Key organisations were named as hosting and enabling networking and peer support:

*"I have to say it's been a real privilege to meet some of the people who've lost somebody and to realise how* . . . *and everybody does it their own way and it's just* . . . *but it is unbelievably painful. I wish I wasn't doing any of this because I wish I didn't know about it, but in some way it's given me some meaning in life. You're not alone. They're not alone. It's not just feeling* . . . *we know what it's like".* (female, 73 years, parent).

One participant took direct action by campaigning locally and setting up an information point at the station where his son died. Such instances of activism and raising public awareness enabled appropriate support based on direct experience being provided at both the prevention and postvention levels. One with twenty years of experience in the peer support movement expressed matured versions of herself as a compassionate and wise older woman:

*"I was around in London when there was AIDS, and we belonged to a group way back then, and I said, if there's anything I can do? And in fact, I've sort of become, I don't know what I am really* . . . *I think I'll step down. And they keep saying, no, no. And I think I'm just a wise old woman".* (female, 73 years, parent).

Another talked about becoming a mental health first aider, which had transformed her life in a positive way. Other turning points were exemplified in finding new relationships and love such as one man had done at the age of 72 yrs.

### **4. Discussion**

This study of the experiences of being bereaved by suicide and how it impacted the bereaved person's later life gave rise to three rich themes from the data collected. The emotional manifestation of moral injury and trauma, negative feelings and cognitions present in those living with the traumatic loss and the wider impact on family and other social networks were emphasised in the narratives of adults in later life. Learning to live with the loss and to navigate multiple transitions and adaptations was central to how people navigated and made sense of their experiences in later life. Given the dearth of research to date, the findings offer a novel contribution to our understanding of the experiences of this population who are less recognised or visible.

Fiegleman, Gordon and Jordan [30] noted the complexity of stigmatisation that older people might face in these circumstances. Internalised ageism and factors associated with ageism, for example, insensitive comments from professionals and other people in their networks were reported by our participants. These manifested at different levels and prevented individuals from accessing support or feeling entitled to ask for support or in prioritising their own health and wellbeing. Participants did not always recognise differences in how the bereavement impacted their physical and mental health and instead attributed these to the natural consequence of ageing. Furthermore, professionals tended not to ask directly about their needs or offer psychosocial support such as counselling, perhaps attributing the persons' problems to ageing. Bereaved parents reported particular strained and harmful consequences of their loss. A lack of recognition of the impacts within their own close networks was complicated where there were blended families or a history of family trauma. Reed [31] found more grief-struck survivors detached from their families than those who were less grief-struck. Grief therapies that use a family-focused approach include family-strengthening skills, particularly for families who show a high level of distress and find social and physical adjustment challenging [30,31]. A conceptual review of ageing and suicide [10] has demonstrated how older people experience the loss of something they had enjoyed doing or feeling, a loss of value, a feeling of tiredness and, in some cases, a feeling that they were in a process of losing themselves. All of these factors that can manifest alongside the physical aspects of caring can pose serious risk factors for self-harm and suicide in later life.

It seems important that professionals actively enquire from bereaved people in later life about the kinds of support they need, given the many examples of people in this study who felt unable to assert their needs or where these were subsumed into a caring role.

The role of the family doctor was commented on by some participants. Foggin et al.'s [32] study of general practitioners (GPs) dealing with parents who were bereaved by suicide, however, revealed an unpreparedness and uncertainty with regard to dealing with suicide and its effects on survivors and recommended that GPs were routinely informed of death by suicide to prepare for such ongoing encounters. In our study, a range of concerns were raised about the lack of skills and confidence that different professionals have in working with suicide and suicide bereavement and linked to the need for a more sensitive and timely approach to people and simply knowing what to offer.

There is much to learn from people bereaved by suicide on what support is needed and when and how to act more helpfully. In light of the intense caring roles that older people had demanded of them to step into, together with the negative feelings and cognition arising from moral injury and trauma, they may need help to navigate and evaluate which relationships they should preserve or even temporarily avoid or discontinue. Feigelman, Gordon and Jordan [30] suggested that professionals could guide bereaved people on how to 'teach' people close to them to overcome their own fears and lack of familiarity with suicide loss. Survivors had to accept that some people close to them or in their

social networks had limited capacity to comfort or respond appropriately. Furthermore, interventions that directly involve the person's family or social network such as partners, family and friends may have the potential to ameliorate some of the distress documented in this research. Ongoing attention to suicide awareness that challenges and reduces stigma must continue. It is clear that we need more skilled professionals in this area of work.

There was a paradox in that many bereaved survivors took up a leadership role in guiding their own support network and this promoted being able to live with their experiences at least. A novel finding lies in some of the positives that emerged for individuals despite the devastating impact of loss by suicide. There were accounts of transformative experiences (with which come opportunities such as understanding, awareness, peer support, and charitable work) that were so valuable to others and helped with the ongoing living experience and radical acceptance [33]. Many were driven to participate in communities with their peers, found strong connections and new belongings to a group. These are important anchors for coping with later-life challenges [7]. Groos and Shakespeare-Finch's [33] evaluation of peer support groups for suicide bereavement found that an effortful thought process and the level of pain experienced were temporal and dependent on the individual's own post-trauma trajectory or meaning-making process. Kasahara et al. [34] found differences between younger and older bereaved individuals. Older people with more significant life events found comfort through open dialogue, while younger individuals tended to conceal their emotions and suffering. Understanding these different experiences is a first step towards developing nuances in responding in later life. Barlow and Coleman's [35] evaluation of a peer support program developed for survivors of suicide suggested that an intervention protocol that is collaboratively developed and delivered by peer supporters *and* professionals can offer cost-effective person-centred support.

While our participants had much in common with people who are bereaved by suicide, there may be generational differences in coping styles, with older people employing more stoic and avoidant coping styles in dealing with traumatic events. For some, their chronological age intersected with their expectations of themselves and others. Some of our participants gave up work earlier than they might have done. They also took up active roles and enjoyed being in groups or company where they could be more anonymous.

These are speculative explanations, suggesting that future research could systematically investigate the general population to see how views of suicide and suicide stigmatisation) may be shifting across generational cohorts. The intensification of time pressure in later life reflected by participants had both negative and positive impacts on how the process of living beyond the bereavement played out and heightened suicide thoughts in some. Some studies [36] have supported specific associations between suicide bereavement and suicide-related outcomes, justifying the inclusion of people bereaved by suicide in national suicide prevention strategies. Most of this research has examined this in relation to younger people [36]. Participants in our study demonstrated a greater awareness of their own end of life, associated with later life and possibly with a reduced fear of death or wish to die made more explicit in relation to their loss and potential losses. A scoping review of suicide and suicide-related concepts in older people [21] included a range of "grey area" behaviours (for lack of a better term) that are either less common, or present differently than they are in younger population groups. These include terms and behaviours such as "completed life", "hastening of death" and "self-chosen death" [37,38]. The expression of these grey area behaviours may also be mistakenly viewed as a 'normal' part of ageing [39], creating further complexity to their identification and subsequent intervention.

The clinical implications of these findings are that those assessing older people thought to be at risk of suicide should inquire about a history of suicide bereavement and its impact on functioning and mental health [36]. Suicide bereavement is an indicator that stigma might be a marker for motivational moderators of suicidality after such a traumatic and often negative life event such as reluctance to seek help, thwarted belongingness or perceived burdensomeness [40]. The findings from this study highlight other indicators for help-seeking, where there is excessive burdens in caring and self-neglect accompanied by

perceived stigma, which warrant further inquiry and inform the development of interventions that address these different impacts of traumatic losses and specifically to mitigate any risk of suicide and to directly ask about this.

There may be a need to unify research from different disciplines, with policy themes on ageing such as healthy ageing, concepts of promoting person-centredness within service provision and giving greater emphasis to participation which enables peer support. Being able to understand the individual experiences and pathways within suicide research can help inform and enrich assessment and evidence-based interventions [21].

Finally, the design of this study enabled the data collection and data analysis to be enriched by the direct insights and contributions of those peer-researchers with lived experience. These methods can be resource intensive, given the time and pace needed to ensure authenticity in this approach, some of which did not always coincide with the need to make progress in terms of project milestones. There was one occasion where the research team took time out and utilised the skills of one team member, a digital artist, in a session to reflect and visualise imagery emerging from the data. This was a valuable team experience enabling restoration and self-care, something not always prioritised in the academy. (One of the images has been included with this paper's abstract). Furthermore, feedback from research participants and our peer researchers reminded the team to take a strengths approach, which offers a perspective on hope and respect for people with lived experience and this was just as important as our robust procedures on signposting and debriefing required in the ethical approval process.

### **5. Conclusions**

The qualitative and exploratory approach provided rich and salient transferable insights concerning bereavement by suicide in later life from the perspectives of those with lived experience. This undoubtedly helps inform future suicide awareness and prevention research. The findings confirmed existing evidence on the experience of bereavement by suicide such as the persistence of stigma, shame and moral injury associated with suicide. We assert the importance of suicide prevention policies in ageing support and the need to target services better. There is a strong indication for the inclusion of older people bereaved by suicide in national suicide prevention strategies and focusing efforts to reduce harm and the adverse impact on ageing experiences. In later life, bereavement by suicide must be considered alongside the effects of other loss experience(s) and in the context of the interpersonal and structural impacts of ageism in society [13]. These are potential areas for marginalising older people from mainstream support. Identifying these individuals may constitute an interdisciplinary approach and improved surveillance including routine assessment in a range of services that interact with people in later life. Professionals in ageing services could also develop competencies around the assessment of the impact of suicide exposure and interventions, particularly given that bereaved people are at increased risk of suicide themselves. Professionals need the right language, confidence, and skills to discuss issues of suicide with people in later life and to articulate concerns where issues are observed [10–12].

Suicide, personal meaning, trauma and membership of marginalised communities should be elevated in the public health conversation surrounding ageing. Critiques of 'successful ageing' encourage us to recognise the intersection of individual and social factors and to consider the life course perspective in research, policy and practice [41]. We recommend further studies comparing the bereavement experiences of those bereaved by suicide in later life with other traumatic bereavements and losses using participatory mixed methods and longitudinal approaches [42]. Framing these within the context of ageing [43] may involve unifying research from different disciplines, with policy themes on ageing such as healthy ageing, personalised support and being able to understand the individual experiences and pathways within suicide research to help inform and enrich assessments and interventions in ageing care.

### **6. Strengths and Limitations**

This study explored experiences of suicide in a hard-to-reach population. The coproduced nature of this study allowed stakeholders and participants to feel comfortable to share experiences which enriched the data and thus improved the quality of the study. More specifically, we believe that employing a co-produced design enhanced communication during the interviews, which adds to the transferability of the materials. However, the sample was self-selective and attracted some participants active in peer support. The findings may therefore only be partially representative. In addition, there were few men or engagement with people from diverse minority backgrounds in this study.

**Author Contributions:** T.H.-L. conceptualised and designed the project with input from J.G.; T.H.-L. managed the project and secured funding; J.H. and T.H.-L. obtained ethical approval; T.H.-L. and J.G. recruited peer-researchers; J.H. coordinated the recruitment and data collection process; J.H., E.G., L.R.-D. and J.G. conducted the interviews; T.H.-L., J.H., E.G., J.G. and N.C. were involved in the data analysis; T.H.-L. wrote this paper with editing and contributions from all J.H., N.C., J.G., S.R. and S.M. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by a small grant from the University of Strathclyde.

**Institutional Review Board Statement:** This study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of The University of Strathclyde in January 2021. Reference: UEC21/10: Hafford-Letchfield/Cogan/Hanna/Rasmussen: Responding to the complex support needs of people in later life bereaved by suicide: A co-produced exploratory study.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Information about the data reporting results can be obtained by contacting Professor T.H.-L.

**Acknowledgments:** The research team wish to thank members of the steering group, Adele Owen, QPM, Ruth Teacher, Naresh Mall, Tim Woodhouse and Sharon McDonnell for her encouragement. We thank the University of Strathclyde for funding this project.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**

