23
"NOBODY TALKS ABOUT SUICIDE, EXCEPT IF THEY'RE KIDDING"
Disenfranchised and re-enfranchised grief and coping strategies in peer suicide grievers
Tanetta Andersson
Introduction
Since Durkheim's ([1897] 1979) classic study, sociologists have understood that while suicide appears to be a highly personal and private act, it is also a social act. Today, nearly 37,000 Americans die by suicide annually (American Association of Suicidology, 2012). Experts estimate that every suicide intimately affects at least six individuals, both family members and friends, connected to the suicide decedent (Shneidman, 1969). A central question in the field of suicide bereavement is how suicide grief differs from other types of loss (Jordan, 2001). However, this focus has restricted suicide grievers studied to next-of-kin relationships, despite emphasis that suicide grievers constitute several populations (Substance Abuse and Mental Health Services Administration, 2010). By investigating suicide loss in peer relationships through a qualitative study, this study serves to diversify scholarly inquiry of suicide grief. Moreover, employing the disenfranchised grief framework (Doka, 1989; 2002) as a theoretical lens emphasizes the sociality of suicide loss, especially in terms of relational status and stigmatized dimensions of death by suicide (Charmaz & Milligan, 2006).
Drawing on a review of grief literature in general and suicide grief literature in particular, the central study aim of this investigation asks: to what extent do non-family status and/or stigma related to suicide affect the social support outcomes of peer suicide grievers? Indeed, the disenfranchised grief framework posits that grief is disenfranchised when it cannot be openly acknowledged or publicly mourned, thereby inhibiting social support for such grievers (Corr, 1998/1999; Doka, 1989, p. 4; 2002). In Disenfranchised Grief: Recognizing Hidden Sorrow, Doka (1989) introduces disenfranchised grief as a concept and proposes that disenfranchised grief may occur along three dimensions: (1) in the context of disenfranchised relationships (friends, colleagues, ex-spouses, or former lovers); (2) disenfranchised losses (i.e., miscarriage and companion animal loss); and (3) disenfranchised grievers (i.e. grandchildren, older adults). A second anthology, Disenfranchised Grief: New Directions, Challenges, and Strategies for Practice (Doka, 2002), added two additional dimensions of disenfranchisement to the original typology, including
289
Tanetta Andersson
circumstances of the death and ways individuals grieve. Doka asserts that suicide, execution, AIDS-related, or alcohol-related deaths may be understood through this former category of disenfranchised grief (Doka, 2002). Therefore, in each of these realms, grievers might experience their relationship, type of loss, style of mourning, and their age status as socially marginalized, trivialized, or stigmatized by others on an interpersonal and societal level (i.e., workplaces, schools, and the media).
Methods and sample description
Twenty-six peers were identified through nonprobability, chain referral sampling strategies (Berg, 2007) at several recruitment sites including eight suicide bereavement support groups, suicide prevention conferences and fundraising walks, bereavement centers, and suicide prevention advocacy email list servers. Study parameters for inclusion were: (1) two years or greater since bereavement; (2) 16 years of age or older at the time of loss; and (3) participant and decedent were friends for at least two years prior to suicide. In-depth, semi-structured, face-to-face and telephone interviews were conducted with participants from eight states ranging in age from 22 to 66 years of age. Interviews ranged in length from 46 minutes to 2 hours and 11 minutes and were conducted between May, 2008 and November, 2009.
Drawing on the semi-structured interview guide elaborated in Davidman's (2000) work on mother loss, open-ended questions and probes in this study address: general background questions, initial loss and years afterward, friendship prior to loss, relationships with other members of peer network, views of suicide prior to loss, life story after friend's death and, finally, broader representations of friendship and suicide. Data analysis included manual precoding (i.e., circling, highlighting, or underlining significant participant quotes or passages), first cycle coding, and second cycle, categorical coding. First cycle or initial coding generated some 55 general codes which broadly reflected psychological, somatic, and social realms in participants' suicide loss experiences. Analytical memos were developed and maintained by the investigator to stimulate reflexivity about possible conceptual categories signaled by the codes generated during the coding process. Drawing from the investigator's reflections in analytical memos created during the initial coding phase, participants' data cleaved along the concept of grief disenfranchisement and re-enfranchisement (Silverman & Marvasti, 2008).
Seventeen women and eight men participated in the study. Of the male study participants, two self-identified as African American and one female identified as African American, while the rest of sample identified as White. Current age of the participants ranged from 22 years old to late sixties. Occupations of participants included several social workers, two psychologists, two retirees, three Master's students and a college student, a researcher, a high school teacher, a legal aid worker, a suicide awareness organizer, a college football assistant coach, a college residence life administrator, a youth camp advisor. Participants resided in Ohio, Illinois, Wisconsin, New Mexico, New York, Louisiana, and California. In regards to bereavement characteristics, respondents' age at the time of bereavement ranged from as young as 8 years old to mid-sixties. The quality of most friendships was close and went beyond "just friends." Many respondents had met their peers during their school years, church activities, and work settings. Suicides included several by gunshot, and also hanging, drug overdose, immolation, carbon monoxide poisoning, and jumping from a bridge. Finally, four respondents had more than one suicide loss, so they spoke to these multiple losses in their interviews.
290
Coping strategies in peer suicide grievers
Findings
Disenfranchised suicide loss
The following data vignettes highlight several participants' accounts of negotiating relationships in the aftermath of suicide and reveal this as a complex task for peer grievers. Consequendy, expectations for social support may be either thwarted or foreclosed by the nature of society's stigma around suicide. Findings identified several new variants of relational and suicide loss disenfranchisement. Because of the limitations on the chapter length, findings are demonstrated through a single vignette to illustrate each finding related to disenfranchised grief. First, this research study identifies stratified relational disenfranchisement, where some but not all of the decedent's family disenfranchise peer suicide grievers. For example, Christy, who is 46 years old, lost her friend, Candace, some 26 years ago during Christy's undergraduate college years. They had been close during childhood and after Christy's family moved away, they kept in touch through letters and would try to see each other a couple times a year. Christy recalls not being able to attend her friend's memorial service because she wasn't made aware of it by Candace's family. Also, Candace was a twin, so Christy is the only co-survivor to which Rachel, her surviving twin, can look to for support:
I'm not even sure there was one. I'm sure because her mom was ... A lot of it is their family dynamic, which is very secretive and didn't want to talk about it and to look like she didn't have a daughter. Oh, but sometimes Rachel would say her mom wouldn't talk about it, so it was almost like her mom is not a support for her. It's almost like—I'm Rachel's twin in a way; I'm not Candace's replacement—we are kind of sisters in that and in a way it's kind of hard for me to really describe, I think.
(Christy)
Later in her interview, Christy explains that it was probably for the best because Candace's mother would be "very upset and very irritated" with how much Christy "knew." Yet, Christy affirms that being included in a memorial service was still important to her.
Second, reverse relational disenfranchisement captures when peers end their relationships with decedents' families. For example, Andrea is 24 years old and lost one of her best friends, Andrew, seven years ago when she was 17 years old. Andrew was 19 years old when he took his life. Andrea was a seventh grader when her friendship with Clayton (Andrew's best friend) began in an internet chat room. Both Clayton and Andrew lived on the West Coast of the United States. Andrea is quick to say she's aware of how meeting through an internet chat room sounds, but she describes her friendship with the boys as "really good long-distance pen pals." When asked about her friendship with Andrew being validated and supported, she pointed to several instances of relational disenfranchisement with Andrew's family, especially their reluctance to share a suicide letter addressed to her:
Yeah, he had written to us. Clayton got his letter because he fought for it. Well, his mom fought for it. She went over there and she, like, started yelling at people, his mom, and she was, like, "You know it's meant for them. You need to give it to them." So the boys got their letters, but because I live in Ohio, and his mom didn't think I was worthy of it, so I never got it, and, like, for a long time I was really angry and, like, when I went there I had said something to [my sister] about going over and trying to get it and she's, like, you know, and she's like, "Just wait. You know what's in that
291
Tanetta Andersson
letter. You know what Andrew had to say and you don't really need to fight with them about it to get it," and I agreed with her on that, like, you know, I didn't push it.
(Andrea)
Third, bilateral relational disenfranchisement refers to peers' experiences of negative support not only from their suicide decedent's family, but also from their own family members. Megan, for example, is 36 years old and lost her best friend, Michelle, nineteen years ago during her early college years. She talks about this kind of disenfranchisement in regards to her own family. She expresses that she sought out college counselors, in part, because her parents did not understand her grief reaction. This was further evidenced by her recollection of her father's angry reaction to her counselor calling their home when Megan was "having a real bad time." Her account follows on the heels of describing a disagreement with Michelle's mother about Michelle's intent to take her life, as Megan believes Michelle's intent was to self-harm and not to take her life:
It was rough and, like I said, my parents just didn't quite understand and, you know,I ended up seeing a counselor at school, which my dad really didn't understand, and that really made him angry. And the counselor called the house one time I was having a real bad time and my dad got on the phone and he was . . . He's a very nice guy, don't get me wrong. He just, I don't think he knew how to handle everything . . . Yeah, and it was, you know, he was "Who are you on the phone with? And you don't need to be doing this," and, you know, it was just basically a "grow up" type of thing and I'm thinking, "This has nothing to do with . . ." It was a lot.
(Megan)
Fourth, secondary relational disenfranchisement reflects disenfranchisement by non-co-survivor friends, as Abby conveys: " I had a lot of them pull away and I think I ended up losing a lot of friends because I needed to talk about it and I was seeking out people to talk to." Abby is 23 years old and a college student; she was 20 years old when her best friend's younger brother, Adam, took his life. Adam was 17 years old at the time of his death.
Fifth, peer co-survivor disenfranchisement reflects relational disenfranchisement by co-survivors who share the same suicide loss. Some participants' experiences reveal that looking to co-survivors for support in suicide loss may prove to be a blocked avenue of support. For example, in an earlier section, Andrea relates instances of relational disenfranchisement upon losing her close friend, Andrew, after becoming close friends over the internet. In the statements below, she describes her concern for Clayton and his well-being. After the loss, he withdrew for weeks and would only communicate about Andrew's loss on days that are symbolically tied to Andrew. Andrea stresses Clayton's deep sense of grief by indicating that Clayton has never visited Andrew's grave. In talking about Clayton, Andrea opens up about the strain in their friendship after Andrew's loss:
I asked if he would be willing to be involved and he said no. When Andrew died, we talked about it the day he died and we talked about it on the day of his funeral, and we talked about it when his ex- . . . Well, when his ex-girl . . . The girl he was dating at the time was pregnant, so when she had his baby, Clayton went to see the baby and that was the last time we talked about it. Otherwise, he's not willing to talk about it. I mean, he feels responsible and he's the one that found him. Yeah. And I mean to this day, like, Clayton won't talk about it. I think he ... It was really rough for him, and it put a strain on our friendship or what happened with us.
292
Coping strategies in peer suicide grievers
In terms of disenfranchisement related to the mode of death being suicide, participants highlighted numerous occasions in which their loss was trivialized, distorted, or rendered invisible across educational, media, and religious contexts. This new subcategory of disenfranchisement is identified as institutional/bureaucratic disenfranchisement. For instance, Abby describes deep anger at her high school for covering up the role of bullying in Adam's suicide loss. Abby indicates the administrators' attempts to shift blame to a suicide pact instead of understanding the bullying problem in their midst as a source of significant anger:
I think some of his friends went to talk to them, but I didn't. I was so mad at the school that I sat there gripping my chair to keep myself from yelling because I was so angry that the Principal wouldn't do anything and wasn't comforting his family at all. Like the school just made it into this big mess and tried to cover it.
Further, the media can sensationalize and disenfranchise suicide grievers in a number of ways. In the case of one participant, for instance, who learnt about her friend's suicide while watching the news on her lunch break at place of employment. At the micro-societal level, another pattern of disenfranchising suicide loss was observed by participants in respect to disenfranchising suicide loss through language or gestures. Below, Beth underscores linguistic suicide loss disenfranchisement:
Beth: But I think on a lot of levels or with a lot of different people, suicide is so far out of their realm of even possibilities that it's almost like, "I've got to look that word up in the dictionary," you know.
Interviewer. Right. Bight.
Beth: It's not. . . Nobody talks about that except if they're kidding.
Interviewer. Yet 40,000, you know 30 or over 30,000 Americans take their lives every year. Beth: Yeah.
Interviewer. And yeah, I think, yeah, trying to sort of. . .
Beth: And I always wondered why we had to have that disease, you know, the depression that led into suicide. Why couldn't we have something that lots of Americans have? You know what I'm saying?
In sum, the preceding accounts have illustrated disenfranchised grief, both in terms of peer relational complexity and distorting or stigmatizing forces associated with suicide loss in multiple social contexts. This work provides an explicit analysis of suicide loss in the disenfranchised grief framework which has been pointedly absent from the grief literature. Moreover, Doka (2008) has called for grief scholars to extend the disenfranchised grief framework by studying which experiences might serve to counteract the type of disenfranchisement described above. The following section, then, describes processes and experiences in terms of support and coping in peer suicide grievers at the individual and community levels and, in particular, re-enfranchisement.
Re-enfranchising suicide loss
Surprisingly, few study participants sought counseling for their grief and, of those who did, their experiences were mixed. This pattern is also supported by a handful of studies in the scholarly literature (Provini, Everett, & Pfeffer, 2000). This section addresses key questions such as: Aside from support groups, what does re-enfranchisement look like in peer suicide grief? Where did
293
Tanetta Andersson
study participants find such experiences? Is there a relationship between these group-based outreach and advocacy social contexts and the likelihood of identifying as a suicide survivor?
The most recent scholarship on disenfranchised grief emphasizes moving beyond simply cataloguing which losses reflect the disenfranchised grief typology and advancing the framework by delving into the processes and outcomes behind such losses and how grievers can be assisted or 're-enfranchised' (Doka, 2008). Study outcomes demonstrate that participants' supportive behaviors towards others dealing with depression or suicide loss, in either informal and formal social contexts, helps to re-enfranchise grievers and, for some, fosters a suicide survivor identity. Thus, a continuum of intrapersonal, interpersonal, and group-based or extrinsic coping behaviors was developed from study findings to conceptualize and understand participants' varied re-enfranchisement experiences. Briefly, intrapersonal coping strategies include keeping mementoes like photographs (though not always displaying them) and notes from suicide decedents. Further, those participants who advocated for others dealing with depression or suicide loss in their personal networks or work spheres, but who did not engage in group-based coping or re-enfranchising strategies, are understood to be on this continuum with interpersonal coping strategies. These strategies are not viewed as mutually exclusive, so participants could engage in both intrapersonal and group-based coping strategies. Of most significance to Doka's call in the study of disenfranchised grief is the final group of strategies along this continuum. For example, these participants engage in group-based re-enfranchising strategies like suicide prevention fundraising Out of the Darkness Community Walks, and Local Outreach to Survivors of Suicide or LOSS programs (see Chapter 22 in this volume).
For instance, of her participation in an Out of the Darkness Community Walk, Lisa says:
We did that walk . . . That was the first one. Well, the first that we had heard about it, and it was just kind of, like, a chance thing. It wasn't like an advertisement or anything like that, you know. It's just, like, it was word of mouth. Somebody found out about it in some other town and told my sister, you know, and said, "Hey, they do this . . . So we went and it was good. It was really good, you know . . . Everybody has like shirts and stuff made up and like just looking around at all the people you know that were affected and it's like you've got to think "This is just this one small area in the country in the world, you know, and these are the people that know about the walk and that feel comfortable coming out and doing it." You know it's just a small representation of the people that are out there. It's amazing.
These organized walks began in 2003 with an overnight walk to raise funds for the American Foundation for Suicide Prevention (AFSP). In the following year, 25 community walks took place involving around 4,000 participants. Since then, the number has ballooned with some 230 being held in 49 states across the United States last year. In 2011, the AFSP reports that more than 90,000 participants have walked in their communities, "to raise over $6.5 million to support suicide prevention research, local prevention and educational programs, advocacy, and survivor loss programs" (American Foundation for Suicide Prevention, 2012).
Grief interventions for suicide grievers like psychological counseling, support groups, and even the Out of the Darkness Walks are all still passive in nature because they rely on suicide grievers to initiate the support-seeking process. On the other hand, the LOSS program is an Active Postvention Model (APM) which aims to deliver immediate support to suicide grievers at the time of death through the LOSS volunteer team. Begun in 1999, the LOSS program coordinates with the local Coroner's Office, and when a suicide occurs, the team is alerted and travels to the scene to sit and talk with family and friends after the police and medics have
294
Coping strategies in peer suicide grievers
finished their duties. The team consists of a mental health professional and other para-professional volunteers who are veteran suicide survivors:
The L.O.S.S. team reaches out to survivors to let them know that they are not alone, provides immediate contact and support, informs them of the resources available to them in the community, and provides an installation of hope that they, too, can survive this traumatic loss.
(Campbell, Cataldie, Mcintosh, & Millet, 2004, p. 30)
Daniel, for example, who is 63 years old and has suffered three suicide loses, including his wife, a girlfriend, and a friend, describes himself as floundering until he found a role in the LOSS program:
Some of it's hard. Some of it's very hard. I think it gives me a sense of well-being to know that I'm at least offering help to people that I wish I'd had 20 odd years ago. Maybe I wouldn't be sitting here today if I had it 20 years ago. Like I say, some of it's hard. I can very vividly remember some and can't remember others at all . . . But it makes me feel good, like I say, to know that I may be giving some hope to people and letting some people know that there are some options. They don't have to sit on it like I did for 20 years. You can start getting help and not have to live with the shame and the guilt all by yourself
Other emergent study findings related to the varied salience of a suicide survivor identity among participants. One participant, Carrie, identifies so strongly with this status, she has "survivor" tattooed on her arm. For Carrie, who is 30 years old and lost one of her very best high school friends, Thomas, around nine years ago, her suicide survivor status is extremely salient:
Carrie: I have, yeah, I have a ribbon, "I'm a suicide survivor," so I have "Suicide Survivor" tattooed on my arm, and then on the back of my neck I have a green shamrock with a yellow ribbon tied around it with a little bow, because yellow ribbons was how we started talking about suicide . . .
Interviewer. So they're all tied to Thomas?
Carrie: Those three, yeah.
Moreover, such participants indicated that their identification with this term was fostered by group survivor events or programs. Another participant, Jonathan, describes his identification as a suicide survivor and explicitly links it to both his advocacy in his occupational sphere and group-based coping contexts like the suicide prevention fundraising walks. Jonathan is in his fifties and lost the mother of his son over five years ago (Jonathan was never married to or lived with the mother of his son):
Well, I do identify. I've had other suicides in my life and I think that they came at really, you know, an earlier life when I was a teenager, and they were very upsetting. I felt very guilty about one of them in particular, that I should've known, should've stopped it, I could've . . . But as I matured and I got older and I could see this as being real and it's my life's work, I more identify as being someone who helps people survive suicide or depression or what have you, but for one day out of the year when I go to that march and I wear a shirt or I have her name on my back, I walk and I identify .. .
295
Tanetta Andersson
On the other hand, the following comments from Bill reflect a number of negative cases of participants for whom a survivor identity held no salience:
There were, and I don't think of myself as a suicide survivor, which is kind of interesting, 'cause I am a suicide survivor, but there were three key people in my background that did suicide ... I guess to a certain extent I've kicked these suicides out of my closet, so to speak, and maybe that's why I don't consider myself a suicide survivor even though I clearly am.
Bill is a 60-year-old social worker who has experienced triple suicide loss (homicide-suicide of a close friend, a family friend, and a coworker). Across these cases, participants drew attention to numerous contingencies in respects to this identity. Some participants expressed concerns about identifying as a survivor that were relational in nature (i.e., can a clinician be a survivor?), whereas other concerns addressed temporal dimensions around when one identifies as survivor (i.e., being a survivor indicates having closure), and some were leery about being mistaken for attempting suicide themselves.
Discussion and clinical implications
Overall, this research is consistent with other researchers' observations about ways to build community for survivors. Given the re-enfranchising value these contexts seem to hold for suicide loss survivors, this sociological research deepens our understandings of these suicide prevention advocacy events and programs and illuminates a critical blind spot regarding the suicide prevention movement. At the macro-level, the lens of the health social movement literature within medical sociology sheds light on this impetus towards advocacy for suicide prevention. According to Brown and his co-authors (2004), such organized efforts represent embodied health movements and challenge knowledge and practice concerning etiology, treatment, and prevention of disease (i.e., Gulf War or Chronic Fatigue Syndrome disease groups). Yet, others outside sociology including suicide prevention experts and advocates do not view these fundraising community walks as a significant part of the suicide prevention movement. For example, in a recent publication by Spencer-Thomas and Jahn (2012), which tracks key events in the suicide prevention movement, the Out of the Darkness Community Walks mobilization were excluded from this ranking.
Unlike other sociological social movement thinkers, Klawitter (1999) includes extrinsic expressions such as performances and practices in their definition of social movement culture. For example, in studying the breast cancer movement, Klawitter asks: How is culture, "enacted, enunciated, and emoted" in breast cancer social mobilization? She asserts that such outward expressions of culture build and shape symbolic communities like those reflected in participants' accounts of suicide prevention and advocacy group contexts. Alternatively, at the micro-level, findings from this study suggest that a suicide survivor identity is a collaboratively based identity, whereby group contexts affect how this status is influenced by extrinsic phenomena. To understand the links between identity and group-based suicide loss coping strategies, the concept of sub cultural identity work offers many insights (Schwalbe & Mason-Schrock, 1996). This concept unpacks how people work together to create signs, codes, and rites of affirmation that become shared resources of identity and sometimes even function to police shared status. For participants, it is clear that cultural symbols present at fundraising walks including tee shirts, signs, and public discussion of this stigmatized loss contribute to signifying a survivor identity and a community.
296
Coping strategies in peer suicide grievers
What are the clinical implications of these study findings? While the recendy proposed changes to the DSM-V rejected medicalizing suicide grief by maintaining the grief exclusion for depression disorder, the push remains (Kleinman, 2012). In the future, growing numbers of individuals with long-term suicide grief may qualify for treatment under their health insurance coverage, subsequendy more mental health practitioners may encounter such patients. Increased awareness of the beneficial dimensions found in these suicide loss group-based coping settings is needed among mental health experts. Unlike other types of grief, suicide loss seems to involve an identity process which for some grievers may aid their efforts to overcome suicide loss. Additionally, acknowledging and remedying social factors which aggravate suicide grief may be more effective for long-term prognosis.
References
American Association of Suicidology (2012). Suicide data page, 2009. Available at: http://www.suicidology.
org/c/document_library/get_file?folderId=232&name=DLFE-382.pdf (accessed March 18, 2012). American Foundation for Suicide Prevention (2012, January 31). Community walks nationwide raise
needed funds and awareness. Available at: http://www.afsp.org/index.cfin?fuseaction=home.viewPage
&page_ID=8A646C2B-E866-F64F-E5E32C885FB71889. Berg. B. (2007). Qualitative research methods for the social sciences (6th ed.) New York: Pearson Education, Inc. Brown, P., Zaestoski, S., McCormick, S., Mayer, B., Morello-Forsch, R., & Gasior Altaian, R. (2004).
Embodied health movements: New approaches to social movements in health. Sociology of Health &
Illness, 26(1), 50-80.
Campbell, F., Cataldie, L., Mcintosh, J., & Millet, K. (2004). Clinical insights: An active postvention
program. Crisis, 25(1), 30-32. Charmaz, K., & Milligan, M. (2006). Grief. In Jan E. Stets, & Jonathan Turner (Eds.), Handbook of the
sociology of emotions (pp. 516-543). New York: Springer. Corr, C. A. (1998/1999). Enhancing the concept of disenfranchised grief. Omega, 38 (1), 1-20. Davidman, L. (2000). Motherloss. Los Angeles, CA: University of California Press.
Doka, K. (1989). Disenfranchised grief. In K. J. Doka (Ed.), Disenfranchised grief: Recognizing hidden sorrow
(pp. 3-11). Lexington, MA: Lexington Books. Doka, K. (2002). Disenfranchised grief: New directions, challenges, and strategies for practice (2nd ed.). Champaign,
IL: Research Press.
Doka, K. (2008). Disenfranchised grief in historical and cultural perspective. In M. S. Stroebe, R. O.
Hansson, H. Schut, & W. Stroebe (Eds.), Handbook of bereavement research: Advances in theory and intervention
(pp. 223-240). Washington, DC: American Psychological Association. Dürkheim, E. ([1897] 1979). Le Suicide Q. Spaulding, & G. Zimmerman, Trans). New York: The Free
Press.
Jordan,J. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide and Life-threatening Behavior, 31, 91-102.
Klawitter, M. (1999). Racing for the cure, walking women, and toxic touring: Mapping cultures of action within the Bay Area terrain of breast cancer. Social Problems, 46, 1, 104-126.
Kleinman, A. (2012). The art of medicine: Culture, bereavement, and psychiatry. The Lancet, 379, 608-609.
Provini, C, Everett, J., & Pfeffer, C. (2000). Adults mourning suicide: Self-reported concerns about bereavement, needs for assistance, and help seeking behavior. Death Studies, 24(1), 1-19.
Schwalbe, M., & Mason-Schrock, D. (1996). Identity work as group process. Advances in Group Processes, 13, 113-147.
Shneidman, E. (1969). Prologue: Fifty-eight years. In E. S. Shneidman (Ed.), On the nature of suicide
(pp. 1-30). San Francisco: Jossey-Bass. Silverman, D., & Marvasti, A. (2008). Doing qualitative research: A comprehensive guide. Thousand Oaks, CA:
Sage Publications:
Spencer-Thomas, S., & Jahn, D. (2012). Tracking a movement: U.S. milestones in suicide prevention.
Suicide and Life-threatening Behavior, 42, 1, 78-85. Substance Abuse and Mental Health Services Administration (2010). Suicide prevention dialogue with
consumers and survivors, from pain to promise (HHS Pub. No. SMA 10-4589). Available at:
http://store.samhsa.gOv/shin/content//SMA10-4589/SMA10-4589.pdf.
297