Continuing Bonds after Loss by Suicide: A Systematic Review

The concept of continuing bonds as an alternative to detachment from the deceased person has gained traction in grief literature over the years. Those bereaved by suicide are likely to experience various grief reactions and may be at-risk for adverse grief and mental health outcomes. However, it remains unclear how those bereaved by suicide experience continuing bonds. To address this gap, we conducted a systematic review according to PRISMA guidelines. Searches of peer-reviewed literature in Medline, PsycINFO, Embase, Emcare, EBM Reviews, and Scopus identified 15 studies (2 quantitative and 13 qualitative) reporting on 12 samples, published between 2010 and 2021. The study quality of the quantitative studies was poor, but it was fair amongst the qualitative studies. People bereaved by suicide experienced continuing bonds across a variety of domains and reported mostly positive experiences. Factors that tended to have an impact on the expression of continuing bonds included time since bereavement, relationship to the deceased, social expectations, sex of the bereaved, and the ability of the bereaved to make meaning of the death. The review concludes that most participants reported positive experiences with continuing bonds. However, discrepancies between males and females and between those bereaved by suicide and those bereaved by other causes warrants further investigation. In addition, longitudinal community-based research involving representative samples is needed to understand the evolution and experience of continuing bonds over time in those bereaved by suicide and to inform future efforts in supporting them.


Introduction
Suicide claims the lives of over 700,000 people per year globally [1]. A recent metaanalysis of population-based studies indicated that approximately one in twenty people experience a loss by suicide in one given year and one in five do so during their lifetime, although the impact of the death may depend on the closeness of the relationship [2]. Due to the complex nature of grief after suicide, individuals bereaved by suicide have a higher risk of adverse mental health outcomes such as posttraumatic stress disorder, depression, suicidal ideation, and attempted suicide than those bereaved by other causes [3]. People bereaved by suicide also have particular needs for professional help in dealing with their grief (for example, regarding feelings of guilt and struggles with 'why' questions) compared to those bereaved by natural causes [4].
Initially, grief literature suggested that bereaved individuals progress through different stages of grief in order to achieve detachment from the deceased person [5]. However, Klass and colleagues [6] challenged this theory and proposed the concept of continuing bonds as an alternative to detachment. They defined continuing bonds as the presence of an ongoing inner relationship with the deceased person [6]. Still, the concept of continuing bonds has been described in cultural literature and various religions over the centuries [7]. Klass and colleagues drew attention to specific rituals which demonstrated the practice of continuing bonds long before the theory gained traction in grief literature [6,7]. They gave the example of Japanese Buddhism, in which the deceased become part of the spirit family and are accessible to the bereaved, and in Judaism, in which the deceased are remembered through prayer and the physical lighting of a candle [6,7].
Recent studies have aimed to characterise continuing bonds as positive or negative and to specify the ways in which they manifest [7]. The process of meaning-making emerged as an important tool in the formation of positive bonds [8]. Meaning-making refers to the way in which bereaved individuals process the death in a way that holds meaning for them [9]. The concept of continuing bonds has gained traction over the years, as witnessed through the development of designated instruments [10] and studies in various bereaved populations (such as after the death of a parent or a child) [7]. However, it remains unclear how continuing bonds manifest themselves in those bereaved by suicide and how this population experiences continuing bonds. To-date, no review on this topic has been conducted. Still, a better understanding of this aspect of grief in people bereaved by suicide may provide useful information for future efforts in supporting them.
This review will address this gap by synthesising and analysing the research on continuing bonds in individuals bereaved by suicide. It aims to characterise aspects of the continuing bond including how they manifest, and whether those bereaved experience them as positive or negative.

Search Strategy
The review adhered to PRISMA guidelines [11], and the protocol was registered in the PROSPERO database (CRD42021271971). The review involved systematic searches of the following databases: Medline, PsycINFO, Embase, Emcare and EBM Reviews (all accessed via Ovid), and Scopus. The search in Medline comprised MeSH and text words: (Continu* bond*.mp OR continu* relationship*.mp OR continu* connection*.mp OR Ongoing bond*.mp OR Ongoing relationship*.mp OR Ongoing connection*.mp OR meaning making.mp OR Memorial*.mp OR Ritual*.mp) AND (Grie*.mp OR Grief/ OR Mourn*.mp OR Bereav*.mp OR Bereavement/ OR Suicide bereave*.mp OR Bereave* by suicide.mp OR loss by suicide.mp OR suicide loss survivor*.mp) AND (suicide.mp OR Suicide/). A similar search string including headings and keywords was used in the other databases.
One researcher (R.G.) conducted the search in August 2021. It was limited to publications in English but not by date of publication. Two researchers (R.G., K.A.) assessed titles and abstracts for eligibility and any discordance was resolved through discussion with the third researcher (K.K.). The same two researchers then assessed the full text of potentially relevant studies using the inclusion/exclusion criteria. Researcher R.G. hand-searched the references of the included studies and conducted a forward-citation search in Google Scholar to identify any further studies. Figure 1 summarises the search strategy.

Inclusion and Exclusion Criteria
Studies were included if: (1) the study population consisted of people bereaved by suicide; (2) the study provided empirical qualitative and quantitative data on continuing bonds with an individual lost to suicide; (3) the study was published in the English language; and (4) the study was published as a paper in a peer-reviewed journal.
The review excluded: (1) studies not providing data specifically on people bereaved by suicide; (2) studies not providing data on continuing bonds in the context of suicide bereavement; (3) studies based on other methods, such as case studies, reviews and opinion paper; (4) studies not written in English; and (5) studies which were not peer-reviewed. Unclarity on the inclusion of three studies was resolved through discussion with the third researcher (K.K.).

Inclusion and Exclusion Criteria
Studies were included if: (1) the study population consisted of people bereaved by suicide; (2) the study provided empirical qualitative and quantitative data on continuing bonds with an individual lost to suicide; (3) the study was published in the English language; and (4) the study was published as a paper in a peer-reviewed journal.
The review excluded: (1) studies not providing data specifically on people bereaved by suicide; (2) studies not providing data on continuing bonds in the context of suicide bereavement; (3) studies based on other methods, such as case studies, reviews and opinion paper; (4) studies not written in English; and (5) studies which were not peer-reviewed. Unclarity on the inclusion of three studies was resolved through discussion with the third researcher (K.K.).

Data Extraction
Two researchers (R.G., K.A.) independently extracted the following data: author, year and location of study, eligibility criteria, sample size, participants' sex, age, time since bereavement and relationship to the deceased, setting, study design, and main findings.

Data Extraction
Two researchers (R.G., K.A.) independently extracted the following data: author, year and location of study, eligibility criteria, sample size, participants' sex, age, time since bereavement and relationship to the deceased, setting, study design, and main findings.

Quality Assessment
Two researchers (R.G., K.A.) independently conducted the quality assessment and resolved disagreements through discussion. No eligible study was excluded based on its quality. Quantitative studies were assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies [12], comprising eight items across three domains: (1) selection (four items), (2) comparability (one item), and (3) outcome (three items). Scores in each domain were totalled to determine study quality as good, fair, or poor. The interrater reliability was high (κ = 0.82).
The qualitative studies were assessed using the Consolidated Criteria for Reporting Qualitative Research (COREQ) [13] consisting of thirty-two items across three domains: (1) research team and reflexivity (eight items), (2) study design (fifteen items), and (3) analysis and findings (nine items). For each study, the number and percentage of items satisfied within each domain and across all domains was calculated. The interrater agreement was high (κ = 0.92).

Study Characteristics
The searches identified fifteen studies reporting on twelve samples. Five studies were conducted in Australia [14][15][16][17][18], three in the USA [9,19,20], three in the UK [21][22][23], two in Israel [24,25], one in Canada [26], and one in Switzerland [27]. There were two quantitative and thirteen qualitative studies. The quantitative studies collected data via online questionnaires [19,24]. One also utilised the Two-Track Bereavement Questionnaire (TTBQ) [10] to measure the level of functioning of bereaved individuals and their relationship with the deceased person [24]. Eleven of the thirteen qualitative studies involved semi-structured or in-depth interviews either in-person or via telephone, one utilised a survey [20] and one collected data through a series of workshops over twelve weeks [18].
The quantitative studies had sample sizes ranging from N = 159 [24] to N = 1301 [19], whilst qualitative studies had sample sizes ranging from N = 7 [14] to N = 50 [27], with the exception of Jahn [19,20] who used the same data set for both a quantitative and qualitative study. Tables 1 and 2 summarise the quantitative and qualitative studies, respectively.

Quality Assessment
Appendix A presents the methodological quality of the quantitative studies, and the two included studies received a rating of 'poor' quality. One study [24] scored well in the 'comparability' domain, but both studies [19,24] tended to score poorly in the 'selection' and 'outcome' domains by using selected samples and relying on self-reported outcomes. Appendix B outlines the quality assessment of the 13 qualitative studies. The studies satisfied between 34% [22] and 75% [15,17] of the COREQ criteria [13]. Most studies reported only few items across the 'research team and reflexivity' domain (on average 35% of items were reported). However, most items (on average 63%) in both the 'study design' and 'analysis and findings' domains were reported.

In What Way Can Continuing Bonds Manifest?
Findings from the included studies showed that continuing bonds manifested or were experienced in various ways. Quantitative data showed that 63% of participants reported having spiritual experiences [19]. The most common experiences included dreams about the deceased (73.4%), feeling the presence of the deceased (53%), and profound coincidences (40.3%) [19]. In qualitative studies, participants reported the use of rituals and memorials (both physical and online) [9,16,21,23], spiritual and religious beliefs [9,26,27], metaphysical experiences [20,26], physical objects [9], and suicide-related thoughts and behaviours, such as a desire to join the deceased and/or understand what they went through [9]. Suicide-loss survivors reported lower levels of close positive continuing bonds with the deceased than did participants from the sudden-and expected-death bereaved groups. Intense grief and preoccupation were associated with less positive personal transformation, particularly among the suicide bereaved. This suggests that continuing bonds in those bereaved by suicide are more likely to be experienced negatively than in those bereaved by other causes.    Three key themes were identified in an earlier analysis (at 6 and 12 months post loss): searching for answers and sense-making, coping strategies and support, and finding meaning and purpose. Further exploration of these themes at 24 months revealed significant differences between mothers and fathers with the latter adopting more maladaptive coping strategies. Maintaining the relationship with the deceased and paranormal experiences were new themes at 24 months (not present at 6 and 12 months) and a shift from brooding to reflection/sensemaking was seen at 24 months. The adaptation process was fluctuating and dynamic. The deceased persons were: four sons, two fathers, two close friends, two uncles and one mother.

Semi-structured interviews
Phenomenological approach, thematic analysis Individuals had difficulty reconciling the suicide death of a loved one with their religious views. This often led to a personally defined spirituality rather than a complete loss of faith.
Many individuals (also non-religious) found meaning in the belief of an afterlife and/or felt hopeful that the deceased was in a better place and would someday reconnect with them. Engagement in activities to maintain a bond were common.   Identified three key themes (searching for answers and sense-making, coping strategies and support, and finding meaning and purpose) in parental responses to suicide bereavement. The phases of sense-making and meaning-making experienced by participants and the range of both adaptive and maladaptive coping strategies indicated that adapting to bereavement is a dynamic and fluctuating process. Suicide bereaved individuals tended to experience continuing bonds across multiple domains both concurrently and over time [15,25]. It was common to experience continuing bonds across a continuum, for example, engaging in both public and private expressions of continuing bonds [25]. A public manifestation may include participation in ceremonies or rituals such as a funeral whilst a private manifestation may include writing to or talking to the deceased [25]. Although the process of developing continuing bonds was never described as linear, time since bereavement did appear to affect how the bonds were experienced. Entilli and colleagues [15] and Ross and colleagues [17] described experiences with continuing bonds as they appeared at 6, 12, and 24 months, observing that memorialisation and intrusive thoughts were present early on whereas paranormal beliefs and the maintenance of the relationship with the deceased were new themes at 24 months. Similarly, Sands and colleagues [18] reported themes as they appeared during workshops spanning over 12 weeks. Participants experienced thoughts around 'why' the person had died by suicide before reconstructing the death story and repositioning the relationship in order to establish positive ongoing bonds [18]. Suicidal ideation with a desire to join the deceased and/or to understand what they went through was another common initial reaction that typically subsided over time [9,14].
Qualitative studies found that most participants wanted to experience continuing bonds and actively pursued them [14,26]. They achieved this through the creation of online memorials [21,22], visiting places that were frequented by the deceased [16], keeping objects that belonged to the deceased [26], actively reminiscing about the deceased [26], and writing to the deceased [15]. However, some participants found that the social expectations of grief and the stigma associated with suicide limited their public expression of continuing bonds, forcing them to express their grief privately [16,21,22]. There were differences in the types of bonds experienced according to sex and type of relationship to the deceased person [15,20,21]. A qualitative study found that female participants and those who had a close pre-death relationship with the deceased family member or partner had more spiritual experiences with the deceased [20]. Females also created more online memorials than males [21]. Conversely, males appeared to engage more in avoidant coping strategies and would express their grief less openly [15]. Though children may experience continuing bonds in similar domains as adults, research suggests they tend to interpret their experiences differently and this varies depending on age [23].

Continuing Bonds as a Positive or Negative Experience
Participants generally perceived continuing bonds as positive experiences [16,17,[19][20][21]27], which they associated with comfort and hope [26]. Although less common, negative experiences were those that were beyond the control of the bereaved individuals and included subconscious thoughts or feelings [25], spiritual or metaphysical experiences [26], or the unexpected discovery of facts relating to the deceased that were not in-line with the perceptions of the bereaved [21]. A quantitative study [19] demonstrated that 74.5% of participants interpreted spiritual experiences with the deceased as helpful whilst only 4.8% viewed them as harmful [19]. However, another quantitative study comparing outcomes of those bereaved by suicide with those bereaved by sudden or expected death found that those bereaved by suicide had lower levels of close positive relationships with the deceased both pre-and post-death, including less expression of continuing bonds [24].

Discussion
This review aimed to synthesise the research literature concerning continuing bonds in people bereaved by suicide, including how they manifest and whether the bereaved experienced them as positive or negative. The review identified 15 studies reporting on 12 samples. Factors that affected the way in which continuing bonds manifested included time since death, type of relationship, societal expectations, sex of the bereaved person, and their ability to make meaning of the death. In all but one study [22], participants reported mostly positive thoughts, feelings and experiences regarding continuing bonds.

Factors That Affect the Manifestation of Continuing Bonds
Aside from two longitudinal studies [15,17], there appears to be little research on the effect of time since bereavement on the manifestation of continuing bonds in those bereaved by suicide. Participants from one study [9] reported that the intensity of the bonds had not lessened up to 10 years following the suicide. This is supported by a quantitative study [24] which found that when compared to those bereaved by sudden or expected deaths, those bereaved by suicide tended to maintain more intense bonds for a longer period of time and consequently took longer to engage in 'meaning-making'. These findings are important due to the strong association between intense grief and less positive personal transformation [24], highlighting the need for more longitudinal, comparative data.
Societal beliefs and expectations may impact on the manifestation of continuing bonds in several ways [16,21,22,27]. Some participants felt they were forced to express their ongoing relationship more privately due to the stigma surrounding suicide [9,21], and the expectation to resolve grief [16]. Our review revealed that suicidal ideation [9,14] in suicide bereaved individuals can be a way to reconnect with the deceased or to understand what they went through, suggesting that suicidal ideation may be a manifestation of continuing bonds in those bereaved by suicide. Interestingly, participants claimed that this process aided their grief work by helping them to make sense of the suicide; however, reported they felt discouraged from sharing these thoughts with others [9]. These findings illustrate the importance of addressing suicidal thoughts in a constructive manner as opposed to inadvertently reinforcing suicide stigma by silencing them [9].
The stigma associated with suicide in the context of religions may be particularly strong, with some bereaved individuals choosing to hold private ceremonies following a suicide death [27,28]. This is supported by a qualitative systematic review that found that religious individuals often isolate themselves due to feelings of shame and suicide-related stigmatisation emanating from religious doctrines [29]. Interestingly, taking part in religious ceremonies was common practice even in those participants who identified as agnostic [27]. A possible explanation for this may be that societal and cultural expectations dictate how we grieve, insofar as rituals such as funerals are expected in western culture [30]. Future studies conducted in different cultures may shed light on the expression of continuing bonds with regards to spiritual and religious themes and the possible stigma in this context.
Referring to the 'Dual Process Model of Coping with Bereavement' [31], studies reported differences between males and females with females engaging in more 'lossoriented' behaviours, including continuing bonds, and males engaging in more 'restorationoriented' behaviours, including learning new skills [15]. Whilst it may be the case that males experience continuing bonds to a lesser extent than females and/or in different domains [32], literature suggests that societal perceptions of gender and masculinity may influence the expression of grief, and grief after suicide, in males [33], resulting in males engaging in restoration-oriented activities as a distraction from or expression of their grief [33]. This view is supported by Entilli and colleagues [15] who found that fathers avoided discussing their feelings regarding the loss by suicide. Future studies may further compare the experience of continuing bonds between males and females and inform services to be directed accordingly.
The process of 'meaning-making' was mentioned throughout the reviewed studies. It refers to the ability of the bereaved person to make sense of or find meaning in the death [8,34] and has been widely recognised in grief literature [8,34]. Milman and colleagues described meaning-making as a method of alleviating the cognitive dissonance caused by the death through purposeful reflection [34]. They highlight the importance of differentiating this process from rumination as the latter fails to negotiate this discrepancy and is characterised by passive, repetitive and negative thoughts [34]. Our review indicated that those who were able to make meaning of the suicide experienced more positive continuing bonds whilst those who were unable to make meaning experienced more negative continuing bonds. In addition, high resilience characteristics and a strong social support network tended to predict less intense continuing bonds and higher levels of posttraumatic growth [24].

Continuing Bonds as a Positive or a Negative Experience
Most participants in the included studies reported positive feelings experienced with continuing bonds [16,18,23], a finding that is mirrored by those of general bereavement studies [35,36]. However, a quantitative study comparing different forms of bereavement indicated that those bereaved by suicide reporting lower levels of close and positive relationships with the deceased both pre-and post-death [24]. The incorporation of multiple factors, including close and positive, and pre-and post-death relationships, make it hard to accurately compare these results with other studies. As demonstrated by Leichtentritt and colleagues [25], a 'close' relationship is not necessarily synonymous with a 'positive' one. Likewise, as suggested throughout this review, the process of meaning-making transforms the relationship so that the pre-and post-death relationships may not be equivalent. Further studies comparing experiences of continuing bonds between those bereaved by different causes may further clarify how to understand these experiences.
Negative experiences occurred when continuing bonds in the form of memories or objects faded or were lost [14,21], when participants were not able to make meaning of the loss [15], or when aspects of continuing bonds were beyond the control of the bereaved [22,25]. Participants experienced feelings of distress at fading memories of the deceased [14], or due to the sudden and unexpected disappearance of online memorials [21], which was described as a 'double loss' [22]. Some expressed apprehension and guilt as contributing to the continuing bonds as they did not want to abandon the deceased person [10]. Additionally, participants experienced cognitive dissonance when their religious beliefs were in opposition to the actions of the deceased [27], or upon the discovery of new information about the deceased that was contradictory to their own internal representation of the deceased person [21,22]. These psychological discrepancies were found to hinder the ability of the bereaved person to make meaning of the death and enhanced negative feelings associated with continuing bonds [9]. Further research may clarify in which circumstances it may be more beneficial for the bereaved person to relinquish than to maintain the bond [35,36].
Participants utilised several tools and behaviours to create or maintain positive continuing bonds. Many studies observed the tendency of participants to omit certain aspects of the deceased personality or behaviour when recalling memories of them [23], or to hold more symbolic or fictitious representations of the deceased [25,27]. Some bereaved individuals favoured online memorials due to them being more interactive than traditional mourning objects [21]. This is supported by literature reporting that this allows the bereaved to explore the relationship in more depth and to discover new things about the deceased, thus enabling the relationship to evolve [37]. Nonetheless, a potential negative aspect of online grief-related activities is the ease with which those bereaved can become preoccupied with the relationship, hindering the meaning-making process [21,38].
Positive and negative experiences with continuing bonds were often intertwined. Wood [23] found that negative thoughts about the deceased's personality or behaviour initially evoked distress but with reflection and perspective, understanding and personal growth could be achieved. This was echoed by Maple [16], who found that parents could initially be distressed at the ongoing 'presence' of their deceased child but in time came to enjoy these experiences. Nonetheless, participants reported a bitter 'aftertaste' associated with positive thoughts about the deceased as they tended to trigger difficult emotions and memories [23]. Remembering the more holistic picture (both good and bad) was beneficial in making sense of the suicide and relieving responsibility and guilt in those bereaved by suicide [23,39].

Limitations
The studies included in the review and the review itself entailed a few limitations. Most studies were qualitative, or cross-sectional (of relatively poor quality) with primarily female participants from western countries, making the impact of culture, sex and time since bereavement difficult to discern. This highlights the need for international research involving representative samples. Also, further studies involving control groups or adopting community-based longitudinal designs may enable researchers to capture the experiences of continuing bonds over time. While the review involved searches in six databases, future reviews can broaden the scope by including more databases as well as grey literature, which may increase, for example, the likelihood of finding negative experiences in the context of continuing bonds.

Implications
A better understanding of continuing bonds in suicide bereavement may inform future interventions and enable service providers to deliver more accurate and targeted support. In particular, the review highlights the substantial impact that societal expectations and stigma continue to have on the experience of grief in suicide bereaved individuals [40]. The findings of this review may direct future studies and help to characterise the experiences of continuing bonds in people bereaved by suicide with greater clarity.

Conclusions
People bereaved by suicide commonly experience continuing bonds and generally interpret these as positive experiences. Factors such as time since bereavement, social and cultural expectations, sex of the bereaved person, and the ability of the bereaved to make meaning of the death may influence how continuing bonds manifest and whether they are experienced as positive or negative (although further research is needed). Postvention efforts should consider the process of meaning-making in creating the basis for positive continuing bonds and should attempt to address the stigma and societal expectations surrounding suicide bereavement. Future studies should involve representative samples, compare with continuing bonds after other causes of death, and investigate continuing bonds in suicide bereavement longitudinally.
Funding: K.A. was supported by a National Health and Medical Research Council Early Career Fellowship (GNT1157796). The funder had no role in the design of the study, in the collection, analyses, or interpretation of data, in the writing of the manuscript, or in the decision to publish the results.
Institutional Review Board Statement: Not applicable.

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

Selection
(1) Representativeness of the exposed cohort (2) Selection of the non-exposed cohort (a) Drawn from the same community as the exposed cohort (one star) N/a X