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Religions 2018, 9(5), 153; doi:10.3390/rel9050153
Spiritual and Religious Issues in the Aftermath of Suicide
School of Social Work Fribourg, HES-SO University of Applied Sciences and Arts Western Switzerland, Rue J. Prouvé 10, 1762 Givisiez, Switzerland
Received: 5 March 2018 / Accepted: 8 May 2018 / Published: 10 May 2018
Introduction: Spirituality and religion have only been marginally investigated in the experiences of the bereaved by suicide (or survivors of suicide). Aim: This article directly addresses two questions: In what way was spirituality or religion an issue for survivors of suicide? How were they helpful (or not) during their reconstruction process? Method: Research involved qualitative studies, carried out in Switzerland with 50 survivors of suicide using in depth-interviews. Data were analyzed according to grounded theory principles. Results: Suicide triggered questioning mainly about the afterlife of the deceased and of how transcendency relates to agency and responsibility in the suicidal act. Spiritual or religious issues play an important role in the process of reconstruction for survivors, notably in meaning-making and responsibility-clarifying processes, in forging a continuing bond with the deceased and in honoring their life and memory. Nevertheless, this role is complex and can either support or make the recovery difficult (or both). Conclusion: Mental health and social care professionals may support survivors’ resilience and their reconstruction process by valuing the constructive aspects of their spiritual and religious experiences and by taking into account the spiritual and religious struggles they face to offer effective support to survivors of suicide during recovery.
Keywords:survivors of suicide; bereaved by suicide; spirituality; religion; meaning making; clarifying responsibility; rites; qualitative study; grounded theory
In times of loss and bereavement, humankind has often turned to religious or spiritual beliefs and practices to find a framework, a way of dealing with and/or incorporating death (Krysinska et al. 2017; Vandercreek and Mottram 2009); or for constructing meanings for death and the world as it is experienced by people in ordinary or difficult times (Holloway and Moss 2010). Despite growing secularism in some parts of the world, spirituality and religion are still elements of the cultural and sociological worldview of many societies, particularly when it comes to life and death. This is especially the case where the death is tragic and violent (Burke et al. 2011).
In this article, the definitions of Canda and Furman (2009) are adopted: “the spiritual relates to the person’s search for a sense of meaning and morally fulfilling relationships between oneself, other people, the encompassing universe and the ontological ground of existence, whether a person understands this in terms which are theistic, atheistic, nontheistic or any combination of these” (pp. 43–44). The authors defined religion as an “organised, structured set of beliefs and practices shared by a community related to spirituality” (p. 54).
Suicide questions the “taken-for-granted” nature of one’s being in the world (Schutz 1987) and the person’s worldview. It can challenge or even shatter both. Suicide is likely to trigger several spiritual questions, such as: How does suicide relate to spirituality or religion? How is it understood in various religious traditions or spiritual beliefs? Was the divinity or spiritual entity involved in what happened? How? Is suicide a divine or relational punishment? What kind of afterlife will people who die by suicide experience?
Concerning suicide, metaphysical, spiritual and religious questions have been raised. Historically, the major monotheistic religions have mostly condemned it; suicide was often seen as a sin against God, humanity and/or oneself, or as an unnatural act, which formed an obstacle to spiritual evolution. Certain religious practices condemned the deceased, by denying them some of the usual privileges attributed to the dead. Catholics, for example, were denied burial in consecrated ground if they had died by suicide, and it was also believed that their salvation might be compromised. Even though, in most religious traditions, beliefs and practices have evolved, it is still the case that loved ones may be faced with confronting beliefs and reactions in civil society and in religious communities
Spirituality and religions are likely to both support the bereaved of suicide, also called “survivors of suicide” and to challenge them during their reconstruction process in the aftermath of suicide.
The great majority of studies have found that religious and spiritual beliefs had positive effect on bereavement in general (Becker et al. 2007), mostly with regard to positive adjustment (Videka-Sherman 1982; Wortmann and Park 2009), creation of meaning (Golsworthy and Coyle 1999), ongoing relationships with the deceased (Maple et al. 2012) and attributions of responsibility (Vandercreek and Mottram 2009). Spirituality and religion are likely to be one of the mediators of post-traumatic growth (Michael and Cooper 2013).
Studies on suicide bereavement and spirituality or religion are scarce. Belief in an afterlife is quite common among the bereaved by suicide (Lichtenthal et al. 2013) and is likely to improve bereavement recovery, as it is the case with other causes of death (Smith et al. 1992), if it provides the hope of being reunited with the deceased (Lichtenthal et al. 2013).
With regard to meaning-making about suicide and spirituality, in the Murphy and Johnson (2003) study, although religious coping and attending a support group predicted finding meaning for parents bereaved by the sudden death of their child, after five years, 61% of suicide bereaved-parents could not find meaning. Lichtenthal et al. (2013) found no significative difference in meaning-making among parents bereaved by various violent causes of death (including suicide), regarding death as being part of God’s plan, the afterlife, and the possibility of being reunited in the future.
Suicide survivors scoring higher on spiritual well-being had lower levels of stress and higher levels of adaptability (Fournier 1998). Spiritual or religious beliefs may however challenge people and the course of their bereavement if the well-being of the deceased in the afterlife is questioned (Krysinska et al. 2017). In some studies, survivors of suicide were likely to struggle with the idea that God was punishing them (Houck 2004). Their beliefs in a benevolent or just God may be challenged. Some bereaved, including suicide survivors, are disappointed that God allowed bad things to happen and therefore doubt or lose their faith (Burke and Neimeyer 2016; Spencer-Thomas 2011). Spiritual struggles after suicide are common (Vandercreek and Mottram 2009). If these personal struggles meet with stigmatizing religious practices or reactions, the bereaved are more likely to move away from spirituality and religion (Spencer-Thomas 2011). In the Jahn and Spencer-Thomas (2014) study, about one third (36%) of bereaved by suicide reported becoming more spiritual after the suicide, whereas about one fifth (19%) became less religious or spiritual and a little less than half (46%) reported no changes. Among the participants in the Jahn and Spencer-Thomas (2014) study, one quarter were religious or spiritual and regularly participated in organized religion, 26% occasionally participated in organized religion, 40% were spiritual but did not participate in organized religion and 10% were neither spiritual nor religious (Krysinska et al. 2017). The same study reported that suicide survivors engaged in positive coping (sought help from God) some of the time and did not or were very little engaged in negative religious coping (for example, questioning God’s love for them), although these scores were higher than in a sample of HIV/AIDS or cancer patients (Krysinska et al. 2017). According to the same study, survivors have spiritual experiences most days.
In several studies, the bereaved by suicide have been identified as seeking spiritual advice and connection with their loved ones (Feigelman et al. 2011; Jahn and Spencer-Thomas 2014). They frequently reported positive after-death spiritual experiences (dreams, intuition, sensations, and feeling a presence) (Jahn and Spencer-Thomas 2014). Religious or spiritual references were found on 14% of online memorials dedicated to people having died by suicide (Krysinska et al. 2014), addressing themes such as suicide as an expression of God’s will, relinquishing control to a benevolent God, believing in an everlasting life, wishing peace to the deceased, and expressing hope for a reunion or seeking forgiveness.
Findings on support for suicide survivors from religious communities are not homogenous: older studies did not find clergy helpful (Flarity 1993) nor was the majority of the clergy prepared to support them (Malikow 1991), whereas 68.7% of suicide survivors in the Jahn and Spencer-Thomas (2014) study reached out to their religious community. Three quarters of the responses were supportive, one fifth neutral or mixed and 7.2% indicated stigma or misunderstanding (Krysinska et al. 2017).
To our knowledge, little is understood in truly concrete and qualitative terms of how the bereaved make spiritual or religious sense of suicide or of how they create a spiritual or religious connection with the deceased. Understanding how people make sense (or not) of their loss in spiritual or religious terms and how spirituality or religion are a resource (or not) in the reconstruction process may help professionals to offer better and more timely support to survivors of suicide during grief and recovery. Since spiritual or religious beliefs and practices inform people’s worldview, the way they choose to live and to interpret what goes on (Holloway and Moss 2010), not taking these elements into account may prevent professionals from appropriately responding to the bereaved’s needs.
This article aims to provide answers to two questions: In what way was spirituality or religion an issue for survivors of suicide? How were they helpful (or not) during their reconstruction process? The article will address the role of religious or spiritual rites in the process survivors of suicide undergo in reconstructing their life and, more particularly, how religious or spiritual beliefs intervened in forging a continuing bond with the deceased, or further still in meaning-making or responsibility-clarifying processes.
Inspired by Vandercreek and Mottram (2009, p. 742), three dimensions of spirituality or religion will be taken into account: intrapersonal religious or spiritual assumptions, beliefs and practices; the function of spirituality or religion in networks of family members and friends; and the relationship to religious or spiritual communities and their leaders.
2.1. Study Design
Given the scarcity of qualitative and experiential data on how survivors of suicide address issues of spirituality and religion in the aftermath and considering that suicide is often experienced as a biographical disruption which calls for an existential reconstruction (Owens et al. 2008), a qualitative narrative approach was adopted, using face-to-face in-depth interviews. Data presented in this article come from three studies: The first one (n = 38) was explorative and investigated the manners in which survivors of suicide reconstruct their life and integrate (or not) the suicide into their life trajectories as well as how they reframe their identity. The second study followed up on some survivors while enlarging the sample (n = 10). The first two studies had the same purposes, design and lead questions or area of investigation. Religious and spiritual issues, while not the main focus of the studies, were addressed through the exploration of beliefs and resources relating to issues after suicide. Two participants were recruited through a different third study aimed at investigating how significant others make sense of suicidal sign and support suicidal persons. Since two of the participants were significant others of living suicidal persons but also had previously lost another loved one to suicide, they were asked if they were would share their experiences about being survivors of suicide. Upon acceptance, they were seen for an extra interview which adopted the same guide for questioning as the two prior studies.
A person was considered as a survivor of suicide if: (1) he/she self-qualified as such; (2) he/she felt emotionally close to the deceased; and (3) his/her life had been disrupted by a suicide (self-perception) (Castelli Dransart 2016). This definition takes into account the typology of survivors bereaved in the short and long term by Cerel et al. (2014). Several qualitative studies were carried out in Switzerland, with recurrent phases of data collection. The following inclusion criteria were adopted: being 18 or older and able to be interviewed in Italian, French or German. Because one goal of the studies was to ascertain the existence of similar patterns of reconstruction among families, parents and siblings were particularly sought out. Nevertheless, in accordance with theoretical sampling—sampling which is theoretically relevant to the phenomenon and theory (Strauss and Corbin 1990)—survivors with other status were also recruited, in order to include variety as a means of contrasting and saturating data.
Either the University Review Authority or the local Ethical Committee in Fribourg, Switzerland reviewed the studies. They were the authority in charge for ethical issues before the enforcement of the Federal Act on Research Involving Human Beings (2011.09.30). Oral (taped) and/or written informed consent was obtained by participants. The procedures were carried out in accordance with the WMA Helsinki Declaration (World Medical Association 2013). Anonymity and confidentiality were assured (Castelli Dransart 2016). A free session with a psychotherapist experienced in suicide bereavement was offered to participants after the interviews. Two participants took up this opportunity. As a trained social worker, the author offered support during and after the interview if needed (Castelli Dransart 2016).
2.4. Data Collection
The recruitment of participants (unknown to the author) took place through social agencies, self-help groups, media advertising and the snowball effect. Interviews, either at home or another place chosen by the bereaved, lasted 2–4.5 h. They were carried out by the author except for five interviews which were conducted by a mental health carer, trained by the author to ensure consistency. No content differences appeared in data collected by the mental health carer. The interview covered various aspects of the bereaved’s experience: the impact of suicide on several areas of their life, coping strategies and adjustments with regard to self-image, the relationship with the deceased, the divinity (if any) or other people, the way they questioned the sense of the event, how they dealt with issues of responsibility, the support sought or received, how they built a memory of the deceased, the rites and public management of suicide, their beliefs in life and death, and their affiliation to associations or groups (including religious or spiritual groups). Field notes were made after the interviews. Documents and data likely to support the reconstruction process, such excerpts of the deceased’s or survivors’ journals, letters or pictures, were made available to the researcher.
All interviews bar two were audio-recorded and transcribed verbatim, and then analyzed by the author using ATLAS.ti (2010), according to the Grounded Theory, which both gives a voice to people who have experienced the death by suicide of a loved one (findings grounded in data) and develops conceptual density (conceptual relationships) and interpretation (Strauss et al. 1994). The Grounded Theory proceeds by constant comparison of data (Glaser and Strauss 1967) through the three steps of coding: open, axial and selective (Strauss and Corbin 1990). Open coding consists of identifying relevant themes and finding similarities and differences in contrasting narratives. Themes (such as hearing voices) were grouped into categories (feeling the presence of the deceased) and their dimensions (contexts, events, and persons). Axial coding consists of refining, condensing and interconnecting themes and categories into more essential categories (manifestations of the deceased). In selective coding, the core categories (believing in an afterlife for the deceased) are identified. These categories tied all the other categories together and made it possible to report on specific aspects of the phenomenon being investigated (spiritual and religious issues during the reconstruction process). The theoretical saturation point was achieved when no new themes emerged from the data (Creswell 1998). Double-checking and coding with colleagues, as well as keeping an audit trail of the research and analytical processes ensured the trustworthiness of the findings. Participants received the transcribed interviews and a summary of the analysis. They were given the opportunity to notify which (if any) parts were not to be quoted publicly and to comment on and add to the text and the analysis (Castelli Dransart 2016).
2.6. Characteristic of Participants and Those They Lost to Suicide
Fifty survivors of suicide were interviewed, 39 of whom were female. The majority were parents (n = 23) and siblings (n = 13). Seven were partners, four children, two friends and one aunt (see Table 1 for more details). Fourteen (3 males; 8 parents, 2 siblings, 1 daughter, and 3 partners) were followed-up over a period of 8 years. Time elapsed since suicide until the first interview ranged from less than a year (n = 2) to more than 16 years (n = 3) (1–5 years (n = 24), 6–10 years (n = 15), 11–15 years (n = 6). At the time of suicide, the age range for survivors was 14–73 (Castelli Dransart 2016). All interviewees but four were of Christian origin by birth (36 Catholics, 8 Protestants, and 2 Evangelists). At the time of the first interview, 22 considered themselves as “truly Christian” (their expression), meaning that they regularly participated in organized religion and followed the Christian faith, including believing in the afterlife. Seventeen were spiritual, believing in a God or transcendence and the afterlife. Some of them participated occasionally in organized religions on special occasions. Ten people declared themselves to be agnostic or atheist. One person sought refuge in Buddhism after the suicide.
Thirty males and five females died by suicide. Eleven died by firearms, seven by hanging, five by jumping from heights, four by overdose and seven by other means. The majority of deceased were younger than 30 (n = 18) and only four were older than 40. Almost half (n = 17) were diagnosed with a mental health disorder prior to their death (Castelli Dransart 2016).
Spirituality and religion were issues for all the interviewees, even for those who declared themselves to be agnostic or atheist; they were spontaneously addressed by the bereaved in their narratives. The main themes/categories emerged from the interview are presented below.
3.1. Spiritual or Religious Rites as a Resource for Saying Farewell and Honoring the Deceased’s Memory
Except for the person who saw suicide as a punishment or the three people for whom suicide caused a crisis in or the loss of faith, spiritual beliefs and religious practices formed an important resource for facing suffering and self-reconstruction, most of all right after the death, when the survivors had to take farewell of their loved one. In the same way, the support of fellow believers was invaluable, as much at the time of the funeral as when everyday life resumed. The majority of the bereaved (38 out of 50) said they were supported at one time or another by ministers of religion, spiritual masters or by people sharing their same spiritual or religious convictions. This support took various forms: practical help in the early days with administrative processes, preparation of the final farewell, cleaning of the suicide site, but also a presence, an emotional support or an accompaniment to their meaning-making and in confronting the question of responsibility:
“The pastor and his wife stayed with me all day, when I had to go and identify my son, each one held me by the arm, then at the municipality for the administrative steps. They organized the funeral, they were wonderful”.(Dak, mother)
Some people were nevertheless disappointed by the lack of support received after the first few days. They would have liked more regular support over a longer period:
“The priest never appeared again after the funeral, not a word, not a visit. Even though I’d been active in the parish”.(Had, mother)
For certain people, faith as an individual experience was the principal resource for being able to face up to the event. For others, it was being supported by the community which made the difference:
“At the time, I had a lot to do with the Jewish and the Catholics (he was a Reformed pastor (ed.)). The Jewish came to my house, in the hours following the death, brought food, stayed with me for a long time, in bare feet, according to their customs. The Catholics called instead, wrote, we celebrated a mass”.(Zum, husband)
This presence, these gestures were very important for the bereaved because they expressed solidarity and compassion and were considered as proof that these believers did not judge the bereaved or shun them after the suicide, nor did they condemn the deceased’s action. Sometimes, exchanges with believers also allowed the bereaved to escape from certain difficulties stemming from the search for meaning and the attribution of responsibility, or to find the force to imagine a future:
“He said to me: can you put things in the hands of God?”.(Lyo, wife)
Generally, spirituality or religion were at the heart of farewell rituals or of letting go of the deceased, as well as in building and maintaining memories of the deceased. Religious farewell rituals fulfil several functions: they activate ties of solidarity within the community, provide an occasion to receive comfort, and finally they pose the foundations for the building of memories of the deceased. All the bereaved (including the agnostics) took part in a religious ceremony of farewell to the deceased, Catholic or Reformed, independently of whether they believed or not, or worshipped or not. “Ordinary” religious funerals neutralize to some extent the extraordinary nature of a death by suicide. They help to insert an unusual and exceptional event into the usual order of an ordinary sequence and pattern. Nobody spoke of having difficulties in obtaining the ceremony they desired:
“In the past, there would have been dramas with the church about a burial after suicide, but fortunately that has changed, the priest said to me: there is not a hint of a problem”.(Teh, mother)
Sometimes, there were questions, perhaps even tensions, within families which emerged when a religious ceremony was chosen, even though the deceased was not a believer:
“He was not a believer, but I still wished to have a mass, I told myself that it wasn’t a profession of faith; a burial mass is a prayer, it’s those around him who are praying for him (…) the priest told me later that one or two people in the family had said to him: but, after all, he wasn’t a believer, why would you bury him with the church and the priest answered: that doesn’t stop his close relations from praying for him”.(Teh, mother)
The ceremonies proceeded as for an ordinary death and were public, with just two exceptions: for these, the families chose a private ceremony. In both cases, the bereaved said they were difficult experiences:
“My parents didn’t want anybody other than us, I thought it was a shame, I would have liked all his friends and everyone to be there. For me, it was dreadful just to be among ourselves for this ceremony, it was awful, I find that having others there helps already, just with their presence you feel less alone, it was unbearable, a dreadful moment”.(Rine, sister)
The ceremony was also a more difficult experience when the family received less support preparing the ceremony, or when the community did not mobilise itself:
On the other hand, funerals or farewell rituals which mobilized the community (help selecting the texts, songs, and music) were appreciated by the bereaved in spite of their pain:
“It was really a beautiful ceremony, of which I have a good memory, there was a lot of sadness in people, but not in what happened, in the songs, the sermon, it was all hope, many people contributed, we really felt carried”.(Bun, brother)
The role of the community of believers was fundamental, as was its acceptance, its capacity to welcome, give comfort and help.
“This community was a great help to me, it seemed to me that God had sent me this group to support me during this time, because the community arrived a year before the suicide and stayed long enough to support me, after it disbanded”.(Dak, mother)
One expression often returns to the bereaved’s mouths: “we were carried”. This refers to their experience of human solidarity, but also refers sometimes to the feeling of having received assistance “on high”.
“I realized that we received many blessings, we were carried by grace”.(Nou, couple)
To feel carried means feeling as though there is a net of affection and support around you, feeling the warmth and the participation of others in your fate or feeling supported by transcendence. The flowers, the condolence cards, and the demonstrations of affection touch the bereaved deeply. They express reactivated solidarity and membership of a community. These contribute to alleviating the shock, they provide a framework for daily life, which has been completely disrupted by suicide. They show that people continue to remain members of the community even when such a drama occurs, and that the bereaved are not alone.
Some bereaved who chose more unusual forms of ceremonies or rites were subject to gossip or judgement:
“My son’s friends did not understand that we decided to bury him in a common grave. For us, a tomb did not make sense, our son is not there. Our son is here where we live, every year we plant a tree on the anniversary of his death”.(Yae, couple)
The son’s friends interpreted this decision as a kind of punishment of the son by the parents because of the act he committed. This reaction can be explained by the fact that funerals are socially coded and often act as rites of passage. They give form to the separation, they clearly establish everyone’s places and roles (those of dead and those of the living), they help to return the deceased to their status as a member of the community, a status sometimes called into question by the act of suicide.
Funerals are not only about saying goodbye to the deceased. They also mark the beginning of the process of building the memory of the deceased and a new bond with them. At the time of the funeral, the family remembers the life of the deceased by publicly presenting certain elements and anecdotes. This memory is of capital importance for the bereaved. It is built up and maintained through spiritual or religious rites, even after the funeral. For the majority of people, especially those who worship more, visiting the cemetery is a rite which remains important even many years after the death. Parents go there regularly and find consolation in it, as proof that the person existed, even if the majority may think that the deceased is elsewhere. For others, visits to the cemetery were important at the beginning, then the need faded.
“There was a time when I needed the cemetery, I felt like it was his new home, his body was really there”.(Bun, brother)
There were a certain number who never found comfort in cemetery visits, though. This is especially the case for young bereaved people who keep the deceased’s memory alive in a different way, not through objects, or places, but in different spiritual gestures, such as lighting a candle, planting plants or flowers, or keeping objects in the places where they were.
“The cemetery doesn’t do anything for me, I find him in everyday life, at the cemetery there are only ashes”.(Ti, sister)
The memory is kept up through the years, by celebrating masses in honor of the deceased, in particular on anniversaries:
“This year it will be the tenth anniversary, my mother wants to organize a mass and a meal to bring family and friends together”.(Hme, sister)
Rites relating to spiritual or religious beliefs therefore contribute not only to giving a place to those who died by suicide, but also to the rebuilding of daily life for the bereaved and the way in which they integrate their loss and maintain a bond with the deceased person. This is possible because almost all bereaved believe in the possibility of pursuing an existence after life.
3.2. Suicide and Existence after Death
Almost all those interviewed believe that the deceased continues to exist (the words used were those of “soul, life energy or simply energy”). This may almost seem logical for those who were already believers and/or worshipping prior to the suicide, especially if they were of Christian faith, which postulates the soul’s enduring nature. Nonetheless, even people who were no longer practicing their faith before the suicide or people who did not claim to have a spiritual or religious dimension, were open to the possibility of life after death.
If the form this existence takes remains more or less unspecified (how the soul or form of energy continues to exist is unclear), the place or dimension seem to be clearer: a space which takes on the contours of heaven (the idea of serenity or pleasure, of being in the presence of God, and a personal relationship); a space/place where the divine Source is (the Creator, universal love, and more impersonal relationship); or still carrying on through reincarnation. These spaces may be given a more or less positive connotation, depending on whether the bereaved believes that the deceased has to be purified after his/her act, before being able to enter heaven or reach the divine source. This belief in a possible continuation of existence after death either comes from the bereaved (see below) or from the beliefs or words of the deceased person:
“What has maybe, not helped me exactly, but simply made it possible to face things, is that I am a believer and that I felt confident that for him, this was not the end. It was a terrible time, but [knowing that] after his death he would find a place which would welcome him (…) I don’t think I could ever have endured it if I had to think: “well, he died, he doesn’t exist anymore”;(Teh, mother)
Underpinning these beliefs are signs, intuitions, and dreams experienced by the bereaved, interpreted as manifestations of the person lost to suicide and indirect evidence that he/she continues to exist. At certain points, mothers and wives heard an interior voice advise them or transmit calming thoughts to them. Almost all the bereaved noted particular situations or coincidences which were interpreted, at least at the beginning, as a sign from the deceased:
“I smelt the perfume of a rose and then I found a rose in the street. I took it as a gift, it’s not scientific evidence but a strange coincidence; maybe it’s an illusion, but what’s important it is that that helps you”.(Bam, sister)
Dreams with a spiritual connotation were very frequent. For example, one mother asked the Virgin Mary for a sign from her daughter. On the following night, she dreamt the girl gently embraced her and then took on the shape of a dove, the symbolic creature of the Old Testament (the dove with the olive branch after the flood) and the New Testament (symbol of the Holy Spirit for Catholics). This dream represented a significant moment, the beginning of appeasement for this mother who was desperate at the idea of her daughter’s soul being in difficulty and who was also experiencing a great feeling of revolt against God.
Several people performed automatic writing:
“I felt like he was writing through me, I wrote in tears and almost in a trance, it was very intense for the first few days, then it gradually faded out over the year”.(Bun, brother)
Others consulted mediums or people who channeled spirits: they reported having received messages from the deceased. The majority of these were messages which not only indicated that the late one continued to exist, but which passed on signs of love which reassured the bereaved about the deceased person’s state. At the time, these messages were very important for the bereaved, but over time, the majority stopped seeking this type of contact and even came to question its meaning.
The need to communicate with the deceased via a medium, to hear their words, generally fades with time, perhaps also because the bereaved are sometimes told they must let the deceased go:
“At the beginning, you seek a link through a medium, to be able to communicate with him, then afterwards you start to feel the link inside you and people tell you, you have to let the dead go and then you feel a fight inside, between wanting to speak to him and letting him go, then you come to understand that beyond words, there are other forms of energy, of possible contact”.(Bam, sister)
Just one person, a mother, was told that the deceased was in a grey zone, that is, a zone not yet completely free of suffering or from the need to be purified. However, none of the people who believe in the afterlife thought that the soul or energy of the deceased was condemned forever by suicide. The majority thought that they would be welcomed with mercy or benevolence by God or the life source, which helped to deal with the questioning and brought a certain appeasement.
People sharing the same community of faith sometimes helped the bereaved to reach this conclusion; it was the case for certain parents who had long exchanges with Ministers of their faith, nuns or other believers:
“We met this nun and she comforted us a little, she spoke about the mercy of God and that he would welcome our son”.(Had, parents)
The bereaved of Christian faith also believe in a possible reunion with the deceased in the afterlife, as indicated by what these parents wrote on their son’s memorial card:
“We believe we’ll see you again”.(Had, parents)
Three people believed in reincarnation and therefore that the deceased would take on another form of life in the future; three others believed that the deceased would become a form of free energy without indicating what could or would become of this energy. Those who refer to a Buddhist tradition were challenged by the means of death:
“The moment of death is very important because the next reincarnation also depends on it (…) reincarnation depends on karma but also on what happens at the time of death and reincarnation”.(Tam, daughter)
This daughter suffered from the idea that the future reincarnation of her father would be made difficult because of the way he died. This is why she asked her Buddhist guide to hold prayers to help her father. For people who believe in life continuing in another form, including reincarnation but according to a vision less influenced by Buddhist teachings, the deceased’s life is put into perspective and forms part of a broader existence. According to this way of seeing things, reincarnation after suicide seems to be less problematic:
“For me it was like a revelation, this death was part of his journey (…) I believe that we come into this world to learn things and have experiences, once we learn, we change and go off in other directions… I have the conviction that we are ourselves before being born and that we continue on afterwards and so, the importance of this life, which is only one bit, is relative, it is only one bit”.(Bam, sister)
Finally, there are the agnostics, who are either unsure about whether there is life after death, or, although they are not believers, hope there is still a possibility of meeting up again somehow:
“I still do not believe in God, but at the same time one day I began to say to myself: one day I will see him again”.(Dra, mother)
Similarly, the great majority of people, whether they were believers, practicing religion or not, said they had felt the deceased’s presence, either as a memory captured and built into their life, or as energy:
“I feel his presence a lot, I have amazing connections to heaven, for me he’s a presence and a force, (…) I feel protected from heaven”.(Ti, sister)
All the people interviewed perceived this presence as something positive for themselves (protection, assistance, consolation) but also on occasion, for others. The deceased indeed seem to play, for a significant number of people, the role of connection to God or the life source. The bereaved address them to draw force, to seek advice, for support in certain situations in everyday life. This was the case for Hme (sister) who had to attend a very important work interview on the anniversary of her brother’s death and thought of her brother. The bereaved also consider the deceased as assistants for the future, when it becomes necessary to cross the threshold of death themselves:
“He’s waiting for me and will help when I have to cross over myself, it’s taken away my fear of passing”.(Vya, mother)
However, the deceased are also called upon to come to the assistance of third parties. This was the case for Teh (mother), who prayed to her son to help an acquaintance in serious difficulty to find work.
If the bereaved ask for help from the deceased rather than from a divinity or transcendence, it is perhaps because their beliefs have been shaken by the suicide.
3.3. Suicide as a Test of Spiritual or Religious Beliefs as Well as of the Relationship with Transcendence
Following a suicide, most of the people who were believers or practiced religion continued to believe in God or in transcendence, not without some heart-rending questioning or even crises of faith; still, there were others whose faith was shaken (n = 3) and who gave up their beliefs. For a minority (n = 4), suicide did not provoke a need for greater spirituality or religiosity, yet, for others, suicide was the starting point for a spiritual or religious quest (n = 8):
“It was a world I discovered after the death of my brother. He’d already spoken to me about it but it was not the right moment, suicide made me open up to this dimension, before it was really a need to find explanations, support, but now it is a search for myself; before, my search was in relation to my brother, knowing if he was ok afterwards (…) I’ve discovered new things which bring peace, which give direction, especially with this concept of karma, of a journey broader than this life”.(Bam, sister)
With some of the people for whom suicide was the beginning of a spiritual quest, this element became a significant part of their ongoing life, whereas for others the spiritual quest and/or religious practice was a resource during the period of rebuilding themselves and their lives.
“At the time I was an atheist like my brother, and then I told myself it wasn’t possible, it was unbearable, because he had got to that point; so, there had to be a God once I admitted that there was a presence, something, that lasted for some time. Now, I’m in doubt once again and the Catholic religion doesn’t suit me at all, so I’ve left religion”.(Hme sister)
If suicide does not seem to shake people’s belief in the afterlife, it can be quite a different story when it comes to the beliefs or representations that the bereaved had of God or transcendence, and of their role in human lives. For some (n = 3), suicide fundamentally called into question their belief in good and just God:
“For my husband, the death of our son was a shock, he was a true believer but afterwards it was really a problem, he revolted against it and I think that revolt is harder to live with than sorrow. He said: “They say that God is good, but why didn’t he stop that?” and his sense of revolt was never resolved, until his death”.(Teh, mother)
The death by suicide of someone close also perturbs the ideas people have about the relationship between God and humans.
For some bereaved, suicide meant their trust in God was broken, with suicide being seen as an injustice, even as a betrayal, by God:
“I always gave everything I had to God, to my family, to others. God should have protected my children, given them good health, instead he wounded me through them. I did everything to live as a good Christian woman and still I find myself with nothing and I can’t believe that God wants that, that he wants to punish me, but I don’t understand how he could allow it to happen, he let me down”.(Dak, mother)
While only one interviewee explicitly interpreted suicide as a punishment, all the bereaved (except the agnostics) raised the question of the spiritual and/or religious meaning of suicide and, more particularly for those who believed and worshipped before the event, of God’s role and agency. Among people who believe in the existence of a distinct entity (of God or of a divine power) with whom they can maintain a personal relationship, there were several interpretations of how such an entity intervenes in human lives and, more precisely, in the case of suicide. Nobody believed that God caused the death by suicide of the deceased. However, several people thought that the death was part of a divine plan. This belief was very strong in certain people, to the point that they expressed it publicly, in the obituary notice, for example:
“Lord, let thy will be done”.(Nou, parents)
An alternative to this belief is one which suggests that God calls the best back to himself:
“Why did you take her with you? She was good here, why did you have to take her back? Yeah sure, if there’s a good person, then God wants her by his side”.(Pan, mother)
This belief in God’s will as linked to suicide generated two types of reactions: some accepted it without calling it in question, choosing to trust in a God who “knows all and knows better” than humans:
“We’ll understand when our time comes, on the other side, when we find ourselves transformed (…) sometimes I wondered: but why? but later, we’ll know why, when we’re in the other world”.(Teh, mother)
This presupposes giving up, at least partly, on understanding while on this earth. However, the majority of interviewees who believed that the will of God was somehow involved in the suicidal act often experienced feelings of disillusionment and particularly great revolt:
“I am somebody who can’t lose faith, but this event distresses me. I act as if God exists and is good and I continue to believe in him, but sometimes after the death of my son, when I was alone, I shouted at God “What’d we do to you? What do you want from us?”.(Had, mother)
Feelings of revolt were also expressed in connection to another belief, rather widespread, that suicide, while not coming about through God’s will, was allowed by God. In this, it is not God’s intention which is in question, but his failure to intervene which causes anger and disillusionment; in the eyes of the interviewees, it also calls into question their faith in his all-powerful nature, his love for human beings or, once more, the notion of divine justice:
“No, the Lord should not allow it, why should things like this happen?”.(Pam, mother)
The two beliefs concerning God’s will and his non-intervention are sometimes conveyed by ministers of Christian faith, which can cause strong reactions:
“My friend wrote me a letter to tell me that she didn’t agree with what the pastor said—even though she is Catholic—because he said several times that God had wanted it, that God had called him back and it was the will of God and had to be accepted”.(Dra, mother)
Moreover, these two beliefs, that is, the supposed will of God and his non-intervention, led certain people to doubt or even reject his existence:
“If there were someone who was stronger and more benevolent than us, why would this happen to us? Why would our children be taken away?”.(Dra, mother)
For people who do not have a personal relationship with God or a defined entity or who do not believe that God intervenes in a concrete way in daily lives, questions about the intention and the non-intervention of God did not cause issues:
“For me, that’s not God’s job, ruling over people’s life and death is not his problem, in my opinion, he has other things to deal with than worrying about every hour and second for everyone”.(Bun, brother)
In the same way, people who believe in an abstract transcendental entity (love or universal energy) did not call on God’s agency to find meaning, but instead came back to the deceased’s spiritual journey:
“There is something which escapes, which transcends, a higher force, a destiny, an individual, spiritual path that it is impossible for us to understand until the end”.(Ti, sister)
3.4. Suicide, Spirituality/Religion and Responsibility
The bereaved called into question the role that spirituality may have played in the suicidal act.
For some of them, spirituality or religion may have been a factor in going through with the suicidal act. Teh (mother) considered that if her son had had faith, it may have leant meaning to his suffering and have given him the force to overcome his difficulties. She attributes his despair to his loss of faith.
Zum, on the other hand, considered that his wife sought refuge in spirituality to too great a degree and that it did not help her face her psychological difficulties or to accept assistance from mental health professionals:
“She ran away into spirituality, which had become like a drug [for her]”.
In three situations, those who died by suicide did so in the hope of being able to pass into the spiritual dimension:
“In his letter, he said that he was going into another dimension and that it was not the end of all”.(Dak, mother)
With regard to the latter situations, the suspicion of a mental health disorder exists.
Others questions related to responsibility touched upon a third party being involved in the deceased’s suicide. In the area of spirituality or religion, these questions relate to God’s responsibility, the deceased’s or of those close to the deceased.As we have seen, some of the interviewees considered that God was involved in the deceased’s act either willingly, or by omission. These beliefs or interpretations, while causing difficult-to-manage emotions (revolt, anger, betrayal, and disillusionment), relieve close relations of some of their sense of responsibility and feeling of guilt:
“My mother-in-law said to my daughter, who didn’t like it at all, that it was God who had come to get her dad, but, well, it was also a way for my mother-in-law to say, there was nothing we could do”.(Lyo, wife)
However, so the bereaved person can continue to believe, approaches which help restore confidence, re-establish the relationship with God or the transcendency, as well as with the deceased person are often necessary. Some people spoke about needing to ask God’s forgiveness for possible shortcomings which may have contributed to the resulting suicide. Here, we can see a subtext of suicide as a divine punishment or as a punishment of the other:
“I needed to be pardoned through confession to be able to cope with this guilty feeling which fills me. The priest told me something very important: God can forgive you and your wife can forgive you through Christ. And that helped me a lot to receive that absolution, it was another way of re-establishing communication and the relationship, different from spiritualism or esotericism”.(Zum, husband)
Feelings of guilt with regard to the departed can subside through the bereaved undertaking a spiritual journey which both restores the bond with the deceased spiritually and widens the understanding of death by including the notion of the other’s spiritual pathway:
“It helped me to feel that he was living in another form, to accept that the suicide was his decision and perhaps that it was part of his pathway in life, of a bigger picture; I can’t tell you that faith helped me, in the sense that I didn’t rely on religious people or practices for support; but to believe that not everything stops, then there is hope, the person has passed into another form of life, he carries on his way and so you feel born again and your guilty feeling is relativized”.(Ti, sister)
Two people said they had granted God their forgiveness:
“I realized that if I wanted to continue to have a relationship with God, it was necessary for me to forgive him for what I believed he had done or not done”.(To, father)
Others chose different paths: they changed their way of seeing the relationship between God and man. They concluded that God, while still a presence among mankind, does not intervene directly in life, but is more of asympathetic witness and a source of strength to help survive whatever happens.
Several people evoked the difficult heritage which certain religions’ past beliefs and practices have left, and which continue to feed a certain guilt:
“A cousin also committed suicide about 10 years before my brother did, the daughter of my father’s brother. He always believed that suicide was a mortal sin and felt terribly guilty and, for him, she was also in sin. It must be awful, not only losing somebody but also considering them guilty and, for him, suicide is wrong … I believe that it comes from the fact that in the past, suicide was deplored, and I believe that the feelings of shame and guilt that you can sometimes feel come from the fact the religious point of view always pretty much condemned suicide”.(Ti, sister)
This article provides unique insights into the manners in which spiritual and religious questions are addressed by survivors of suicide. It shows that these questions play an important role in their process of reconstruction, notably in saying farewell to the deceased, in meaning-making and responsibility-clarifying processes. Furthermore, spirituality and religion help to forge a continuing bond with the deceased and honor their life and memory. Nevertheless, this role is complex and can support recovery or complicate it.
Spiritual and/or religious rites were paramount in saying farewell, honoring and keeping the memory of the deceased. All the survivors participated in, and most of them contributed to organizing, religious ceremonies; even the agnostic and atheistic ones felt the need to resort to symbolic and spiritual procedures. No one found there to be any obstacle of a religious nature with regard to the ceremony. Most survivors found the religious ceremony helpful, except when it was private (only family members attending) or when the family was not supported by the religious leaders or by the community. It seems that religious ceremonies contribute to making survivors feel supported, rather than condemned by the community. They offer an opportunity to find solace and receive reassurance and for the community to concretely and collectively express their concern and sympathy. On a more general level, religious rituals and spiritual symbols contribute to forge and maintaining a continuing bond. Nevertheless, some survivors reported difficulties with regard to the way suicide was publicly addressed and interpreted by some religious leaders. Education may prove useful in this regard.
In line with Vandercreek and Mottram’s (2009) findings, most survivors were provided with various kinds of support, both material and emotional, by their religious community, principally in the first days following the suicide. Religious communities seem to act as first responders yet often struggle to find the balance between honoring the deceased, supporting the family (Krysinska et al. 2017) and giving a sense to suicide within the religious framework. Unfortunately, only very few survivors benefited from support following the ceremony and a number reported disappointment with this. Spirituality and religion are important for building and preserving the memory of the deceased and forging a continuing bond. This aspect seemed to be underestimated by the leaders and community members in our study. Dissemination of sound knowledge and literacy for community members and postvention education for religious leaders are likely to improve how support is provided and help leaders to convey spiritual and religious messages which help to foster recovery. Education and training may prove the best way to bridge the gap between the survivors’ spiritual or religious experiences and the support of communities and professionals. In our study, mental health care and spiritual or religious support were not integrated, as already noted by Spencer-Thomas (2011). Since, according to Thompson (2010), spirituality is essentially about meaning-making and mental health or social work care is often about developing more empowering meanings and understandings to foster resilience, some integration may prove beneficial not only to survivors but also to religious leaders and mental health service providers in their role. Clarifying the survivors’ religious positioning and beliefs, investigating the role of spirituality and religion in coping with death by suicide and exploring the stances held by survivors’ spiritual or religious community on suicide are likely to foster effective use of positive coping and to limit less constructive factors (Krysinska et al. 2017; Kaslow et al. 2011). Mental health and social care professionals may support the bereaved’s resilience and their reconstruction process by valuing the constructive aspects of their spiritual and religious experiences; and by taking into account the spiritual and religious struggles they face by providing appropriate support to the bereaved.
Interviewees, even the agnostic or atheist ones, usually believe that their loved ones pursue their existence in another dimension or space. For Christians, this means the deceased being with God and the survivors having an opportunity to be reunited with them in the future. For survivors whose vision is more abstract and undefined, the deceased becomes a sort of energy which may (or may not) take on another life form in the future. The belief in an afterlife seems to help survivors let go to a certain extent and forge a continuing bond with the deceased on a spiritual or religious level, which is considered helpful for the bereavement process (Jahn and Spencer-Thomas 2014).
For most survivors, a belief in the afterlife is supported by external spiritual experiences they have had, which they interpret as signs from the deceased. Indeed, in line with Jahn and Spencer-Thomas’ (2014) findings, the majority of our interviewees acknowledged having had spiritual experiences following the suicide of the deceased; however, contrary to the former study, the great majority of our participants did not share their experiences with others or if they did, only with very close family members. Survivors reported fears of being considered psychologically disturbed. Since these after-death experiences seem to be common for survivors (Jahn and Spencer-Thomas 2014; Vandercreek and Mottram 2009), survivors of suicide are likely to benefit from open communication about them with leaders of religious or spiritual communities and mental-health professionals.
As mentioned in previous literature (Krysinska et al. 2017; Vandercreek and Mottram 2009; Jahn and Spencer-Thomas 2014), spirituality or religion were important for making sense of suicide. For some survivors, suicide challenged existing beliefs and faith, for others suicide was the starting point of a spiritual or religious quest. Only a minority did not use spirituality or religion for meaning-making. Even if some survivors thought that being religious (or not) might have played a role in the suffering of the deceased, no one considered that the suicide was directly caused by religion, spirituality or God. Nevertheless, the agency of God or transcendence was questioned (intention and action or omission). Survivors who believed in an all-determining God, involved in people’s daily lives, or those who considered God the master of life and death, questioned why God did not intervene to prevent the suicide. For some, suicide was somewhat related to God’s life-plan for the deceased (God’s will). For others, suicide was not part of the plan, but God allowed it (or did not prevent it) out of respect for human free will or for another reason (perhaps to be understood after the survivors’ death). These two beliefs challenged other beliefs or worldviews such as the benevolence, the justice or the all-mighty nature of God or the benevolence and meaningfulness of the world (Jannoff-Bulman 1992). Both beliefs were likely to cause two sorts of reactions: some survivors, even if it was hard, ended up accepting one or both of them, by choosing to trust in God or spiritual transcendence by relinquishing control (Krysinska et al. 2017) or by accepting that answers would come after their death. For other survivors, the “suicide as God’s will or God allowed it” belief deeply shattered their relationship with God: a minority lost their faith (as mentioned also in previous studies, Burke and Neimeyer 2016; Spencer-Thomas 2011), others changed their beliefs and ended up thinking either that God does not get involved in human life in concrete ways, or that God’s involvement is more like companionship in walking the pathways of life than in mastering life issues, a caring yet not all-determining role.
Some survivors reported that the above beliefs about God’s agency were conveyed and publicly mentioned by leaders of religious communities. This was experienced as a strain by most survivors. Therefore, leaders and fellow believers should be made aware of the possible impact of their words on survivors’ perceptions and meaning-making processes. They may benefit from postvention education (Krysinska et al. 2017).
For survivors with a more “abstract” view of spirituality or religion, suicide was related not so much to the agency of transcendence but rather to the existential pathways of the deceased. For these survivors, suicide was a step on the way, a stage of existence, as part of the deceased’s learning and evolution. This belief did not challenge their trust in the spiritual entity, but for believers in the Buddhist version of reincarnation, it triggered questions and sorrow with regard to the future lives of the deceased. Exchanges with Buddhist masters have proved to be helpful for some survivors.
Spirituality and religion played a role in the survivors’ processes of clarifying responsibility as well. Survivors who believed that suicide was somewhat related to the agency of God or transcendence often dealt with feelings of anger, betrayal and disappointment towards the divinity, but often felt less responsible and guilty themselves toward the deceased. Nevertheless, this attribution of responsibility was likely to disrupt their relationship with God and, in the long run, prevent them placing trust or seeking solace in other difficult times, thereby endangering the positive coping effect of spirituality or religion found in previous studies (Jahn and Spencer-Thomas 2014). If some people could not come to terms with believing God was involved in the suicide, the majority could restore their sense of positive spiritual coping by changing their beliefs about agency (see above) or by accepting or forgetting the God who did not prevent suicide.
Survivors who did not think that the divinity or transcendence was involved in the suicide resolved the responsibility issue within the existential trajectory of the deceased by situating the suicide as part of the deceased’s evolution. This put in perspective their own involvement and their feeling of guilt.
Even though none of the interviewed survivor believed that the deceased would be damned following his or her suicidal act (as in Vandercreek and Mottram 2009), cultural or religious beliefs which referred to suicide as a mortal sin, condemnation of the deceased and/or the stigmatization of survivors caused added distress and feelings of guilt and shame for survivors, as found in previous studies (Vandercreek and Mottram 2009; Rubey and McIntosh 1996).
Survivors of suicide also found solace in spiritual or religious acts and beliefs with regard to their own feeling of guilt. Christian believers sought forgiveness from God and from the deceased, for things considered may have contributed to the deceased’s suffering. The Buddhist asked her guide to say the ritual prayers to help her father on the way to reincarnation, as she felt guilty for not having assisted him at the time of death. To our knowledge, the role of spirituality and religion in atonement procedures related to suicide bereavement has not been investigated previously. Future research may help in ascertaining how spirituality and religion can contribute to restoring self-esteem, the relationship to the deceased and to transcendence and, ultimately, to bringing peace.
Further research is also needed, for example, to investigate the spiritual or religious experiences of survivors in greater detail: how they influence outcomes of reconstruction processes and possible avenues of collaboration between various spiritual or religious communities and care professionals.
The original studies suffer from several limitations (Castelli Dransart 2016). First, they did not focus primarily or exclusively on spirituality or religion. These topics emerged regularly from the narratives of the survivors with regard to issues such as resources, coping strategies and group’s affiliation or activities after the death; they were therefore taken into account in the analysis and conceptualization of the reconstruction processes. This article focuses on these specific aspects.
Secondly, although significant for a qualitative study, the size and the nature of the sample do not allow for generalization. Self-selection, the various ways of recruitment, and survivors’ motivations for participating (since it was a voluntary study) are all likely to have biased the results, as well as the fact that most respondents were female, or parents and siblings. More balanced gender samples and a larger number of survivors with various relationships to the deceased might result in varied themes with regard to spirituality or religions. Participants in our sample were mostly from a Swiss background, and all but four were of Christian faith at birth. Investigations of survivors from other religious faiths or spiritual traditions, as well as from various ethnic and cultural backgrounds, may broaden the spectrum of spiritual or religious questioning and coping mechanisms. Moreover, studies specifically investigating various cohorts might show differences in how different generations deal with spiritual and religious issues with regard to grief and bereavement, most of all in contexts of secularism or in societies where “believing without belonging” (Davie 2006) is widespread.
Despite these limitations, our study is likely to contribute to extending the limited knowledge on the experiences of survivors of suicide with regard to spiritual and religious questions. It provides unique insights into how survivors dealt with issues such as the afterlife, God’s agency, survivor-transcendence relationships, spiritual or religious meaning-making, attribution of responsibility, and the role of spiritual and religious rites in honoring the memory and maintaining the bond with the deceased. Moreover, since several survivors of suicide were followed-up, the study was able to identify several changes and evolutions in belief and practices over time. This is likely to open new avenues for further research and add further perspectives for supporting survivors in their journey.
As Holloway (2007) (in Holloway and Moss 2010) put it: “spirituality is not all sweetness and light”. Spirituality and religion can contribute to the meaning-making process, the clarification of responsibility, the honoring of memory or the forging of a continuing bond with the deceased, in constructive or more complicated ways. They can support the recovery process or challenge it. Nevertheless, only very few survivors could openly address the above-mentioned issues with families, leaders of religious or spiritual communities or fellow believers. No one mentioned spiritual aspects or their struggles to social care or mental health professionals, not even with psychotherapists. This may result in feelings of secrecy or isolation, preventing survivors, professionals and spiritual or religious leaders from making the most of the survivors’ spiritual or religious coping mechanisms and growth. Survivors of suicide expressed the wish for faith or spiritual leaders as well as for mental health or social care professionals to address religious and spiritual issues in open communication. This might prove valuable for survivors, for spiritual or religious leaders, fellow believers and care professionals. Making religious or spiritual aspects more visible may also help prevent them from becoming supplementary sources of strain or distress. Faith leaders should pay particular attention when addressing issues regarding God’s agency with regard to death by suicide in face-to-face or public settings, and be aware of the possible distressing impact of their words on survivors of suicide.
The studies were financially supported by the Swiss National Science Foundation, the HES-SO University of Applied Sciences and Arts Western Switzerland and the School of Social Work Fribourg.
The author expresses her deepest gratitude to the survivors who shared their experience.
Conflicts of Interest
The author declares no conflict of interest. The founding sponsors 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.
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Table 1. Characteristics of the interviewees by status.
|Status||n||n Participants with More than 1 Interview|
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