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ORIGINAL RESEARCH

Experiences of parents whose sons or daughters have (had) attempted

suicide

Niels Buus, Jimmy Caspersen, Rasmus Hansen, Elsebeth Stenager & Elene Fleischer

Accepted for publication 3 August 2013

Correspondence to N. Buus:

e-mail: [email protected]

Niels Buus PhD RN

Associate Professor

Institute of Public Health, University of

Southern Denmark, Odense, Denmark

Jimmy Caspersen MHs RN

Clinical Nurse Specialist

The Mental Health Services in the Region

of Southern Denmark, Odense, Denmark

Rasmus Hansen

Research Assistant

Network for the Suicide Struck (NEFOS),

Odense, Denmark

Elsebeth Stenager PhD MD

Consultant Psychiatrist

The Mental Health Services in the Region

of Southern Denmark, Odense, Denmark

Elene Fleischer PhD

Counsellor and Daily Leader

Network for the Suicide Struck (NEFOS),

Odense, Denmark

BUUS N., CASPERSEN J., HANSEN R., STENAGER E. & FLEISCHER E. (2014)

Experiences of parents whose sons or daughters have (had) attempted suicide.

Journal of Advanced Nursing

70(4),

823–832.

doi: 10.1111/jan.12243

Abstract

Aim.

The aim of this exploratory study was to gain further insights into the

experiences of parents of sons or daughters who have attempted suicide and how

these parents respond to the increased psychosocial burden following the suicide

attempt(s).

Background.

Suicide is a major public health problem and relatives are

understood as playing an important role in suicide prevention; however, suicide

and suicidal behaviour affect the relatives’ lives profoundly, both emotionally and

socially, and the psychosocial impact on families is underresearched.

Design.

Focus groups with parents of sons or daughters who have attempted

suicide.

Methods.

In January and February 2012, we interviewed two groups of parents

recruited at a counselling programme for relatives of persons who have attempted

suicide. The analysis combined a thematic analysis with a subsequent analysis of

how the themes were negotiated in the conversational interactions. The ﬁndings

were interpreted and discussed within an interactionist framework.

Findings.

The participants in the study described their experiences as a double

trauma, which included the trauma of the suicide attempt(s) and the subsequent

psychosocial impact on the family’s well-being. The pressure on the parents was

intense and the fundamentally unpredictable character of suicide attempts was

frequently emphasized.

Conclusion.

Being the parent of a child who attempts suicide meant managing a

life-threatening situation and the additional moral stigma. In part, the

participants did this in the group by negotiating the character of the suicide

attempt(s) and who was responsible.

Keywords:

adolescence, attitudes to mental illness, family relations, focus groups,

injuries, nursing, parental attitudes, psychosocial, qualitative studies, self-inﬂicted,

suicide, support

2013 John Wiley & Sons Ltd

823

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N. Buus

et al.

Why is this research or review needed?

Families can be a valuable resource in suicide prevention

and postvention.

Suicidal behaviour can have a destructive impact on fami-

lies, but this impact is underresearched.

What are the three key ﬁndings?

Parents of children who have attempted suicide describe

the suicide attempt as a dramatic life-overthrowing and

identity-deﬁning event profoundly affecting the whole fam-

ily.

Parents of children who have attempted suicide do not

delimit the trauma to the suicide attempt, but to their

child’s psychosocial problems and interpersonal behaviour.

For the participants, the life-threatening character of a sui-

cide attempt seemed to open new, socially legitimate

opportunities for ﬁnding help and support and for generat-

ing social resources.

suicide (Krug

et al.

2002). The initiative included not only

an emphasis on identifying and eliminating factors that

predict suicide but also an emphasis on providing psycho-

social support to people who exhibit suicidal behaviour

and to their relatives. The relatives were understood as

playing an important role in the prevention of further sui-

cidal behaviour; however, suicide and suicidal behaviour

affect the relatives’ lives profoundly, both emotionally and

socially (Krug

et al.

2002, Cerel

et al.

2008). Finally, stud-

ies show an association between suicide and suicide in

close family (Brent 2010, Hawton

et al.

2012). A way to

prevent the transmission of suicide and ease the suffering

of suicide survivors, is postvention, which is the focused

provision of help for people affected by suicide with the

aim of reducing the after-effects (Shneidman 1975, Briggs

2008).

Background

A formal deﬁnition of what constitutes a suicide attempt is

not simple. WHO deﬁned parasuicide (suicide attempt) as a

type of self-harm: ‘an act with nonfatal outcome, where an

individual deliberately initiates a non-habitual behaviour

that, without intervention by others, will cause self-harm…

and which is aimed at realizing changes which he/she

desired via the actual or expected physical consequences.’

(WHO 1986, p. 2). The deﬁnition emphasized the nonfatal

outcome of the act and the person’s deliberate intention to

change his or her situation by means of the act. However,

the deﬁnition was problematic for scientiﬁc classiﬁcation

because of the difﬁculties related to discerning/reconstruct-

ing a person’s intentions behind an act (Krug

et al.

2002,

Hawton

et al.

2012). One strategy has, therefore, been to

ignore the issue of intention and the inﬂuential NICE

guidelines on self-harm (National Collaborating Centre

for Mental Health 2004, 2012) adopted a shorter and

broader deﬁnition of self-harm (including suicide attempt):

‘self-poisoning or self-injury, irrespective of the apparent

purpose of the act’.

While categorizing suicide attempts as a type of self-

harm has some scientiﬁc advantage, the category can be

seen as problematic for lay people. This is because the

term ‘self-harm’ minimizes the particular connotations of

potential life-threatening danger and extreme recklessness

commonly associated with a ‘suicide attempt’. Finally,

some types of dangerous self-harm or self-harm with

strong suicidal intent are often articulated and treated as

‘suicide attempt’ by healthcare staff and other people in

the immediate context. In this paper, we use the term ‘sui-

How should the ﬁndings be used to inﬂuence policy/

practice/research/education?

The study emphasizes a need for psychosocial postvention

on those parents and families, who struggle coping with

the impact of suicide attempt(s) and suicidal behaviour.

Evidence-based suicide prevention and postvention should

be part of standard nursing education as nurses encounter

many families affected by suicidal behaviour.

Introduction

Suicide is a major public health problem. Drawing on data

from the Global Burden of Disease 2000 database, World

Health Organization (WHO) estimated that more than

800,000 people die from self-inﬂicted injury each year and

that among those aged 15–44 years, self-inﬂicted injury

was the 4

leading cause of death (Peden

et al.

2002).

Suicide is part of a larger problem concerning suicidal

behaviour, which also includes suicidal ideation, communi-

cation of suicidal ideation and intent, planning suicide and

suicide attempts. Suicide attempts are far more frequent

than suicides and a person can attempt suicide multiple

times. A suicide attempt is an important predictor for

future suicide (Nordentoft 2007). It is suggested that a sui-

cidal person intimately affects six other people (Shneidman

1969, Andriessen 2009) and suicidal behaviour is most often

an event with serious repercussions affecting a multitude of

people.

Not all suicides can be prevented, but many can. In

1999, WHO launched an initiative for the prevention of

824

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JAN: ORIGINAL RESEARCH

Experiences of parents whose sons or daughters have (had) attempted suicide

cide attempt’ to indicate a type of self-harm with a high

level of potential lethality or danger regardless of the per-

son’s suicidal intention.

There are only a very limited number of articles report-

ing qualitative research into parents of sons or daughters

who have attempted suicide. Torraville/Daly (Torraville

2000, Daly 2005) worked from within a phenomenologi-

cal perspective and interviewed six mothers of adolescents

who exhibited suicidal behaviour (ideation or gesture) or

att-empted suicide. The essence of the mothers’ experi-

ences was ‘multiple loss and unresolved grief’, which

encapsulated how the children’s self-destructive behaviour

created constantly recurring emotional turmoil and dam-

aged the mothers’ sense of self and hope for the future.

The mothers grieved over their children’s suffering, but

they also expressed socially illegitimate feelings of anger

and hate towards the children, who caused damage to the

family’s life. Rutherford interviewed four mothers of chil-

dren who had had ‘at least one signiﬁcant suicide attempt’

(2005, p. 20). Rutherford interpreted themes from the

interviews from a psychodynamic perspective and

described how the mothers continued to be emotionally

traumatized even though the interviews took place one

year after the suicide attempt. The mothers expressed feel-

ings of fear and helplessness, but also anger and rage

towards professionals and their ex-spouses, who were

depicted as critical, dismissive and not understanding.

Rutherford suggested that these latter feelings could also

be interpreted as a way for the mothers to protect them-

selves from guilt and realistically reﬂecting on problems in

their lives that may have contributed to the child’s situa-

tion (Rutherford 2005).

We adopted an interactionist perspective on psychosocial

responses to the burden caused by suicidal behaviour. The

parents’ interpretations of the personal and social meaning

of their offspring’s illness (suicidal behaviour) were based

on their interactions when dealing with the situation. These

meanings inﬂuenced the parents’ cognitive and emotional

coping strategies and their sense of identity and social

status (Bury 1982, 1991).

Design

The study was designed to use focus groups with parents of

children who have attempted suicide. Focus groups in quali-

tative research are characterized by the production of con-

versational data through group interaction around topics

supplied by a facilitating researcher (Morgan 1997, Halkier

2008). This approach is an appropriate way of exploring

group meaning and norms (Bloor

et al.

2001).

Sample

We recruited the focus group participants from among

persons who took part in a support and counselling

programme for relatives of persons who attempt suicide. The

programme is run by a non-governmental organization,

Net-

værket for Selvmordsramte

(The network for the suicide

struck: NEFOS). The programme has existed for ﬁve years in

Southern Denmark and offers individual and group-based

counselling to the relatives after suicide or suicide attempts.

All parents of children who had attempted suicide and

who had participated in NEFOS group sessions in 2010 and

2011 were invited to participate in a focus group. Written

invitations were sent out to 17 parents. Later, reminders

were sent out to ensure a high level of turn-up at the focus

groups. Two parents declined to participate for personal rea-

sons and one parent did not participate because of an emer-

gency immediately before the interview. The purposive

sample (Patton 2002) included 14 parents.

Data collection

The focus groups took place in January and February 2012

on NEFOS’ premises, where the counselling also took

place.

Facilitation of the interviews

NB who is a trained and experienced research interviewer

facilitated the focus groups and JC co-facilitated the groups

and took ﬁeld notes during the discussions. The facilitators

had no prior knowledge of the participants and had no per-

sonal experience of being next of kin to a suicidal person.

The groups were started with a brief introduction to the

study’s purpose and a clariﬁcation of the ground rules of

the session regarding time frames, mutual respect and conﬁ-

dentiality. The group interviews were focused by means of

an open agenda. The agenda included six topics, which

were developed on the basis of clinical experience: 1. The

programme at NEFOS; 2. Communication with other

children (in the family); 3. Stress and strain in everyday life;

825

The study

Aim

The aim of this exploratory study was to gain further

insights into the experiences of parents of sons or daughters

who have attempted suicide and how these parents respond

to the increased psychosocial burden following the suicide

attempt(s).

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N. Buus

et al.

4. Coping with difﬁcult thoughts and feelings; 5. Communi-

cation with family, friends and colleagues/acquaintances; 6.

Inﬂuences on the parents’ relationship. The issues were

introduced on plastic-coated notes (size A5) and the partici-

pants were asked to collaborate and arrange the notes in

the order where they preferred to address the issues. This

focusing technique had been planned to create transparency

about the agenda and to engage the participants in a collab-

orative exercise right from the beginning. The groups were

ended with a debrieﬁng evaluation of the session. The level

of facilitator involvement was deliberately low, because we

were interested in how the participants negotiated the issues

through the group conversations.

The focus groups were audio recorded. The recordings

were transcribed by JC, who used transcription conventions

that indicated basic conversational turn-taking. The accuracy

of the transcriptions was checked by NB and by JC. The ﬁrst

focus group lasted 2 hours and 40 minutes; the second

2 hours and 30 minutes (both including a 10-minute break).

transcripts and identiﬁed four categories, which had some

resemblance to the topics from our interview agenda: (1)

Psychosocial strain and stress; (2) Effects on the parental rela-

tionship; (3) Effects on the family; (4) Effects on relationships

with others. Second, we divided the transcripts according to

the four categories and analysed the conversational turn-take

structures and the topic-organization to identify how speak-

ers presented and negotiated the conversational content

(Hutchby & Woofﬁtt 1998). In the analyses, we identiﬁed

two central themes across the preliminary four categories.

These two themes concerned the participants’ descriptions of

emotional strain and how the strain affected their family.

Third, we further explored and described the characteristics

of the two themes through systematic comparisons of the the-

matic content and the two themes were linked to exemplary

data extracts. Fourth, we re-examined the original audio

recordings and the transcripts to determine whether the two

themes and the data extracts represented a nuanced and

balanced interpretation across the two interviews.

Ethics

The interview topic was highly sensitive (Lee 1993) and we

organized our approach to protect the health and well-

being of the participants. The high level of participation

was most probably linked to participants’ positive experi-

ences at NEFOS. Trust and reciprocal relationships had

been established prior to research and that could to some

extent be interpreted as deceiving participants into the

research-context, like a Trojan Horse (Fog 1994). If any

participant felt distressed beyond what could be managed

at the scheduled debrieﬁng, a NEFOS councillor was on

call. As it was, several of the participants expressed grati-

tude for the opportunity to, once more, talk about their

experiences in a supportive environment.

In accordance with Danish legislation, we informed the

National Committee on Health Research Ethics and the

Danish Data Protection Agency about the study. All partici-

pants gave their consent to participate based on written and

verbal information about the study. Data were handled con-

ﬁdentially and the data extracts presented in the following

results section were anonymized to protect the participants’

identity. NB translated the data extracts into English.

Results

There were six participants in the ﬁrst group and nine

participants in the second; by coincidence, one parent par-

ticipated in both groups. In our sample, the median age of

the participants’ children at the time of the suicide attempt

(s) was 15 years, ranging from 14–35 years; Table 1 gives a

more detailed description of the sample and their offspring.

Emotional responses and stress

The participants had experienced the period before their

child’s suicide attempt(s) very differently. For the majority

of the parents, the suicide attempt was the culmination of a

prolonged period, often several years, where their child had

suffered from psychological problems and exhibited highly

disturbed behaviour, such as self-harm or eating disorders.

These parents had struggled trying to help their children

and to mobilize the appropriate health and social care ser-

vices and felt powerless because of their inability to stabi-

lize the child’s deteriorating situation. Some of these

children were formally diagnosed and had received treat-

ment, whereas others had not. Some of these parents

described the ﬁrst suicide attempt as also being relieving,

because they had feared a disastrous event for a long time;

they hoped that hitting rock bottom could be an eye-opener

for the child who might be more willing to accept help. For

the minority of parents, the ﬁrst suicide attempt had come

with very short or no prior warning and they were shocked

by their child’s severe problems and lack of well-being.

2013 John Wiley & Sons Ltd

Data analysis

The analysis combined a thematic analysis with a subsequent

analysis of how the themes were negotiated in the conversa-

tional interactions (Morgan 1997, Halkier 2010). First, we

coded (Coffey & Atkinson 1996) the thematic content of the

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Male

Yes

2011

Experiences of parents whose sons or daughters have (had) attempted suicide

Same person participating in both groups.

The participants were not explicitly asked about the characteristics of their suicidal child or about the suicide attempt(s), the information in this Table is extrapolated from the focus

groups.

†

Female

Yes

Eating disorder

The participants described how the children’s suicide

attempt(s) and later suicidal behaviour threw them into a

state of panic and horror. Some of the parents had found

their child after a suicide attempt, whereas others had

received news about the attempt from emergency healthcare

staff. All participants described an all-consuming state of

alarm as they fought to keep their child safe after a suicide

attempt. This included numerous and lengthy telephone

conversations with the child about their emotional distress,

and physical intervening, such as standing guard, stopping

suicidal behaviour and bringing the child to safety:

Participant #5, Group 1:

Those six months, when Susan [his

daughter]. When it was really at its worst. When she did the, I

don’t know, three, four ﬁve more or less whole-hearted suicide

attempts. It was red alert 24 hours a day. I slept outside her door.

Sometimes she ran off and I had to follow her. Over the ﬁelds,

through the woods and up to the railway line. It was a nightmare.

And she ran bloody fast, I couldn’t keep up with her (laughs). It

was just terrible and once I had to pull her out of the lake (…)

…

Participant #6:

As you say, you slept outside her door. Just a tele-

phone ringing, you [sighs heavily]. ‘What now?’ ‘Where are we

going now?’ It was really hard.

Female

Yes

2011

Still active

Female

Yes

2011

Female

<18

Yes

Borderline

Female

Yes

4–5

Female

Yes

Cutting

Male

Yes

2011

Female

2011

Focus group 2

Female

Yes

Male

Yes

2009

Male

Schizo- affective

disorder

Yes

Male

>18

Yes

Drug

abuse

Yes

Female

14–15

Yes

Female

2010

The state of acute alarm was gradually succeeded by a

period dominated by fear of a new suicide attempt. All par-

ticipants described how fear would slowly ease off when

the child was in a stable period, but that small reminders

could trigger and reinvigorate the full and overwhelming

feeling of fear. The most commonly described trigger was

the sound of incoming telephone calls and text messages,

which for many was associated with catastrophic or threat-

ening news from or about their child. Most participants

described long periods of continual ruminations and

worries about the child:

Participant #2, Group 1:

I think I’ve been like that for a long, long

time, in that state. I’ve also thought that ‘this is going really well’

and ‘now I’m not scared of anything anymore’. But this Monday

she didn’t come home. And she hadn’t said she was going any-

where and time just passed. She is usually home at twenty to four

and she still wasn’t home by 8. And I couldn’t get her on the phone

and she hadn’t got in touch, she hadn’t said where she was or any-

thing. Then it’s back again. Oooh. My heart pounds and, then

there was a perfectly natural explanation why she didn’t come

home, but it’s there again. I can just feel all of it again.

#1*

Female

Yes

2010

Female

4–5

Female

Yes

Cutting

Male

Yes

2010

Male

Yes

#4*

2009

Male

Yes

Focus group 1

Table 1

Description of the participants.

Characteristics of participant

Gender

Female

Spouse participating in interview #2

Spouse participating in group-

Yes

counselling programme

Year of exit from programme

2010

Characteristics of suicidal son/daughter

†

No. of suicide attempts

Gender

Female

Age

Suicide threats

Yes

Psychiatric comorbidity

2010

Current suicidal behaviour

All participants described how they had made supreme

efforts to try to save and support their child after the suicide

attempt and how these efforts had most often been futile

and left them with all pervasive feelings of powerlessness.

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N. Buus

et al.

All participants described discouraging setbacks, such as

new attempts or renewed suicidal behaviour and broken

agreements and promises. Both groups described hopeless-

ness and anger towards the child, who was seen as partly

responsible for setbacks and for corrupting all other family

members’ well-being. In the second group, the majority of

participants described current or previous feelings of intense

hate and blame towards the child and how they would give

in to the child’s threats about suicide:

Participant #4, group 2:

But there’s also that, that it can push you

so far out, that something you love most in your whole life, that

you can and I’ve been lying there, when I couldn’t sleep and then,

‘Well do it then for Christ’s sake’. ‘We might as well get it over

with, mightn’t we?’ ‘Also because I bet you’re going to do it in 5

or 10 years anyway.’ ‘So you might just as well do it now, so I can

get.’ ‘Why the hell should I spend ten years of my life trying to

save you, if you can’t?’ Well, you just get pushed so far out, that

you end up throwing in the towel, it’s really amazing.

people. Because they couldn’t understand that we didn’t, that she

didn’t just go, that we didn’t do anything. But in reality we did do

everything, in our opinion, we did. I think it was terrible.

The pressure on the parents and families was intense and

the fundamentally unpredictable character of suicide

attempts was frequently emphasized. A participant described

the parents as acting under the same level of psychological

pressure as the children and two participants said that they

had thought about committing suicide themselves because of

the prolonged and unbearable pressure.

Double trauma: Effects on families and relationships

The participants described the fear of a repeat attempt making

them hyper vigilant and attentive of the suicidal child. Many

participants described being manipulated by their child,

because of a combination of guilt and fear. Despite being

aware that giving the suicidal child special privileges under-

mined the parents’ fundamental values for upbringing and

threatened to corrupt all relationships in the family, the par-

ents found it very challenging and sometimes impossible to

confront the child and, in time, to reclaim special privileges:

Participant #9, group 2:

And then it affects the way you think you

want to raise your children and what you want to teach them

about life. Suddenly the foundation you have built on crumbles,

because you always go round with a guilty conscience about doing

something wrong. And suddenly you begin to be a pleaser, because

you are frightened out of your wits that if you aren’t a pleaser in

this situation, when they begin to threaten you, if I face hard with

hard, then it will be my fault if they kill themselves. So suddenly it

slowly turns into a sort of downward spiral, where the one who

threatens us who has sort of taken over and who decides what the

rest of us may think and do and use in the upbringing. Because we

carry a guilty conscience the whole time.

Most participants stated that they, in particular in the

period immediately after the ﬁrst suicide attempt, felt very

guilty because they were responsible for bringing up their

child. Later, most parents felt guilt towards other children

in the family, which they believed had been neglected

because of the massive focus on the suicidal child:

Participant #3, group 1:

It’s more the handling of the feelings of guilt

and that kind of thing that I’ve found difﬁcult (…) I felt so guilty, that

it was my responsibility. It was me, who brought her into the world,

me who formed her and it was me who let her down and it was more

or less my fault that she got so far out as to trying suicide.

The participants described how they felt isolated after the

suicide attempt, mainly because they were convinced that

nobody would be able to understand the horrible event.

Some participants felt uncomfortable sharing their story

because they felt shame. The belief was that a child’s sui-

cide attempt would only happen in a sick family. Some par-

ents were ashamed of their child’s highly disturbed

behaviour and that they were not able to stop it

–

even

though they tried their utmost to do so:

Participant #3, group 2:

We were so ashamed of it. It was on

account of what she went through that people couldn’t understand

why she didn’t just leave it all. [On top of threat of suicide, the

daughter was in a violent relationship.] Or ‘Why didn’t we sound

the alarm and fetch her home’? Or ‘Why didn’t my husband do

something like that?’ And then I say, ‘Bloody hell man, of course

we’ve done everything.’ ‘We’ve been down on our bended knees to

the police and said, ‘Do something’.’ So we certainly reckoned we

had done whatever we could…It was bloody hard to go and say to

All participants were in long-term relationships and

acknowledged that arguments and conﬂicts in the family

were a threat that could easily lead to a divorce. Most

participants described how the suicidal child would play

the parents off against each other. This often happened if

the child exclusively told one parent about his/her emo-

tional stress, which meant that the parents generated com-

pletely different images of the child and felt different levels

of strain. A further source of conﬂict was differences in the

way the parents managed the situation. For instance, all the

participants shared stereotype ideas about women needing

to talk more about things than men and this could also

trigger conﬂicts when women felt rejected and/or men

felt intruded on. During the groups, several participants

828

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Experiences of parents whose sons or daughters have (had) attempted suicide

confessed to being disloyal to their partner, simply trying to

help their child the best they could. However, they would

at the same time disregard explicit and implicit agreements

with their partner, who would feel hurt and very angry:

Participant #5, group 1:

In the beginning when there was a deﬁnite

aim, keeping Susan [his daughter] alive. We really stuck together,

there were no problems. A vacuum develops afterwards, where you

realize that it is perhaps difﬁcult to keep your balance right there.

‘Who did what?’ ‘Did you say something wrong or?’ ‘I don’t think

you should have done that.’ ‘You shouldn’t have let her go to that

party’, or something or other.

Participant #6:

It’s absolutely plain to see there’s a test of the rela-

tionship there.

Participant #5:

But it’s the same again, those conﬂicts you have in

all other families. There’s just the unique difference that the

consequences can be fatal, if you make a wrong decision.

Some participants described their other children as behav-

ing similarly to themselves: sensitive and protective towards

the suicidal child. Other participants described how siblings

felt neglected because of the extra focus on the suicidal

child, which often led to conﬂict with parents and with the

suicidal child. According to the parents, some siblings

explicitly stated that they hated the suicidal child and

avoided having any connections. Some parents believed that

some of the problems and illnesses the other children expe-

rienced had been caused by the damaged family dynamics

and neglect:

Participant #3, group 1:

I think that the brothers and sisters of

such a child who is threatened by suicide become more protective

and sensitive and have their antenna out. I have a daughter who’s

just turned eleven now, so she was 8 at that time, 7 or 8 years old,

she is very aware of the older sister and she doesn’t say anything

directly. But I can feel that there’s something there, that you have

to take special care of Joan [the older sister].

Although participants had come to a greater understanding

of the dynamics, fear, guilt and good intentions continued to

generate conﬂict in the relationship. It was difﬁcult to main-

tain a stable and giving relationship, because the child was

always

in-between

the parents and a participant described

her child’s suicide attempts as a ‘double-crisis’ because of the

secondary trauma and stress on family and marriage.

Discussion

Participants described themselves as severely emotionally and

socially traumatized by their child’s suicide attempt and as

2013 John Wiley & Sons Ltd

being caught up in a very disempowering situation, where the

psychosocial effects of the son or daughter’s suicidal behav-

iour threatened to corrupt all interpersonal relationships in

the family. These ﬁndings were in line with previous research

on parents of sons or daughters who attempt suicide

(Torraville 2000, Daly 2005, Rutherford 2005).

The suicide attempts were highly ‘disruptive’ events (Bury

1982) in the families’ lives and the group conversations

contained numerous instances where the participants

attempted to manage societal reactions and repair the

disruption. The participants’ accounts were focused on

legitimizing their roles as morally adequate and responsible

parents who should not be held responsible for their son or

daughter’s unhappiness and socially disturbing behaviour.

Such emphasis on identity work was also described by

Owen

et al.,

who analysed narratives of parents of sons

who had committed suicide (Owen

et al.

2012). In particu-

lar, the parents in Owen

et al.’s

study construed explana-

tions of the son’s reasons for committing suicide and

thereby displaying anger and guilt and placing blame and

exoneration (Owen

et al.

2012). The parents in the present

study were not as deﬁnitive in their explanations of the

suicide attempts and negotiations of parental responsibility

and blame were open and sometimes volatile. The on-going

stress and the double trauma indicated that challenges to

their parental roles and social status were evolvable and

outside the parents’ control.

The participants’ experiences of parenting under the

threat of the self-inﬂicted death of a son or a daughter were

similar to parenting under other life-threatening conditions,

such as a heart surgery where immediate survival and safe-

guarding are paramount (Rempel & Harrison 2007) and

the more long-term management of caregiving-stress related

to having a child with a chronic and life-limiting disease,

such as congenital heart disease and cystic ﬁbrosis (Moola

2012). Whereas these illnesses share the same level of life-

threatening seriousness, they differ signiﬁcantly with regard

to the levels of imputed responsibility for the illness. One

part of this issue was related to the participants’ feelings of

guilt, because they regarded themselves as being responsible

for the child’s situation. Another part of the issue was

related to the participants’ feelings of blame, anger and hate

towards the child who was regarded as responsible for con-

tinual strategic manipulations of relationships in the family.

In general, these latter feelings were not socially legitimate:

parents are not expected to blame or hate their children for

their illness-related behaviour. Finally, the parents felt

ashamed by the situation. The child’s disruptive behaviour

and the suicide attempt were a moral stigma on the whole

family, which the parents were expected to have sorted out

829

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N. Buus

et al.

or prevented. Thus, suicide attempts and suicidal behaviour

shared some basic resemblances with other life-threatening

illnesses, but the participants had to cope with additional

moral stigma and they did this in the group by negotiating

the character of the illness and who was responsible for it.

The sons’/daughters’ suicidal intent was not an explicit

concern to the participants who were outcome oriented, in

the sense that they regarded the life-threatening gravity of

the suicide attempt as crucial. The suicide attempt was

described as a dramatic life-overthrowing and identity-

deﬁning event profoundly affecting the whole family. More,

the gravity of the suicide attempt could be seen as having a

double meaning for the participants. It was the crux of the

emotional and social trauma: the undeniable evidence of a

family with a child with a severely disturbed behaviour and

the source of profound emotional strain. At the same time,

the sheer gravity of a life-threatening situation had the

power to legitimize the participants’ feelings and actions

and it created new possibilities for coping with the situa-

tion. It assisted them in meeting other parents in spite of

feelings of shame and embarrassment and with the help of

a councillor, they learned to open a space for mutual sup-

port where they were able to share and discuss their

attempts to manage the situation, to articulate socially

illegitimate feelings and to confess wrongdoings.

Third, the size and group composition of the two groups

differed. A larger proportion of the participants in the sec-

ond focus group were still very emotionally affected by the

suicide attempt(s) and by their children’s disturbed behav-

iour. Additional longitudinal data from focus groups or

from individual interviews are needed to conﬁrm if there

could be a psychosocial trajectory following the trauma

caused by suicidal behaviour and to hypothesize on the key

inﬂuences on such a trajectory.

Conclusion

The trauma of being the parent of a suicidal child was

experienced as a double trauma. The double trauma

stemmed from the effect of a suicide attempt on the entire

family of the suicidal person. The parents were scared of

a repeated suicide attempt and they would generally inter-

pret the children’s acts as ‘suicide attempts’ and not as

‘self-harm’. Possibly, some of the parents more strongly

linked the events with a deadly outcome than the sons/

daughters and the councillors did. Further exploration and

deeper insight into individuals’ meaning(s) of self-harm

and how it relates to family relationships might be helpful

in minimizing the psychosocial burden (Hawton

et al.

2012).

Suicidal behaviour aggregates in families and the ﬁndings

emphasize a need for the nursing professionals to recognize

the potential need for postvention/prevention for parents

and families, who struggle coping with the impact of self-

harm using more dangerous methods or with clear suicidal

intent. Supportive family-orientated postvention could

include psychosocial interventions including counselling and

psychoeducation focused on recognizing warning signs,

communicative skills and coping strategies.

Limitations

Several situational conditions inﬂuenced how the dataset

was produced and, consequently, the ﬁndings. First, study

participants were recruited after participating in individual

and group-based counselling. During the counselling ses-

sions, the parents were introduced to new ways of thinking

about their situation. The parents adopted these new ways

of thinking and they would emerge both explicitly and

implicitly during the focus groups, e.g. ‘If they really want

to do it [commit suicide], there is nothing you can do to

prevent it’. In other words, participants’ experiences were

framed by the counselling intervention.

Second, data were produced during group conversations

where the facilitator involvement was deliberately low. We

prioritized letting the participants themselves negotiate the

conversational topics and interactions. This meant that the

facilitators rarely interrupted to explore loose ends in indi-

vidual participants’ accounts and some of these open-ended

issues remained unexplored. However, the participants

seemed very open about their experiences even though some

of the topics were very challenging. This was probably

because they had good prior experiences of sharing from

the group-counselling sessions.

830

Acknowledgements

The authors thank the participants of the focus groups and

the Network for the Suicide Struck (NEFOS). The Munici-

pality of Odense, TrygFonden, and The Ministry of Social

Affairs and Integration fund NEFOS.

Funding

The Psychiatric Research Fund of the Mental Health Ser-

vices in the Region of Southern Denmark funded the study.

Conﬂict of interest

No conﬂict of interest has been declared by the author(s).

2013 John Wiley & Sons Ltd

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JAN: ORIGINAL RESEARCH

Experiences of parents whose sons or daughters have (had) attempted suicide

Krug E.G., Dahlberg L.L., Mercy J.A., Zwi A.B. & Lozano R.

(2002)

World Report on Violence and Health.

World Health

Organization, Geneva.

Lee R.M. (1993)

Doing Research on Sensitive Topics.

Sage,

London.

Moola F.J. (2012) ‘This is the best fatal illness that you can have’:

contrasting and comparing the experiences of parenting youth

with cystic ﬁbrosis and congenital heart disease.

Qualitative

Health Research

22(2),

212–25.

Morgan D.L. (1997)

Focus Groups as Qualitative Research.

Sage,

Thousand Oaks, CA.

National Collaborating Centre for Mental Health (2004)

Self-

Harm. The Short-term Physical and Psychological Management

and Secondary Prevention of Self-Harm in Primary and

Secondary Care. National Clinical Practice Guideline Number

16,

National Institute for Clinical Excellence, London.

National Collaborating Centre for Mental Health (2012)

Self-Harm: Longer-Term Management. National Clinical

Guideline Number

133, National Institute for Clinical

Excellence, London.

Nordentoft M. (2007) Prevention of suicide and attempted suicide

in Denmark. Epidemiological studies of suicide and intervention

studies in selected risk groups.

Danish Medical Bulletin

54(4),

306–69.

Owen G., Belam J., Lambert H., Donovan J., Rapport F. & Owens

C. (2012) Suicide communication events: lay interpretation of

the communication of suicidal ideation and intent.

Social Science

& Medicine

75(2),

419–28.

Patton, M.Q. (2002)

Qualitative research and evaluation methods.

3rd edn. Sage, Thousand Oaks, CA.

Peden M., McGee K. & Krug E. (2002)

Injury: A Leading Cause

of the Global Burden of Disease, 2002.

World Health

Organization, Geneva.

Rempel G.R. & Harrison M.J. (2007) Safeguarding precarious

survival: parenting children who have life-threatening heart

disease.

Qualitative Health Research

17(6),

824–37.

Rutherford P. (2005)

An Exploration by Interview of the Feelings

of Mothers of Adolescent Children who have attempted Suicide.

Tavistock Clinic/University of East London, London.

Shneidman E. (1969) Prologue: ﬁfty-eight years. In

On the Nature

of Suicide

(Shneidman E., ed.), Jossey-Bass, San Francisco, CA,

pp. 1–30.

Shneidman E. (1975) Postvention: the care of the bereaved. In

Consultation-Liaison Psychiatry

(Pasnau R.O., ed.), Grune and

Stratton, New York, pp. 245–56.

Torraville M.A. (2000)

Adolescent Suicidal Behaviours: A

Phenomenological Study of Mothers’ Experiences.

School of

Nursing, Memorial University of Newfoundland, St. John’s.

WHO (1986) Working Group on Preventive Practices in Suicide

and Attempted Suicide. Summary report (document ICP/PSF 017

(S)), World Health Organization. Regional Ofﬁce for Europe,

York.

Author contributions

All authors have agreed on the ﬁnal version and meet at

least one of the following criteria [recommended by the

ICMJE (http://www.icmje.org/ethical_1author.html)]:

•

substantial contributions to conception and design,

acquisition of data, or analysis and interpretation of

data;

drafting the article or revising it critically for important

intellectual content.

References

Andriessen K. (2009) Can postvention be prevention?

Crisis

30(1),

43–7.

Bloor M., Frankland J., Thomas M. & Robson K. (2001)

Focus

Groups in Social Research.

Sage, London.

Brent D. (2010) What family studies teach us about suicidal

behavior: implications for research, treatment and prevention.

European Psychiatry: The Journal of the Association of

European Psychiatrists

25(5),

260–3.

Briggs S. (2008) Postvention: the impact of suicide and suicidal

behaviour on family members, professionals and organisations.

Relating to Self-Harm and Suicide: Psychoanalytic

Perspectives on Practice, Theory and Prevention

(Briggs S.,

Lemma A. & Crouch W., eds), Routledge/Taylor Francis Group,

New York, pp. 224–237.

Bury M. (1982) Chronic illness as biographical disruption.

Sociology of Health & Illness

4(2),

167–82.

Bury M. (1991) The sociology of chronic illness: a review of

research and prospects.

Sociology of Health & Illness

13(4),

451–468.

Cerel J., Jordan J.R. & Duberstein P.R. (2008) The impact of

suicide on the family.

Crisis

29(1),

38–44.

Coffey A. & Atkinson P. (1996)

Making Sense of Qualitative Data.

Complementary Research Strategies.

Sage, Thousand Oaks, CA.

Daly P. (2005) Mothers living with suicidal adolescents: a

phenomenological study of their experience.

Journal of

Psychosocial Nursing and Mental Health Services

43(3),

22–8.

Fog J. (1994)

Med samtalen som udgangspunkt.

Akademisk Forlag,

København.

Halkier B. (2008)

Fokus grupper.

Forlaget Samfundslitteratur,

Frederiksberg.

Halkier B. (2010) Focus groups as social enactments: integrating

interaction and content in the analysis of focus group data.

Qualitative Research

10(1),

71–89.

Hawton K., Saunders K.E. & O’Connor R.C. (2012) Self-harm and

suicide in adolescents.

Lancet

379(9834),

2373–82.

Hutchby I. & Woofﬁtt R. (1998)

Conversation Analysis.

Polity

Press, Cambridge.

2013 John Wiley & Sons Ltd

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