Unspoken, Unseen, Unheard: Using Arts-Based and Visual Research Methods to Gain Insights into Lived Experiences of Suicide in Young Adults

Abstract

Suicide is often referred to as a silent killer, and the need to break down barriers and build bridges to communication and understanding remains of vital importance. Working within the field of further and higher education for more than 18 years with students experiencing suicidal thoughts, feelings, and behaviours has highlighted how often deep pain, grief, and trauma go unspoken, unseen, and unheard. Societal and cultural stigma, judgement, misunderstanding, and assumptions remain, all of which silence and can lead to a negative sense of self, others, and a person’s experience of being in the world. This article shows how using arts-based and visual research methods, as part of a mixed methods study, can offer unique insights into the inner world of lived experiences. It draws on analysis of 62 artworks made by 20 students between the ages of 16 and 25 with personal experiences of attempted suicide. These included two-dimensional pieces, sculpture, photography, poetry, and digital art. The research methodology is also discussed, including a 5/6-step approach to the analysis of visual data and data synthesis that has been created to ensure a robust, socially contextualised, and framed analysis. This follows polytextual thematic analysis using a multimodal approach and draws on visual social semiotics. Analysis of visual and arts-based data has revealed aspects of meaning that would otherwise not have been identified. This has led to the development of a model that can help us better understand the cycle of stigma and judgement and how we may be able to break it. This article demonstrates how a creative approach provides a means to share some of the complexity of feelings in a relatable way that has the capacity to bridge the divide between what is hidden and what is seen, bringing this human experience out of the shadows. It aims to honour everyone whose experiences have gone unseen, unspoken, and unheard, as well as the research participants’ wish for their artworks to be shared as a way to challenge the stigma that silences. It further hopes to demonstrate the power of arts-based and visual methods in research whilst also acknowledging some of their limitations so that they can be used more widely with under-represented, marginalised, and silenced voices.

1. Introduction and Context

Art is a universal communicator, and symbols and metaphors have long been used in images and visual storytelling. Art transcends language and offers something unique in its ability to visually communicate what is hard to put into words or verbalise. The impact of participatory creative approaches has been widely documented (McNiff 2013; Muhr 2020) and, as this article will also demonstrate, an arts-based and visual methods approach is an ethical (Hansen and Colucci 2020), trauma-informed, and inclusive way to gain insights, whilst providing the conditions and space for communication that transcends language and the barriers that limit and silence.

Experiences of suicidality often go unheard, unseen, and unspoken. People can feel silenced, judged, and defined by negative assumptions and stigma. These become internalised, leading to self-stigma and a negative sense of self. Although each person’s lived and living experience is unique, the themes and motifs explored in this study include mortality, constraint and freedom, fear and hope, isolation, masking, reflections on one’s place in the universe, and the polarities, paradoxes, and evident split between what is seen/unseen and voiced/unvoiced.

This article draws on arts-based material from a mixed methods study into what we can learn from further and higher education students’ lived experiences of attempted suicide. Although much has been written about suicide and suicidal behaviour in post-16 education (e.g., Gunnell et al. 2020 and Kabira et al. 2024), this research project and the inclusion of arts-based and visual methods were driven by the need to find ethical and inclusive ways for individuals to share their lived and living experiences so that we can learn from them and find ways to destigmatise what has become an increasing reality for many young people.

This mixed methods study comprised three related studies: a national online survey with 121 completed responses, 21 semi-structured interviews, and 62 arts-based responses communicating people’s lived experiences of suicidality. Participants ranged from 16 to 25 years old and included people of colour, neurodivergence, diverse genders and cultural beliefs. The images shown in this paper are some of the pieces produced and have been part of a series of exhibitions displayed nationally and internationally.

2. Methodology

The participants were invited to create artworks in response to their lived experiences of attempted suicide. To gain the depth of the experiences, participants were encouraged to think symbolically, using metaphor and imagery, to convey their feelings. No prior experience in artmaking was needed, and all art forms and pieces were welcomed and valued without limitation or censorship in their production.

In parallel with the unique nature of human beings and their lived and living experiences of suicidality, it became clear that no single method fully fit the analysis of the artworks and, therefore, a framework was needed for all artworks to be explored together from different angles. This led to the development of the five-step integrated framework for arts-based analysis (Figure 1), using a multimodal approach that incorporates polytextual thematic analysis (Gleeson 2021) and draws on social semiotics (Jewitt and Oyama 2007).

Polytextual thematic analysis holds the view that meaning is derived from comparing modes of data, irrespective of their form—in this case, poetry, two and three-dimensional visual arts, and digital arts—by viewing them as dependent on each other. Therefore, any emergent codes or themes in one artwork can only be viewed in relation to the others. Social semiotics draws on Kress and Leeuwen’s (1996) use of ‘system networks’, building on the work of Halliday’s (1978) linguistic theories. Social semiotics is not considered to be a means to an end but “resources to ask questions” (Jewitt and Oyama 2007, p. 136); the process consists of first viewing the data and identifying descriptive elements before moving to interpretation (Gleeson 2021). Thereby, we can conceptually consider ‘possible’ and not ‘probable’ meanings, removing limitations and allowing for many layers of meaning (Jewitt and Oyama 2007) to emerge—what is seen and what is implied. While what is communicated in the artworks can be seen to have both implicit and explicit meaning, viewing data semiotically (Penn 2000) and inductively through a social semiotic lens (Jewitt and Oyama 2007) enables us to consider the potential external and internal influences and the impact of socially constructed norms and stereotypes.

The system for analysis presented in Figure 1, including steps 2, 3, and 4, ensures a rigorous and thorough analytic approach. Step 1 provides a comprehensive initial overview by familiarising with the entire dataset, looking specifically at features such as shape, form, size, symbol, and colour and starting to note any observations without interpretation. Steps 2 and 3 involve a two-part process of analysis and coding. Step 2, coding (a), builds on knowledge and insights gained from data familiarisation. It involves revisiting the data and identifying initial codes across the dataset using a polytextual thematic approach. Review of implicit and explicit meaning (step 3), a further methodical inductive review of the codes, and revisiting the whole dataset (step 4) allow an analytic approach that makes any interpretation transparent. Each step builds on the preceding one, making this a robust and systematic process to ensure internal validity. Once the process is complete, the findings can be reported.

For a mixed methods approach, this includes a sixth step before the final report that cross-references with interview data, looking for convergent and divergent themes (Figure 2).

As will become evident, these steps revealed aspects of meaning that would otherwise not have been identified, and they have led to the development of a model that can help us better understand the cycle of stigma and judgement and how we may be able to help break it. As discussed, integrity and respect for participants were paramount, and this framework incorporates participant validation, as it requires us to look and listen to what is being communicated and to derive as many layers of meaning as possible.

2.1. Ethical Considerations

The integrity in our work as researchers always means considering why, how, and what we are asking people to share and whether this is in their best interest. In the context of suicide research, we need to ask ourselves the question, “Who gets to speak of suicide?” (Marsh, p. 18 in White et al. 2016). It is important to reflect on privilege and possible power dynamics from the outset to ensure that we break down any barriers and enable a collaborative and respectful space that honours individual voices and their lived and living experiences, providing a platform for communication where we can bear witness, honouring and learning from experiences, rather than pathologising them.

The lead researcher has extensive experience both in clinical practice with people experiencing trauma and suicidality and in research projects with under-represented and marginalised voices. This is supported by invaluable input and expertise from the co-authors, who bring many years of research and ethics engagement through their work and experience as a visual anthropologist with lived experience of suicidal behaviours and as clinical and community psychologists and academics.

University ethics approval was a rigorous process, and the survey, interview questions, participant information sheet, and consent form were developed in consultation with a participatory research group (PRG), which included people with lived experiences, Samaritans, a mental health and education visual media specialist, academic experts and senior college/university welfare and safeguarding staff. Data protection and protecting identity were carefully considered.

The participants were provided with clear information about the study at the start, outlining the process, how their contributions would be used, and that the artworks would be part of an exhibition. In order for participants to make a conscious, fully informed, and empowered decision to participate, time was given between receiving this information and giving consent, and a further period of time was incorporated post-participation for participants to withdraw their consent.

The participants were asked to make art after taking part in a one-to-one interview. Brief written guidance was provided, although limited and non-directive, so as not to shape the work with any bias or expected outcome. The decision to make art post-interview was a carefully considered choice. The arts can bring up powerful feelings, and creating art alone in response to a traumatic time in one’s life without any containment could reinforce feelings of isolation (Leavy 2020; Kuri 2020; McNiff 2013). Participant wellbeing remained a constant priority, a thorough debrief was offered at each stage of the process, and consideration was given to any potential/possible need for ongoing psychological support. Without realising it at the time, this approach enabled access to precious material that may otherwise not have been shared. Having built a connection with enough trust, some participants asked to include works made at times when they had felt actively suicidal or to incorporate components from memories such as photographs, screenshots, and writings. These pieces held a history all of their own and had been waiting in silent vigil for their witness.

2.2. Barriers

Stigma means that suicide remains a “whispered word” (Grollman 2011), and some of the biggest barriers and challenges are society’s fear, judgement, and myths around suicidality. Challenges encountered during the recruitment process highlight the systemic and institutional fear that contributes to the silencing of voices and to keeping these very human experiences hidden.

The main barrier was gatekeepers. When trying to share information about the study with potential participants, all professionals who were contacted and replied were personally supportive, often feeling passionate about the topic and willing to share within their professional networks. However, organisational structures and fear of consequences meant that they felt unable to share directly within the organisations. Consequently, as the information was shared with more and more people at an organisational level, it was not reaching the people it was aimed at. Additionally, although the ethics-approved language for advertisements had been carefully chosen and reviewed by an ethics board as well as a participatory research group, which included people with lived experience, alterations were made by some gatekeepers to the agreed text without the researcher’s knowledge or consent. Adapted wording included subjective language that signified fear-averse or punitive elements. Comments towards the researcher also included that the information would be taken down if any concerns were raised by the public. There were none.

Overcoming these challenges took determination and continued effort and highlighted the need to extend kindness and compassion to people whose potential judgements or unconscious bias may be borne out of a lack of knowledge or their own fears. Much has changed since the start of this work, and the findings presented in this paper demonstrate how the arts and visual methods have begun to create a bridge to communication and are challenging stigma by opening up and facilitating spaces for shared reflection and open and honest discussions about suicide.

3. Findings

Survey and interview data analysis identified key overarching themes: the impact on a person’s sense of self, others, society/the wider world and one’s place in it, and ways of being in the world and relating. Arts-based analysis and visual methods have revealed an additional sub-theme that connects ‘self’ and ‘ways of being’—a place of parallels and paradoxes. An additional theme has emerged in the arts-based analysis: beyond the self, the sense of the transpersonal. For continuity and to preserve anonymity, some artworks and quotations have been interwoven (See

Table 1. Themes identified in arts-based/visual data.

Themes Identified in Arts-Based/Visual Data
(Sense of) self 1. Parts: (a) Parts of the body: Mouths and beaks Head Hands and arms The whole (b) Isolation and out of reach
(Sense of) self 2. Polarities and paradoxes
(Sense of) others, society and the world
Ways of being
Transpersonal—beyond the self

).

3.1. (Sense of) Self

3.1.1. (a) Parts

In many of the two-dimensional images and photographs, only parts of the body are visible, for example, the head, skull, eyes, mouth, and hands. This is also evident in poetry, where parts of the self, or a former self, are addressed as separate, for example, “you” or “the girl that was”. Some images contained circles and cut-out or torn pieces of paper. These fragments represent imprisoned, contained, or isolated parts. There are parts that have barriers around them and parts that are held in darkness.

The lack of a whole person is notable and symbolic of parts that are seen, parts that are or remain hidden, and parts that are kept separate. Viewing the images through a social semiotic lens and considering implicit meaning, the artworks communicate the evident impact of social stigma and the ambiguity of needing to hide but wanting to be seen.

Images and writings show other parts that are separate from the self, some out of reach but longed for and others fully embraced with determination, agency, and hope. Although the all-consuming nature of thoughts and feelings is presented throughout the works, the concept of ‘parts’ can be interpreted in several ways. On the one hand, it shows what is compartmentalised or hidden. On the other, it suggests that a suicidal ‘part’ lacks access to other parts of the self that hold hope for connection or contact with/recognition from the external world.

Parts of the Body—Mouths and Beaks

Open and closed mouths and beaks are depicted in the artworks. Image 1 is dominated by a large, bright red, smiling mouth surrounded by blackness. A small person with no mouth or eyes is trapped and silenced behind the bars of “friends, university, expectation, society, and family”.

The participant commented, “The expectation of being okay and functional also further fed into that forced silence that I and my experience of a suicide attempt felt barricaded behind”. The smile hides the burden of expectation and contrasts with the figure holding on and looking out in the hope of being seen and free to speak out.

During a period of active suicidality, a participant had created an image of a skull, a symbol of mortality, capturing the emotional and psychological weight of their experience (image 2). The skull is blindfolded and unable to see out, with an open mouth releasing the perceived burdensomeness of all the pain and suffering held inside. A participant summed up this feeling: “While I was depressed, it was a big problem for me, like this notion that for every breath you take, you are using up carbon, you’re emitting things, you know, your impact on the world is purely negative. And that’s a debt which you can never pay”.

Parts of the Body—Head

The disembodied skull in image 2 is in keeping with recurring motifs of brains and silhouettes of heads. These indicate how much mental space is taken up, isolated and trapped in unvoiced thoughts. A participant reflected on the loneliness of being trapped in these thoughts and having to wear a mask, “None of my friends actually know. It’s a desperation and hopelessness where the prospect of dying sounds better than suffering with your thoughts”.

Like image 1, the theme of imprisonment is present in image 3, as well as that of being locked in and held tightly by defining thoughts. Each of the links is a contributing factor to suicidality: “bully, identity, relationship, trauma, sexuality, pain, money, family, hopelessness, illness, loneliness, loss, isolation, alcohol, abuse, drugs, friends, addiction, work, culture, and fail”. The thought bubbles reflect the impact of these chains: resignation and a loss of identity.

Similarly, image 4 and 5 show what the world sees, what is hidden, and the internalised negative voices, with the repeated word ‘self’ at the top of image 5. The grey shadow surrounding image 4 symbolises the barrier to the outside world.

Parts of the Body—Hands and Arms

The recurring motif of hands represents a ‘reach’. Symbolically, this can be interpreted as reaching out with a wish to be met, letting go or defeat of being unmet. The ambiguity of the ‘reach’ is evident in a three-part digital artwork that incorporates hands emerging and disappearing (image 6). This reflects reaching out and withdrawing, as well as crossing each other as a barrier. A piece in the series features the same gold hand reaching up out of the water and then disappearing underneath again. The motif of water itself represents a vast expanse with unexplored, hidden depths.

A participant made an image in memoriam of a friend who died by suicide, which further illustrates the multiplicity of possible meanings within an artwork (image 7). The upwards reach of the fragmenting hand, surrounded by petals and thorns, has various interpretations. Firstly, the barren stems and thorns communicate the pain and suffering of loss that remain for the person left behind. Secondly, the suffering of the suicidal person themself, the unmet reach. Thirdly, the petals floating upwards represent letting go, the release of burden, leaving the pain and sorrow behind.

Some hands that reach are harmful and threatening. The figure in image 8 is turned away in despair, small, exposed, and trapped with hands on their head, surrounded by dark hands reaching towards them, with no space for escape.

Image 9 is a visual dialogue between the world and self: society’s throwaway nonchalance is shown in the way the hand is holding the bag with the words “Is this my bag for life?”, ready to discard it. In contrast, there are hands tearing their way out of the bag, expressing determination, fight, and breaking free.

The Whole

One sculptural piece (image 10) contains a whole figure holding tightly onto a tree whilst appearing to be pulled towards a hole cut out of a book. The words “do not go gentle into that good night”, referencing the Dylan Thomas (1952) poem by the same name, are cut from the pages. This symbolises both the struggle and determination to hold on. The book itself holds symbolic meaning, metaphorically being considered either an ‘open’ or ‘closed’ book, and also symbolising what is unread, hidden in the pages.

3.1.2. (b) Isolation and out of Reach

The impact of being alone, cut off, trapped, or stuck is evident in images and writing. This is represented by size, words used, space (or lack of) taken up, lines, mark-making, fences, thorns, and shadows surrounding figures. Bars, chains, and the blindfold around parts of the body have already demonstrated the isolating impact of hiding away the trauma, pain, suffering, grief, fear of judgement, stigma, and expectation. The ‘self’ is separate and out of reach, with no access to what lies beyond. The ‘reach’, as identified by hands and arms threatening, unmet, holding on tight, or letting go, reflects the ambiguity that is lived day to day.

In image 11, a participant made a small sketch whilst feeling actively suicidal, and this was incorporated into a collage for the research study. The hearts symbolise much-needed love, inaccessible to the darkness held within. Two further examples are a fence cutting across the page with green grass beyond and a withered rose surrounded by thorns with bright and colourful flowers (image 12): “The flower thorns represent a barrier between me and the world… I felt dead, isolated, and surrounded by people who were well and health and flourishing. I felt out of place. A dead flower in the midst of flourishing life that I am gated away from”.

Although symbolically the withered rose connotes dying, death, and being cut off from the world, further exploration extends to the wider concept of mortality and impermanence. The flowers beyond have been cut and will eventually wither and fade, as we all will eventually. The difference is in the brightness of the life we have to live before death versus a deathlike and isolated existence in life. One needs to look closely to see the barrier of thorns, which is in parallel with people’s lived and living experiences of how much is missed and goes unseen. One participant commented, “I was, you know, absolutely determined that I must be in hell, this couldn’t be life because everybody just seemed not to see it when I felt like I was screaming out”.

Another example of this is image 13. Held within the pages of a small notebook is a tiny person, barely visible amongst scratched markings, head down, legs pulled in, arms tightly crossed and tucked in the corner, taking up little space. This can be viewed on two levels. Firstly, how small and overwhelmed someone can feel, having given up hope for rescue, as indicated by the closed body language. The scratched markings themselves symbolise suffering and despair. Secondly, you need to look carefully to be able to see the tiny figure, almost lost amongst the dominant scratched markings. This communicates the need to look for what is beneath the surface or may be hidden in the pages, as in image 6 (digital image) and image 10.

The size of text and capital letters are used in various images to emphasise the overwhelming extent of despair and frustration, as seen in image 13. This feeling of being lost in overwhelm is communicated by the repetition of the word ‘alone’ in another artwork. One large “ALONE” and a command to die dominate the page, but nearly off the page, tucked in the corner of the canvas (image 14), are the words: “Can’t cope. Help.” The words are small and hard to find amongst a sea of other words—negative self-statements, words of judgement, trauma, and emotional pain. Similarly, a collage contains the repeated words “This has to stop”. These messages are the last hopes for someone to reach out and offer support. Not feeling able to reach out or experiencing perceived burdensomeness recur across the dataset. Any contact with others or the world requires a masked-presented self, reinforcing a lack of a sense of belonging and not being sure of one’s place in the world.

3.2. A Place of Polarities and Paradoxes

Close analysis of survey and interview data suggested that stigma leads to self-stigma and that fear of judgement creates and maintains a silent cycle of stigma (Figure 3). Based on these findings and drawing on many years of experience working with marginalised communities, the first author developed a model to demonstrate the silencing impact of stigma and how “the pervasive nature and impact of shame…has become bound in with the self” (Smit 2022, p.125).

Steps 3 and 4 of the integrated framework for arts-based analysis (Figure 1) started to reveal a dominant sub-theme that had not presented itself in survey or interview data. This related to ‘self’ and ‘others’: a place of polarities and paradoxes. There is a clear and evident split between what is seen and not seen, heard and not heard, what is masked/hidden or revealed, what is deemed acceptable and unacceptable, wanting to escape but feeling trapped, external and internal, self and other, determination (with evidence of agency and hope for something different) and resignation/defeat, contained or uncontained, fragmented and whole, and imprisoned or bound and breaking free. Life and death are depicted in nature: barren vs. fertile, alive and dead or dying. The polarities in the artworks revealed themselves and led to the development of a revised model: the Paradoxical Cycle of Stigma (Figure 4).

The model reflects the internal and external relationship within the ‘self’ and ‘self/other’ dynamics. The polarities identified co-exist inside the self, but they are also directly and indirectly impacted by external, intersubjective, and interpersonal factors. A lack of access to these feelings paradoxically holds a person in a constant cycle: the need to maintain a mask further isolates and hides the feelings that most need to be witnessed with compassion and validation. Consequently, this reinforces the very factors that contribute to suicidality. If we were able to meet someone with the validation and compassion that is needed, then it could become possible for hope, connection, agency, and empowerment to be accessed. Although this model has been developed in response to suicide research, it can be applied to any situation where stigma is experienced.

3.3. (Sense of) Others, Society, and the World

Societal and cultural stigma, judgement, misunderstanding, and assumptions lead to a negative sense of self, a person’s experience of others, of society, and of their perceived place, or lack of it, in the world. The dehumanising impact of ‘othering’ and of pathologising suicidality on the self is implicit and explicit in the artworks. One person commented on “having to deal with the fear of being considered an unperson”. The Paradoxical Cycle of Stigma directly relates to the themes of ‘sense of others’ and ‘society/the world’ as shown by the unmet reach discussed, isolation, and the barriers to support and the outside world.

Image 15 contains the word “alienated”, taking up the whole brain space. This participant remarked, “My head feels nothing other than ‘ALIENATED’ from everything and everyone…I still, to this day, feel alienated sometimes. Surviving a suicide attempt is not a pleasant topic, but when we avoid talking about it, we fuel it with stigma and fill the person’s life with loneliness, estrangement, and always, always, feeling like the odd one out”.

The impact of bullying and relational hurt is evident in various collages, writing, and poetry, for example: “All I want is to escape from this cold, hard world” and “Wasn’t I matching to your so-called expectations?”. Returning to the “bag for life” (image 9), the throwaway nature can be interpreted as a lack of care, and the barriers in many images convey an immense sense of isolation. A participant stated, “I felt silenced whenever the topic was brought up.”. An image of two birds sitting next to each other on a branch but facing away shows/reflects this (image 16). Disconnection remains even without visible bars or constraints—together but still alone.

Mental health and diagnosis also feature within the works. The use of irony is seen in image 17, with reference to the mental health system and its effect. Participants described the vast differences in the responses they received from police and medical professionals. Messages challenging stigma and perceptions are communicated/presented in writing, for example, “You’re not a bad person trying to get good, you’re a sick person trying to get well”.

A lack of belonging or feeling ‘met’ in the world is conveyed in a small oil painting with layers of colour on the surface descending down to darkness underneath (image 18). The painting starts with the address “Dear World” and goes on to describe the challenges experienced. However, the words are obscured, covered over, and eventually lost in the darkness, unread, in parallel with the experience of being unmet and unheard. Pain is written in bold, a theme that presents itself throughout the artworks, and the dark stain over the top is keeping with the dirt and mark-making that depict the visceral reality, the messy and unsanitised reality of trauma and emotional pain presented in this and other participants’ works.

Many images of despair, defeat, death, and hopelessness contain large amounts of black, contain black holes, or are surrounded by darkness. The contrast between dark and light and the brightness of the colours used in some images can be viewed in a number of ways. In images such as image 11, 12, and 15, the outside world is out of reach. The colours within are either separate or inaccessible to the self and kept out of reach by suicide. Alternatively, the presented self, the mask, is hiding the depth of darkness and feelings.

3.4. Ways of Being

Having to separate and mask is a dominant and recurring motif. Being in the world means only a part of the self is ever visible or has access to others. Medicalised terms such as ‘recovery’ and expectations that this is a linear process mean that the hidden suicidal part is left alone and unmet, as shown in the images discussed. To be defined by an experience is reductive and creates separation, also from the self, leading to this mask-presented self. One participant explained, “I kind of tried to smile my sorrows away, to try and laugh, but eventually they all just came crumpling down”. This split between hidden and presented self manifests in feelings of defeat and further isolation or withdrawal from others, reiterating the Paradoxical Cycle of Stigma.

Surviving and finding ways to live are also presented in the artworks. There is a part that has fight, determination, and hope that something can be different. This part is holding on tightly, as seen in image 10, and wanting to break free (image 9). A photograph (image 19) of a barren space surrounded by vegetation contains new growth, the determination to survive and find a way to live in a place burnt to the ground. Image 20 is another example of this, showing a small wildflower finding a way to grow between stones.

In writing, compassion is reflected in messages of recognition and encouragement, validation and empowerment for self and others: “It is terrifying, finding love in myself, however it has made me love others stronger” (poem quote), as well as clear voices that are calling out to “hold on” (image 21) and the frustration of expectation and how hard they are trying (image 22).

A large-scale canvas entitled ‘4046 Days’ (image 23) expresses the challenge of keeping going each day and existing in a world without a sense of belonging. Each of the marks carved into mud and paint is a day lived beyond the onset of suicidal thoughts. The need for containment and having to hold everything inside is represented by the scratched boundary line that surrounds the time marks. It barely contains them, as there are so many. This image also highlights the burden and effect of discrimination. The participant had felt invalidated and marginalised by the process of police and mental health system interventions. Symbolically, each carved mark is like a mark on a prison wall, representing both the daily challenge of living with suicidal thoughts and linking to the historic shame associated with suicide as a criminal act.

Fear, feeling lost, and finding a way to live after trying to die are also themes. The distinction is made between living and surviving, as seen with the withered rose surrounded by inaccessible colour (image 12). One participant described how frightening it is to be in an “unknown place” (participant quote), feeling lost in a “suicide mist”, and not knowing how to be in the world.

3.5. Transpersonal—Beyond the Self

The concept of a death date, living beyond a death date, and near-death experiences had been discussed by several participants, “It’s almost like you’ve got a life that I didn’t expect to have”. The trauma of an attempt, not expecting to live and then living, alters one’s relationship with oneself, others, the world, and ways of being in it. The exploration of the artworks offered further insights that words alone could not convey, a transpersonal layer of connection with what is beyond the self: transcendence, a sense of possibility, rebirth, or renewal, but also a curiosity about the space beyond, something other-worldly, celestial, and bigger than the self. Some images have religious overtones, using religious iconography, whilst others are more directed towards nature, connection with the elemental, space, and the universe.

These various strands can be interpreted as a step into the unknown, the transpersonal realm beyond the self, irrespective of religious affiliation, or of the undetermined and unplanned life that lies beyond a death date. Building this new life holds fear and uncertainty: “It felt like I had to plan my life over again, because in my head I wasn’t going to be here after that set date”, as well as potential and possibility: “In regard to my place in the world, I haven’t yet found my purpose but I’m ok with that…I’m just waiting until a time I’m like, ok this is what I’m here for”. There is evident exploration of something beyond, trying to make sense of what has happened, as well as exploring and redefining one’s place in a wider context.

As discussed, determination, strength, and endurance are evidenced, even in places where it is bleak (images 19 and 20). Plants and flowers feature in some of the visual and written works, and new growth symbolises rebirth, coming through winter from a dormant and barren time to the possibility of “buds that bloom” (poem quote), offering hope and possibility as well as renewal and transformation. Conversely, petals can be seen as letting go, fragmentation and coming apart, or released particles (image 15). The cut flowers in image 12 symbolise both beauty and what is out of reach, but also death as the universal equaliser, inevitable for us all in the end. New beginnings are also represented in birds—the parallel between death, a bird skull with its closed mouth, hollow eyes, and surrounded by flames, and the image of a phoenix reborn from the ashes, rising up in flight (images 24 and 25).

Doves are religious symbols of peace and/or hope (images 26 and 27). In image 26, olive branches surround the dove, similar to ones in some religious imagery. This is based on the story of Noah, who was trapped on a boat and sent out a dove to look for land and life. Hope returned in the form of the dove with an olive branch in its mouth, symbolising that the endless wait was over and life could begin again. The olive branch has also come to represent reaching out in peace and friendship.

Further religious symbolism is used: a cross, a tombstone (image 27), a crown of thorns (image 28), and a doorway with steps into the unknown to a blank beyond in what appears to be a tomb or mausoleum (image 29). Blankness is presented in many images as either empty white or black space and represents the liminal space (Denham-Vaughan 2018; Stenner 2018) of the unknown, a void, or a sense of nothingness. One person explained, “It’s like I felt nothing, I was just completely empty”. This blankness has been interpreted scientifically, spiritually, and religiously in relation to near-death experiences (Fritz et al. 2024; Hashemi et al. 2023).

Space and the universe recur in various images. Like the markings made in image 24, the moon phases around an eclipse mark time (image 30) and go through a process of waxing and waning, revealing more or less of the moon. Opposing light and shadow sides are clearly shown in a series of planet images (example: image 31). Symbolically, these hold a deeper meaning. The moon and every planet that is lit by the sun inevitably have a side that is in darkness. This mirrors the split between what is visible and what is hidden and the polarities and paradox explored in Figure 4. It also reflects the transitory nature of suicidal thoughts, which, for some people, can increase and decrease in intensity and frequency. One participant described, “I think I definitely felt suicidal for many years, and it comes, you know, in like waves, so like, you know, sometimes it’s more intense”. The alienation this causes is explained by another participant, “It’s such a natural thing that you know your purpose in life is living, is to stay alive…we’re all here for that reason, so it’s unfathomable to a lot of people, I think, how anyone could ever have the opposite experience, which can make you feel quite excluded”. Fear and stigma create barriers and censorship. For many, the taboo nature of their experience means that they feel unable to integrate these experiences into their lives. Perhaps, to live an integrated life, either beyond a suicide attempt or alongside suicidal thoughts and feelings, both light and shadow aspects need to be accepted without judgement, so that there will no longer be a need to hide behind a false smile.

4. Conclusions/Key Findings

The findings presented in this article have notable implications for suicide prevention and research. The development of the Paradoxical Cycle of Stigma highlights the implications of internalised stigma, prejudice, and positivist representations of suicide and that further reflection on ways that we can break it is needed to enable access to validation, compassion, hope, connection, agency, and empowerment.

The emergent themes explored in this article signpost a need for further exploration of the impact of near-death experiences specific to suicide and support approaches to living consciously with and alongside the concept of mortality following an attempt. This is particularly pertinent in Western culture, where the topic of death is avoided and sanitised (Graham-Wisener et al. 2022; Wilson et al. 2022), and consequently, the idea of self-directed death is taboo. Furthermore, there is a need to foster different ways to support people with living beyond a defined death date, such as significant birthdays or other milestones in one’s life.

The additional theme identified within the artworks, ‘beyond the self’, and the insights gained from the transpersonal aspects communicated through visual narratives signify an area for further exploration. Both this theme and the additional layer of meaning derived from the arts-based data analysis that led to the development of the Paradoxical Cycle of Stigma show the power of incorporating visual methods as part of qualitative enquiry. Incorporating this methodology for underrepresented and marginalised voices enables access to meaning that transcends verbal communication and to what is hidden or masked, as evidenced by the works themselves.

When reflecting on the efficacy of this approach, it is important to also consider its limitations. To provide containment and hold the participant’s wellbeing at the heart of the process meant that some of the artwork was informed by the semi-structured interview and thereby potentially more open to interpretation. The structured approach to analysis limits potential bias, but it is not absolute. Equally, although rich in its inclusion, incorporating some artworks made at a time of active suicidality alongside artworks made in response to further reflection means that a comparative study of data is limited to the overall content and thematic analysis. This was an informed decision, as much to honour the gift of the artworks shared by participants, as for the unique insight this additional material provided. Initially, the aim was to be able to track across the three studies; however, given the nature of the topic, it quickly became apparent that it would not be possible.

The approach discussed in this article offers a unique way to communicate what is hard to put into words. Several exhibitions of the artworks have already taken place nationally and internationally, and this active use of arts-based and visual data has started to break down barriers and provide a bridge to communication by challenging preconceptions and opening up ways for discussion and reflection to take place. Furthermore, it has begun to help people understand that the feelings communicated are human and relatable, not isolated or ‘other’. As expressed by an exhibition visitor: “A really useful way of expressing the complex nature of suicidal experiences. Everyone’s experience is different, and that was clearly reflected in the artwork. Also, if I wasn’t told this was about suicide, I’m not sure I’d know. I think I would believe it was an expression of emotions”.

Curating the exhibition was a carefully considered process. Participants had reflected that material relating to suicide prevention and support is often presented in a way that ends with positive or more hopeful content. This does not honour the experiences of those who struggle each day to keep going or who have died by suicide. Participants shared the ongoing challenge of living with/alongside the voice of suicide, and this positivist approach to suicide and suicide prevention can present a barrier to engagement. In keeping with accounts of the challenges faced, the artworks were displayed in a way that the exhibition could be accessed from any place and not follow a set narrative. An exhibition visitor with personal experience shared their feedback, stating that they “really found oddly comforting to see that I was not the only one who had felt similar feelings or had similar thoughts”.

As outlined at the start, it is so important to consider power dynamics and partnership working when building a study that includes lived and living experiences. It is hoped that the approach taken in this study and shared here has started, in some small way, to pave the way to breaking the silent cycle of stigma.

The findings from this study provide valuable insights that not only contribute to our academic understanding but also to society’s understanding on a human, individual level. It is our hope that this paper will encourage renewed consideration and reflection on innovative ways to use arts-based and visual methods to challenge preconceptions, stigma, and social injustice and to create spaces for marginalised voices to be heard so that lived and living experiences can be witnessed with kindness, compassion, and validation, and for the unmet reach to be met. It is hoped that these new insights will encourage wider reflection and be used to bring about change.