Layout 1 [Qualitative Research in Medicine & Healthcare 2022; 6:10437] [page 1] Introduction In December 9, 2021, The New York Times ran an article with this gripping headline: “Where the despairing log on, and learn ways to die.”1 The topic is a “pro-suicide” website called Sanctioned Suicide, which the authors deem respon- sible for more than 500 deaths worldwide since its creation in 2018 (roughly two deaths per week, the authors tell read- ers). Sanctioned Suicide is a place where users post suicide means and methods, solicit suicide partners, post suicide timelines, and in extreme cases, share links to live broad- casts of “real live” suicide, also known as “deathcasting.”2 To date, attempts by grieving family members to track the site creators, who go by the alias “Marquis” and “Serge,” and shut down the site have met little success. The New York Times coverage of Sanctioned Suicide is noteworthy because it concretizes longstanding con- cerns about the internet’s possible role in driving upward trends in suicide. (Like Baym and Markham, I do not spell “internet” with an upper-case “I” because doing so would suggest that the internet is a specific place or an agentic/monolithic being.)3 According to the World Health Organization (WHO), more than 700,000 people end their lives across the globe every year (WHO, Suicide preven- tion. Accessed 02/03/2022: https://www.who.int /health- topics/suicide#tab=tab_1). For each death by suicide, an additional 20 people attempt suicide, totaling 14 million suicide attempts annually worldwide. In the United States, the number of suicide deaths jumped from 30,000 in the year 2000 to 49,000 in 2020; when adjusted for popula- tion growth, this represents a non-trivial leap from 10.4 to 14 per 100,000 over a twenty-year period.4 The time frame overlaps with the advent of Web 2.0 and the diffu- “Life is about trying to find a better place to live”: Discourses of dwelling in a pro-recovery suicide forum Mike Alvarez Department of Communication, University of New Hampshire, Durham, NH, USA ABSTRACT In the two decades since the advent of Web 2.0, scholars of cybersuicide have identified many beneficial and harmful uses of the internet. However, the discursive meanings interactionally created by suicide website users have scarcely been attended to. The present study uses the theory and method of cultural discourse analysis (CuDA) to arrive at meanings about place that radiate from online com- munication among users of SuicideForum.com (SF), a pro-recovery website. Analyses of 2,119 posts across 131 threads reveal two overarching discursive themes. The first speaks to problematic discourses about place, including the role of placelessness and entrapment in the genesis of suicidality and its affective states, leading to further diminution of experiential worlds. The second theme taps into participants’ notions of what constitutes safe spaces, such as the presence of empathetic others who respect one’s timetable for personal disclosure, and the freedom to experiment with new ways of inhabiting the world. The study has numerous implications for clinical practice, including recasting psychological disturbances in terms of self-world relations and reconsidering involuntary psychiatric hos- pitalization in light of forum participants’ preoccupation with entrapment. Correspondence: Mike Alvarez, Department of Communication, University of New Hampshire, Horton Social Science Center, 20 Academic Way, Durham, NH, 03824 USA. Tel.: 413.341.2339. E-mail: mike.alvarez@unh.edu Key words: Internet; suicide; digital media; cybersuicide; cultural discourse analysis; ethnography of communication. Conflict of interest: The author declares no conflict of interest. Acknowledgments: The author would like to thank Donal Car- baugh, Martin Norden, and Daphne Patai for prior comments on different portions of the article. I would also like to thank the anonymous reviewers for their feedback and time. Any errors that remain are my own. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate: Not applicable. Informed consent: Not applicable. Received for publication: 2 March 2022. Accepted for publication: 27 March 2022. Publisher’s note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Qualitative Research in Medicine & Healthcare 2022; 6:10437 doi:10.4081/qrmh.2022.10437 This article is distributed under the terms of the Creative Commons Attribution-NonCommercial International License (CC BY-NC 4.0) which permits any noncommercial use, distribution, and reproduc- tion in any medium, provided the original author(s) and source are credited. Qualitative Research in Medicine & Healthcare 2022; volume 6:10437 No n- co mm er cia l u se on ly sion and penetration of digital and mobile media into myr- iad arenas of social life. The harmful content, contexts, and uses of digital media and the internet are manifold. These include pro- suicide message boards like Sanctioned Suicide where the desire for death goes largely unchallenged, online suicide manuals which provide “tips” and “tricks” for enacting self-harm,5 net suicide pacts where two or more strangers on the Web agree on a physical place and/or time to end their lives together,6,7 suicide due to cyberbullying, or “bullycide,” which extends the temporal and spatial reach of malicious behavior,8 and, as mentioned above, death- casting, the live broadcasting of one’s suicide which is frequently goaded by other users’ incendiary messages.9 These specific instances tap into more general concerns about the explosion and accessibility of triggering content on the Web and the disinhibitory effect of online commu- nication on risk behavior. But as I have written elsewhere, “for every destructive potential of the internet, there is a corresponding construc- tive potential.”10 In the arena of suicide prevention, these include formal and informal message boards with a pro-re- covery orientation,11 support groups within existing social networking sites (SNS) like Facebook,12 online delivery of psychological treatment to vulnerable and hard-to-reach groups,13 dissemination of empirically validated informa- tion such as warning signs, risk factors, and treatment op- tions,14 and online gatekeeper training programs which prepare professionals to “question, persuade, and refer” sui- cidal people they are likely to come across.15 Such applica- tions tap into hopes that technology could augment efforts to identify, educate, and extend aid to vulnerable popula- tions and the people entrusted with their care. Research on suicide and the internet has largely oper- ated from a benefits/harm paradigm,16 which reflects the monopoly of the “psy” disciplines (i.e. psychology and psychiatry) on the study of cybersuicide. In most studies of cybersuicide, the unit of analysis is typically the indi- vidual, who is presumed to be afflicted with an underlying pathology, and the internet, in turn, is viewed as a dou- ble-edged tool that can prevent or promote suicide. Al- though the “psy” disciplines have advanced our understanding of the promises and pitfalls of digital tech- nologies in the realm of suicidality,17,18 it has excluded end users’ perspectives and meanings. This is in line with crit- icisms leveled at mainstream suicidology by scholars and practitioners of critical suicidology19 – in particular, the former’s disavowal of suicidal individuals’ lived experi- ence and the qualitative and interpretive methods that make those experiences humanly intelligible. The present study is a modest endeavor to arrive at meanings about place, including cyberspace and symbolic space, that are discursively created by users of a pro-recov- ery suicide forum and the implications of these meanings for clinical and therapeutic practice. Without eschewing utopian hopes and dystopian fears about the internet, I at- tend to the medium’s syntopian capacity for meaning gen- eration,20 and heed the call to treat online mental health fo- rums as discursive communities,21 thus shifting the focus away from the pathologized individual as the unit of analy- sis. Furthermore, I conceive of internet users as agents who utilize the affordances of Web platforms (as opposed to pas- sive recipients of beneficial or harmful content) and the in- ternet as a heterogeneous space (as opposed to a mere tool) in which discursive communities co-create meanings about their communicative worlds.22 In what follows, I first provide an overview of the con- ceptual framework (specifically, the theory and method of cultural discourse analysis), the communication scene in question, and procedures for collecting and analyzing data. I then present interpretive findings in two parts: Part I probes the notion of suicidality as failure in dwelling, and Part II explores the qualities that constitute safe spaces from forum participants’ discursive point of view. I conclude with a discussion of the study’s main findings, contributions to research and clinical practice, and av- enues for future exploration. Materials and Methods Conceptual framework There have been many attempts to identify the paradig- matic dimensions of “community,” especially online com- munity. Moores argues that a sense of belonging is key and, citing Castells, adds shared initiatives, values, affinities, and projects.23 Willson postulates four key dimensions, including bonding (which is synonymous with Moores’ belonging), reciprocity (the joint solicitation and offering of support), commonality (the perception of similarity), and intersubjec- tive identity (an identity possessed by the whole community, distinct from yet contributing to individual identity).24 Baym concurs with Willson’s intersubjective identity (which she calls “shared identity”) and adds shared practices, shared re- sources, and interpersonal relations.25 Finally, Meyers asserts that a bounded space, be it physical or virtual, is crucial to community, along with interpretive strategies that align one’s values with the group.26 Though a more exhaustive treatment of community is beyond the scope of the present study, this overview serves as a useful starting point for ex- ploring the culture of a community, and the role of commu- nication in constituting community and culture. The present study takes up the call to extend the assig- nation of “culture” to groups and entities not previously considered as such.27 Thus, I view “suicidal” persons as a cultural rather than a diagnostic category and the suicidal users of a pro-recovery forum as members of a discursive community,28 defined here as a group of people whose communicative practices underlie common values, be- liefs, and strategies at meaning-making. (Throughout, I use the term “discourse” to refer to multi-utterance units of talk, and “discursive practices” to call attention to the [page 2] [Qualitative Research in Medicine & Healthcare 2022; 6:10437] Article No n- co mm er cia l u se on ly idea that talk is an activity that has many different parts.)29 Moreover, I adopt Carbaugh’s four-part communication definition of culture, which sees culture as i) an expressive system, ii) of symbols and symbolic forms, iii) that are meaningful to participants in situated contexts, and iv) are transmitted by members over time.30 This definition dis- lodges culture from the constraints of geographical space, allowing productive application of the concept to virtual contexts. This definition also calls attention to the consti- tutive role of communication, without which cultures and communities would not exist. Methodologically, I use cultural discourse analysis (CuDA), a powerful tool for theorizing, describing, and interpreting communicative practices and their meanings to those who engage in them.31 CuDA has a rich theoret- ical lineage that includes the ethnography of communica- tion,27 which sees communication as locally shaped, and the theory of cultural communication,32 which attends to the “membering” functions of social interaction. Building upon its predecessors, CuDA operates under two key as- sumptions: i) that communication is particular to places and varies from one context to the next; and ii) that mem- bers of a discursive community actualize their social lives through the communicative practices in place.33 From the standpoint of CuDA, communicative prac- tices are imbued with deeply meaningful messages called “cultural discourses.” When members of a discursive community speak, they are not merely stating something about the topic at hand. They are engaging in metacultural commentary about how to act, how to feel, how to relate to others, how to be, and how to inhabit the world. Car- baugh calls these “radiants of meaning” – acting, feeling, relating, being, and dwelling, respectively – and they are invoked whenever “discursive hubs” are used.30 “Hubs” are the explicit units of analysis and “radiants” are the im- plicit meanings; the two are inseparable. To provide one example: In a previous study of online communication among people who engage in routine non-suicidal self-in- jury (NSSI), I tracked usage of the terms “self-harm” and “self-injury” (discursive hubs of action in CuDA’s parl- ance), and in the process, arrived at participant meanings about self-harm as crisis management (radiant of feeling), relational maintenance and control (relating), and punitive self-discipline (acting and being).15 Discursive hubs assume many guises, including, but not limited to, terms, phrases, images, gestures, symbols, and symbolic forms (e.g. ritual, myth, social drama). Fre- quency of invocation is but one marker of a hub’s potency and meaningfulness; other considerations include em- phatic usage, particularity of usage, mutual intelligibility, and accessibility to participants. A hub need not be affili- ated with only one radiant of meaning because a single hub can activate multiple radiants at once, as the above example shows. Hubs can also work singly or jointly to activate meaning, but not all hubs/radiants are relevant or salient in every communicative scene. In the thirty years since its inception, CuDA has been fruitfully applied to a wide range of communicative prac- tices and discursive communities across the globe (see the anthology by Scollo and Milburn),34 including users of web platforms and online mental health communities.9,15,35 These applications demonstrate CuDA’s reach in expli- cating diverse communicative phenomena and broadening our understanding of how cultural meanings are produced through talk of various kinds. The communication scene This article is based on a larger ethnographic study of SuicideForum.com (SF) – one of the largest pro-recovery websites in existence, housing more than 150,000 discus- sion threads, two million posts, and 53,000 registered members worldwide since its creation in 2005. Though registration is required to participate in threads, it is not necessary to access much of the site’s content; registration is free and does not require personal information. And while SF has a global user base, communication in the site is primarily in English. SF describes itself as a “peer to peer community support forum and chatroom for people in need,” and it adheres strictly to a “Do no harm, promote no harm principle” (Sui- cide Forum, Mission statement, accessed 02/03/2022: www.suicideforum.com/about-sf/). Members are free to discuss their past and present struggles with suicide, pro- vided that they do so in a non-triggering manner (e.g. avoiding minute details of prior attempts). Members are prohibited from sharing suicide methods, soliciting suicide partners, posting suicide plans and timelines, encouraging others’ plans, and dissuading others from seeking formal treatment and support. Committing any of these infractions results in immediate account termination. Unlike Sanc- tioned Suicide in this article’s introduction SF is expressly pro-recovery; members are committed to improving their mental health, to contributing positively to others’ mental health, and to providing informal support online as a com- plement (rather than substitute) to formal treatment re- ceived elsewhere. Additionally, SF provides links to crisis websites and numbers for crisis hotlines for 80 countries and territories as well as reference materials on various mental health struggles. SF is neither run nor moderated by an organi- zation, but is staffed by former members who volunteer their time as administrators. Their responsibilities include monitoring threads and redacting messages with objec- tionable content, imposing sanctions for infractions, re- sponding to member queries, and keeping the site running. The site’s operations are supported entirely by donations covering server costs, licensing fees, and security updates. Data collection and analysis As mentioned, this study is part of a much larger ethnographic study on SF. I spent an initial seven months [Qualitative Research in Medicine & Healthcare 2022; 6:10437] [page 3] Article No n- co mm er cia l u se on ly browsing SF to familiarize myself with the site’s technical affordances, layout and design, content, rules of conduct, and norms of interaction. I then conducted an additional thirty weeks of non-participant observation, during which I utilized Hymes’s descriptive theory to understand the in- dividual components of the “communication scene”27 and how the website’s discursive architecture, as a whole, structures the meanings created therein. These observa- tions were recorded via field notes and scratch notes. More relevant to the present study, I also collected and analyzed a purposive sample of 2,119 posts across 131 threads during the thirty-week period. I did not set an a pri- ori number of posts to collect, as that would go against CuDA’s spirit of discovery and immersion; instead, I made sure to draw from every major section of the forums during the study’s time frame. These sections were: New Mem- bers, Suicidal Thoughts and Feelings, Road to Recovery, Let It All Out, Support and Advice, You Are Not Alone, and The Gathering. The posts amount to 683 transcript pages, which constitute the data corpus for this study. I did not use data scraping software in order to preserve the message structure of threads. All threads were printed to facilitate hand coding which I conducted myself. Using CuDA, I systematically tracked SF members’ usage of “suicide” (a discursive hub of action) and “suici- dal” (a discursive hub of emotion and personhood) in order to arrive at corresponding radiants of meaning. For analyt- ical purposes, “suicide” and “suicidal,” and their more col- loquial variants, like “killing myself” and “throwing in the towel,” constitute the primary hubs. I probed the transcript for each of the five radiants (being, relating, acting, feeling, dwelling) one by one, formulating a research question for each. For the radiant of dwelling, the focus of this article, I posed the question: What meanings about place are discur- sively constructed by SuicideForum members in their on- line communication about suicide? Because hubs can activate other hubs, I also tracked discursive hubs of place that were invoked by members in reference to “suicide” and “suicidal.” After all, verbal or written depictions of place are not merely descriptive, but suggest ways of relat- ing to that place. These secondary hubs include “world,” “nowhere,” “home,” “safe place,” “safe space,” “here,” “SF,” “this forum,” and “this site.” I conducted multiple rounds of coding for each radi- ant, including dwelling. In CUDA’s parlance, interpretive accounts may take the form of “cultural premises,” which are abstract formulations of participants’ taken-for- granted knowledge and beliefs about the way things are, and/or the way things ought to be.30 Drawing on the afore- mentioned study of non-suicidal self-injury, an example of a cultural premise would be: Self-harm disciplines the uncooperative body and manages intense feelings tem- porarily.15 In the present study’s initial coding stage, I generated as many cultural premises as possible based on recurring patterns in the transcript. Next, I reviewed the transcript to verify these cultural premises, identify new premises that I previously missed, check for discrepan- cies, and combine similar premises. In the final stage, I grouped together related cultural premises to identify overarching discursive themes and sub-themes, resulting in two grand discourses – one relating to problematic places, the other to safe spaces (more on these ahead). Ethical considerations Before I present my findings, some words about ethics are in order. This study does not meet the institutional def- inition of human subjects research because neither inter- vention nor interaction with members of the SF community took place and because analysis was restricted to extant data on publicly available threads with heavy user traffic. Moreover, SF prohibits members from using real-life photos as avatars, from using real names as han- dles, and from reusing handles associated with other on- line accounts. Thus, individual posts are not linked to personally identifying information, and throughout data collection and analysis, I encountered no evidence to the contrary. In short, transcripts are already anonymized. Another concern relates to the ethical and legal re- sponsibilities of researchers should they encounter dis- tressing information.36 As I mentioned, SF abides by a “Do no harm, promote no harm” principle that it strictly enforces; I did not encounter posts in which there is im- minent threat to group or individual safety and warranted intervention on my part. Results SF members’ online communication reveals two over- arching sets of discourses about dwelling which I address in the following two sections. In the first section, I explore the notion of suicidality as failure in dwelling, from which three related sub-themes emerge: i) problematic relations to place (i.e. placelessness and entrapment) that produce suicidal crisis, ii) the expansion and constriction of per- ceived space brought forth by suicidality, and iii) the cre- ation of and retreat to symbolic spaces as escape from problematic places. In the second section, I unravel SF members’ notions of a “safe” space, the people who in- habit such a space, its temporal and spatial boundaries, and how the discursive space of SF exhibits these desired qualities. I present interpretive findings as cultural prem- ises (italicized throughout), which are supported by brief excerpts from the transcript. Part I: Suicidality as failure in dwelling Relation to place as precursor to suicide It is apparent from SF members’ messages to one an- other that a problematic relationship to place can provoke suicidality, though the nature of this relationship varies [page 4] [Qualitative Research in Medicine & Healthcare 2022; 6:10437] Article No n- co mm er cia l u se on ly from person to person. For some members, the issue is a sense of entrapment in a place that is anathema to sur- vival. The precipitating environment has been described as “hostile,” “alien,” and “uninhabitable,” and includes places that others typically associate with warmth and safety such as the school or the home. Recalling the days of his/her youth during which s/he was chronically suici- dal, one user writes, “I was profoundly alone in a world of evil vindictive children, teachers, and parents,” while another user, who claims to have been “abused at school, tortured at home,” writes of “having nowhere safe to be” (Italics added here and below for emphasis; spelling and grammatical errors in user posts have been preserved.) In these examples, the negative qualities of relational space are extrapolated to the rest of the world, heightening the sense of inescapability. Although extrication from the pre- cipitating environment may alleviate thoughts and feel- ings of suicide, it is not always possible due to relations of dependence that keep one in place, as is the case for underage minors, students who rely financially on their parents, or spouses without means of making a living. Not every SF member is a recipient of chronic mis- treatment and abuse, but even those without an apparent history of trauma may invoke a sense of entrapment in their posts. In other words, entrapment is not contingent upon a traumatic social milieu. One user captures this feeling when s/he writes, “I was going nowhere and I ba- sically dug my life into a hole….”. Expressing their sym- pathies, another writes: I know what you mean. Still in the looping life you don’t want and not able to shift into getting the help that you need, including helping yourself. Those moments where you have the idea of what you need to do but you are in the quicksand of the situation and you think you need superhuman strength and the willpower it would take to pull a tree up by the roots in order to do it. The invocation of “looping life” in the above post speaks volumes, for it suggests being stuck in place re- visiting the same dramas. The “quicksand” metaphor adds to the feeling of inextricability by invoking the sensation that one is slowly but surely sinking, even when the path to freedom is painfully in sight. For other SF users, it is not a sense of entrapment, but its dialectical opposite, the feeling of being unsettled, dis- placed, and without place that is the source of much an- guish. One member who had spent years in jail cites “homelessness” as a precursor to a suicide attempt. In his statement, “I had nowhere to go,” alludes not to being stuck in place, but to having no place to be; not to prob- lematic emplacement, but to alienating displacement. An- other SF user compares him/herself to a “giraffe in space…not sure how I got here and probably can’t get back to earth on my own.” By comparing oneself to a helpless animal, and by conjuring the vastness of outer space, the user appears to be drifting aimlessly in the world, without the power to alter his/her trajectory. In both examples, the sense of placelessness is discursively linked to a directionless life. Placelessness may also be expressed in terms of in- compatibility between self and world, as the following two extracts illustrate: Still don’t really want to be alive but I’m [no longer] suicidal, it’s more boredom that I can’t function in the real world so I sit at home without a thing to do, just sick of it. The future is just so unclear and unsure for me, idk [I don’t know] if i have a place in it or for how long i can keep up or if i can even make it. Both users have a history of suicidality, but were not actively suicidal when they posted the above messages. Both users also evoke the sense that they do not belong in the world (“idk if i have a place in it”), whose demands exceed the users’ capacity to function (“can’t function in the real world”). Despite their surface differences, a feeling of entrap- ment, and a feeling of placelessness, both indicate that the person is not where s/he ought to be. To paraphrase, the disjuncture between the place where one is (or is not), and the place where one should be, can be a source of despair. Suicidality’s impact on place So far, I have explored the discursive links between a fraught relationship to place and suicidality. That relation- ship, however, is not uni-directional; it is reciprocal. Just as place influences affect, affect also influences percep- tion of place. Thus, we must also attend to how affective states associated with suicidality influence the perception and experience of place, from SF users’ discursive point of view. The above cultural premise is most apparent in mem- bers’ characterization of depression. For many SF users depression is auratic, enveloping the person wherever s/he may go. Wrote one user: “A constant low level de- pression follows me and sometimes really rises up and feels overwhelming.” For this user, depression contracts (“low level”) and expands (“rises up”) to unbearable lev- els (“feels overwhelming”). Depression taints perception of the world, and it is not surprising that SF members de- scribe depression in spatial terms. One member likened depression to a “long and dark tunnel,” without a foresee- able end in sight, while another compared it to being at the center of a cyclone or storm. In both examples, there is a sense of engulfment as well as entrapment, which we also find in these data strips: “I’m in a dark place,” “be- tween a rock and a hard place right now,” “I have reached rock bottom,” “I am in such a pit.” [Qualitative Research in Medicine & Healthcare 2022; 6:10437] [page 5] Article No n- co mm er cia l u se on ly From these examples, a curious dialectic of expansion and constriction emerges. Negative affect engulfs the per- son, which results in the diminution of space, producing a sense of inescapability. To paraphrase, negative affect expands out into the world which causes that world to shrink for the suicidal person. The dialectic finds parallel in the dialectic of entrapment and placelessness I men- tioned previously. I should note, however, that this cul- tural premise is not limited to depressed mood. After all, suicidality is neither synonymous with nor reducible to depression. Suicidality implicates multiple affective states other than depression, including but not limited to fear, anger, rage, and even boredom.34 As a case in point, one SF user suffers from anxiety so debilitating that it has en- veloped his/her entire world, greatly reducing the param- eters of navigable space: “I had a nervous breakdown and lived in my closet for four months until I couldn’t take the pain any longer.” At its most extreme, suicidality can disrupt indwelling, or the habitation of one’s own body. Recounting his/her sui- cide attempt, a member writes: “I was so empty inside that it felt like an out-of-body experience, like something meta- physical was happening.” The person became a disembod- ied spectator of his/her own imminent demise, which was fortunately aborted. In this example, failure in dwelling ex- pressed itself as disembodiment, as displacement from the corporeal body and evacuation of self. The retreat to symbolic space To escape the “cruel world” that they inhabit, a number of SF users create symbolic spaces where they can seek refuge, however fleetingly. In the words of one member, “Making up my reality eases the emotional pain. I can be anything and do anything I want.” Such a space grants one freedom that by implication is lacking in the material world – in this case, the freedom to act and the freedom to be. In SF users’ discourse, the symbolic space has at least two variants. The first variant is the temporal space of an idealized past. In a thread where members discuss their reasons for choosing their avatar, idyllic images of the nat- ural environment are a recurrent motif and are discur- sively linked to memories of a bygone past. Discussing their avatars, two users write: “nature is all love in the world, manifesting as a perfect playground for us hu- mans…a happy content place,” and “I like to think I can get back to that feeling of pure happiness.” Positive qual- ities associated with the natural world (e.g. unadulterated happiness, contentment, and resplendent love) are im- puted to the temporal space of the past, before it was con- taminated by time’s march forward. The past is ideal compared to an imperfect present marked by suicidality. The second variant is the imagined space of the after- life. In this afterlife, there is no more suffering, and one may be reunited with a departed loved one. One member uses cloud pictures as their avatar to represent heaven which s/he uses as windows “to catch a glimpse of some- one…just to know they are there and I will one day join them.” The possibility of a reunion in the afterlife brings this member much needed solace in the present. Of course, not all SF users believe in an afterlife. Some are neither spiritual nor religious, espousing the belief that conscious- ness ends with termination of the body’s cellular activities. Others believe that neither heaven nor hell is a place, but in the words of one user, “a state of mind we inflict upon others and ourselves.” Nevertheless, the lack or absence of spirituality or religiosity does not preclude non-believers from crafting their own secular versions of the afterlife. From the examples above, one could say that the cre- ation of symbolic space is symptomatic of a problematic relation to the external world. But the imagined act goes beyond mere escapism; it also grants temporary reprieve and offers windows into more hopeful ways of dwelling, as the following post eloquently captures: My avatar is a balloon flying over a cloudy sky. It represents the goal where I want to find myself in the end. I think when you stand below the clouds – on earth – the clouds can darken your view by getting in the way of the sun. But on the other side of the clouds you are always near the sun. In this example, despair and hope are spatially differ- entiated. Despair – suicidal despair – is earthbound (“below the clouds – on earth”), and hope, which may at times seem unreachable, lies “just on the other side of the clouds.” Thus, the creation of symbolic space may also be an act of future-forming,37 on which notions of a safe space and place may be erected. Part II: On safe dwelling spaces SF as lifeline and respite As I have shown in the previous section, a problematic relation to place, characterized by entrapment on one hand and placelessness on the other, can contribute to thoughts and feelings of suicide. In both scenarios, one is not where one should be. It follows that finding a good place can greatly alleviate suicidality; in the words of one SF user, “Life is about trying to find a better place to live.” For many users, SF serves as a waystation to that destination, a safe space that can mean the difference between life and death. Interestingly, many SF users stumble upon the forums when they are searching the Web for the means to their demise. One does not seek out SF, but instead, “find one’s way here.” Although these users are fortunate that they stumbled upon SF rather than a pro-suicide venue like Sanctioned Suicide, their good fortune is not solely due to blind luck. For the site’s English-speaking users, at least, search engines like Google yield prevention-ori- ented results first, even when users type in search phrases like “suicide methods” or “how to commit suicide.”38 [page 6] [Qualitative Research in Medicine & Healthcare 2022; 6:10437] Article No n- co mm er cia l u se on ly (This benefit is not evenly distributed across the globe, however.) Users describe their serendipitous discovery of SF as a “lifeline,” with one member writing: “Finding this…helped me keep it together.” Tracking members’ usage of “SF” and deictic words or phrases like “here,” “this site,” or “this forum,” not only reveals concrete mes- sages about the virtual terrain of SF; it also reveals par- ticipant meanings (i.e. metacultural commentaries) about what constitutes a “safe” place to be. From SF members’ discursive point of view, a safe space is a place for the management of acute crises and provides momentary respite from the stresses of life. Comparing SF to a hospital’s ER, one user writes, “I will always come here first, on this forum, my local Emerg.” Before resorting to self-injurious or life-threatening be- havior, and before life’s hardships become overwhelming, they seek out SF first: “If things become over bearing and too much to handle I know where to come to before I break down from it again.” Unlike real-life emergency rooms, however, a safe space imposes no temporal limits on the frequency and duration of one’s stay, with one member attesting that SF “has helped keep me alive for about 3 years now.” It is a place where one can go how- ever many times necessary. Members suggest that had it not been for the forums, they would be in an even more perilous situation, if not already dead: “Without this site, I don’t know what I’d do,” and “I have had a stroke of luck today…If it wasn’t for everyone here I don’t know what would have happened.” Empathy, reciprocity, and belonging As the last extract indicates, a safe space is filled with empathetic others who provide much needed support. One user writes, “I am so glad I found this place when I did. I never realized others felt exactly like I did and I never dreamed of the support and care I’d find right here on this website.” To this post, another responds, “That’s part of what this forum is all about j - giving us all perspective on our issues…and showing us that other people are hurt- ing too and know how we feel j.” Having gone through similar crises (“are hurting too”), these empathetic others mirror one’s life experiences (“felt exactly like I did,” “know how we feel”), thereby communicating that one is not alone in the world. The realization that one’s burdens are shared by others can be life-affirming, shifting one’s perception of singu- larity to that of shared humanity. Moreover, as the above posts illustrate, the users who provide support are them- selves recipients of other users’ support. This suggests that safe spaces like SF are governed by the norm of reciproc- ity, with participants taking on the dual role of giver and receiver. This is consistent with previous studies of online mental health communities,39 where giving and seeking support (emotional, informational, network, or tangible aid) is a joint responsibility assumed by users, so that over time, everyone is expected to provide. In statements of affirmation and support – by members who had been in crisis, to members currently in crisis – the first-person, plural pronoun “We” surfaces frequently, as in these two examples: We want you here. All of us on this site. Please don’t do it. We are genuinely here to help you through this dif- ficult period of your life, it does get better. Feelings change. Life changes. Circumstances change…. These messages communicate to acutely suicidal users that a safe space like SF is a shared space where every life counts. Participation in the site makes one a valued mem- ber (“We want you here”), and one’s words of pain and anguish are heard not by an individual, but by an entire community (“All of us”). The community will endeavor to alleviate one’s suffering (“help you through this diffi- cult period”), and in this context, the alleviation of suffer- ing (“it does get better”) is a genuine possibility, rather than wishful fantasy. After all, statements like, “Feelings change. Life changes. Circumstances change,” carry dis- cursive weight when they are drawn from first-hand ex- perience rather than contrived, meeting the criteria for authentic talk. Freedom of emotional expression and mobility The discursive space of SF affords members freedom of emotional expression, provided that it does not harm others. In a safe space like SF, one can freely ventilate one’s feelings, without fear of judgment and reprisal. Cathartic ventilation is seen in positive terms: “keep let- ting it out here, it is good for you.” It is facilitated in part by the physical and psychological safety afforded by anonymity: “no one here can hurt me cause we’re anony- mous,” and in part by other users’ suspension of judg- ment: “This place is here to ask questions, I’ve never seen anyone judged for anything they’ve said here so happy to answer anything I can.” Although catharsis is encouraged, members are under no time pressure to ventilate their feelings. “When you do want to talk,” one member writes reassuringly, “there will always be someone here to listen.” In other words, within the safe space of SF, choosing if and when to speak is at the discretion of the individual; members can speak their hearts and minds when they feel the time is right. Such re- spect for other members’ agency has also been observed by Sharkey et al. in an online community for young people who self-harm (YPSH).41 In this community, members re- frain from giving direct advice and coming off as imposing via the use of mitigating devices, such as hedge phrases and tag questions (i.e. advice presented as questions). The con- ditional “when” in the above example is another such de- vice, relieving the addressee of imposition. Given suicidal individuals’ preoccupation with threats [Qualitative Research in Medicine & Healthcare 2022; 6:10437] [page 7] Article No n- co mm er cia l u se on ly to the maintenance of agency,34 the respect for SF members’ agency in the realm of emotional self-disclosure is unsur- prising. This respect for agency surfaces again in members’ view that “staying” in SF is also a choice. As one veteran user writes to a new member, “If you decide SF is not for you then I hope you find something better with a therapist, friend, or other site.” In other words, everyone is welcome to “stay” in SF, but no one is forced to stay against their will. Those who decide not to stay are wished “good luck” in their path to recovery. Since entrapment is a major pre- cursor to suicide among SF members, as I illustrated in the previous section, their respect for one another’s choice to stay or to leave is also unsurprising. Thus, a safe space nei- ther traps people in nor keeps people out. Testing new ways of being and relating As a place, cyberspace provides many uses for many users. Marciano’s typology conceives of three such uses:42 As a complementary sphere, cyberspace acts as a supple- ment to the offline world, such as teenagers’ use of social media to maintain relationships with peers after school hours. As an alternative sphere, cyberspace becomes a par- allel world of sorts, with users living out virtual identities separate from that of their offline selves. An example would be a transgender user with a biologically male body pre- senting as a cisgender female online. In the third and final model, cyberspace acts as a preliminary sphere, a place where one can safely test the waters (so to speak); for in- stance, learning and adopting new coping mechanisms on- line, with the hope of applying them successfully to offline encounters. For members of the SF community, the use of cyber- space as a preliminary sphere – a place for testing out new ways of being – is especially pertinent. Members recog- nize that SF is not the solution to all of life’s problems, but it is an important waystation in their path to recovery. For one user, it is the place where the process of opening up about suicidal thoughts and feelings began to unfold. In his/her message to a new member, s/he writes: “Keep reaching out. That’s the best before-first-step I did. And this is where it happened.” For this user, emotional self- disclosure in the presence of similar others online was an important “before-first-step” to seeking formal treatment and support offline. Several users enlist the forums as a preliminary sphere in yet another way: as a place for testing new modes of relating, for starting relationships online with the hope of continuing them offline. While this is not the avowed goal of most users, or their primary motivation for participating in the site, this premise is supported by threads in which users arrange to meet in person. In one such thread, the topic creator (TC), who lives in London, gauges the in- terest of other London-based users in meeting face-to- face. Wary of “predators” who stalk vulnerable people online and might “go looking for targets,” participants suggested a variety of protective measures. These include meeting in a public place, sending via private message the meeting time and location, and creating a password-pro- tected space within SF for those who agree to meet. Discussion Summary of findings The cultural discourse analysis of SuicideForum users’ online communication reveals a range of discursive mean- ings about place. These meanings (presented throughout as cultural premises) are captured by two overarching themes. One pertains to problematic discourses about dwelling, the other to emancipatory discourses. From SF users’ discursive point of view, a problematic relationship to place can provoke suicidality. The nature of this relationship is two-fold. On one hand is a sense of en- trapment, which can be exacerbated by relations of depend- ence within an abusive social milieu. On the other is a sense of placelessness, which may be symptomatic of a direction- less life or felt incompatibility between self and world. Whichever the case, there is a disjuncture between the place where one is (or is not), and the place one ought to be. While the relationship to place certainly influences af- fect, the converse also holds true: affect colors perception of place. The negative feeling states of suicidality can en- velop the person and extend outward, causing the world to shrink for the suicidal person. The consequence is a sense of inescapability from a world that is asphyxiating or terrifyingly lonesome. At its most extreme, acute sui- cidality can disrupt indwelling, or the sense of emplace- ment in one’s body. To seek refuge from problematic places, the suicidal person might create symbolic spaces, such as the temporal space of an idealized past, or the imagined space of the afterlife. These spaces are symptomatic of an inhospitable external world, but they may also offer glimpses into more hopeful ways of dwelling. Thus, to create symbolic spaces in which to dwell is to engage in future-forming.36 In SF users’ online communication, a folk model of what constitutes a safe space also emerges. According to this model, a safe space serves as a haven from life’s myr- iad crises, without imposing temporal limits on the fre- quency and duration of one’s stay. In this safe space, every life matters. Ideally, it is filled with empathetic others who have firsthand experience with suicidality. These others take on the dual role of giver and receiver, earnestly pay- ing forward the support they have received. One can safely ventilate one’s feelings in a safe space, without shame, fear of judgment, or reprisal. However, one’s timetable for personal self-disclosure is respected in a safe space; there is no pressure to disclose. The bound- aries of safe spaces are also permeable, respecting people’s freedom of mobility so they do not feel trapped. Lastly, one can try out new modes of being and relating in a safe space in order to better cope with the external world. [page 8] [Qualitative Research in Medicine & Healthcare 2022; 6:10437] Article No n- co mm er cia l u se on ly Research contributions In the two decades since the advent of Web 2.0, main- stream suicidology has advanced our knowledge of the relationship between internet and suicide. It has identified beneficial as well as harmful content, contexts, and uses, and the factors that predispose individuals toward such uses. However, the “psy” disciplines’ monopoly on the subject and the general lack of involvement or exclusion of other fields have caused the study of cybersuicide to retread the same steps. The “Internet” (with capital ‘I’) is conceptualized as monolithic, its effects rigidly determin- istic of human behavior, with internet users as mere con- duits of these effects. Because mainstream suicidology operates from a deficits (rather than strengths) model,18 suicidal users are seen primarily through the lens of psy- chopathology, which brackets from consideration their agency, their embodied perspectives, and the cultural con- struction of suicidal subjectivity. Without discrediting the contributions of routinized ways of seeing, the present study adds to the literature by linking the study of cybersuicide to the cultural construc- tion of meaning. Using the Communication theory and method of CuDA, I approached the users of a pro-recov- ery suicide forum as a discursive community, with shared values, beliefs, and strategies for meaning-making. I also conceived of the internet as a space rather than a mere tool, in which suicidal users jointly create meanings about their communicative worlds. Because of its strict adher- ence to an evidence-based paradigm, mainstream suici- dology has limited the discursive resources we have for addressing multifaceted social issues like suicide.43 It has also focused on static factors that are directly observable and measurable at the expense of those transient, change- able, and highly contingent factors that give suicidal peo- ple hope. This study sought to expand our discursive resources by incorporating suicidal people’s grounded perspectives – in particular, folk understandings of the role of place in the exacerbation and amelioration of sui- cidality. When listened to, participants’ own terms and meanings have much to offer existing paradigms of care, to which I now turn. Therapeutic Implications CuDA has five investigative modes which follow a weak linear design.30 In the first three modes – theoretical, descriptive, and interpretive – communicative practices are theorized and described and their meanings to partic- ipants interpreted. These three modes are essential to any culturally-based analysis. The present study engages in the theoretical mode by applying a Communication defi- nition of culture29 to a pro-recovery suicide forum, whereas the descriptive and interpretive modes are on dis- play in my presentation of research findings and cultural premises. The fourth mode, the comparative mode, com- pares two or more situated instances of an expressive ac- tivity. In the fifth and final mode, the critical mode, dominant discourses and practices are evaluated from the standpoint of local theory. A study employing CuDA can proceed without the fourth or fifth modes, though much can be gained from engaging in one or both. In this section, I engage in the critical mode of CuDA by making modest suggestions for remediating, and aug- menting, dominant treatment models using SF users’ grounded perspectives. Based on the present endeavor’s findings, at least five recommendations emerge. First, treatment providers must resist the tendency to succumb to panic with regards to the online activities of their suicidal patients. In light of spaces like Sanctioned Suicide that foster extreme views and defer the possibility of help-seeking, it is important for clinicians to warn pa- tients of the dangers posed by websites with triggering content. Having said that, the internet is not a uniformly dangerous place, and clinicians can endeavor to recreate, in the therapeutic encounter, some of the qualities that make pro-recovery forums safe spaces. Second, clinicians who adhere dogmatically to the prin- ciples of reality-testing will miss the recuperative potential of imagined spaces. Imagination is a powerful window to distant others and places – and to possible futures and lives.44 For suicidal persons, that could mean imagining a better world where one could continue living. Rather than dismiss the retreat to imagined space as mere escapism or failure in reality-testing, clinicians ought to mine these re- treats for the concrete solutions they may offer. Third, suicidal people’s negative face needs, or desire to be free from imposition,45 need to be respected. At the practical level, this could entail creating a space in which the patient’s (rather than clinician’s) timetable for fraught emotional disclosures is honored. On that note, one of the biggest impediments to help-seeking among suicidal peo- ple is the threat of involuntary admission and psychiatric coercion.46 In light of SF users’ preoccupation with en- trapment, inpatient hospitalization needs to be reconsid- ered. A discursive space in which this threat is attenuated can facilitate self-disclosure. Fourth, clinicians need to perfect the art of double lis- tening so that they can attend to the absent but implicit di- mensions of patients’ utterances.47 When people speak of pain, they are also referring (implicitly) to the salve that can alleviate that pain. When people speak of despair, they are also invoking the hope that had been crushed – and the possibility of its restoration. Thus, when a suicidal per- son speaks of being unable to function in the real world, the clinician can respond by bolstering the person’s sense of efficacy until s/he feels empowered to meet the de- mands of the external world. And lastly, the individualist – and decontextualized – perspective championed by mainstream suicidology needs to be tempered by consideration of the role of place. Se- [Qualitative Research in Medicine & Healthcare 2022; 6:10437] [page 9] Article No n- co mm er cia l u se on ly vere psychological disturbances that appear to arise from within, such as the disembodiment produced by acute sui- cidality, become more comprehensible when considered in terms of self-world relations. After all, self loss is world loss, and vice versa.48 Directions for future study The present study uncovered a range of discursive meanings about place that radiate from SuicideForum users’ online communication. Although CuDA’s five ra- diants of meaning are analytically separable, in actuality, radiants criss-cross in myriad unexpected ways.30 We see this, for example, in participants’ notions of a safe space, which are inextricably bound to meanings about self, re- cuperative action, reciprocal relations, and emotion ex- pression. In this study, I have centered the radiant of dwelling, and a previous study has attended specifically to messages about personhood (being) among suicidal in- ternet users.9 Subsequent research can foreground mean- ings about sociality (relating), emotion (feeling), and conduct (acting). Another extension of this study can en- list CuDA’s comparative mode to bring into sharp focus general and particular features of online suicide forums. One could compare and contrast SF users’ meanings about place with those radiating from other pro-recovery fo- rums, as well as pro-suicide venues like Sanctioned Sui- cide mentioned in this article’s introduction. Lastly, future extensions of this study can contribute to theorizations on liminality – by expanding our understanding of the inter- stitial space between place and placelessness, life and death, suicide and renewal. References 1. Twohey M, Dance GJX. Where the despairing log on, and learn ways to die. The New York Times [Internet]. 2021 Dec 9 [cited 2022 Feb 28]: A3. Available from: https://www.ny- times.com/interactive/2021/12/09/us/where-the-despairing- log-on.html 2. Seko Y. “Suicide machine” seekers: transgressing suicidal taboos online. Learn Inq 2008;2:181-99. 3. Baym N, Markham A. Introduction: making smart choices on shifting ground. In: Markham A, Baym N, eds. Internet inquiry: conversations about method. Thousand Oaks: SAGE; 2009. pp. vii-xix. 4. Ahmad FB, Anderson RN. The leading causes of death in the U.S. for 2020. JAMA 2021;325:1829-30. 5. Westerlund M. The production of pro-suicide content on the internet: a counter-discourse activity. New Media Soc 2011;14:764-80. 6. Ozawa-de Silva C. Too lonely to die alone: internet suicide pacts and existential suffering in Japan. Cult Med Psychiatry 2008;32:516-51. 7. Ozawa-de Silva C. Shared death: sociality and internet group suicide in Japan. Transcult Psychiatry 2010;47:392-418. 8. Recupero P. Suicide and the internet. In: Simon RI, Hales RE, eds. Textbook of suicide assessment and management. 2nd ed. Arlington: American Psychiatric Publishing; 2012. pp 515-38. 9. Stamenkovic M. In full view: cybersuicide, hypervisual self and public showcase of death (for real). Medijski Dijalozi 2011;5:73-101. 10. Alvarez M. The suicidal self in cyberspace: discursive con- structions of identity in a pro-recovery suicide forum. Front Commun 2021;6. Available from: https://www.frontiersin.org/ articles/10.3389/fcomm.2021.674893/full#B45 11. Ekman I, Söderberg S. “Across the street – not down the road”: staying alive through deliberate self-harm. In: Sher L, Vilens A, eds. Internet and suicide. Hauppauge: Nova Sci- ence Publishers; 2009. pp 221-32. 12. Murphy G. The National Suicide Prevention Lifeline and new technologies in suicide prevention: Crisis Chat and so- cial media initiatives. In Mishara BL, Kerkhof JFM, eds. Suicide prevention and new technologies: evidence based practice. London: Palgrave Macmillan; 2013. pp 111-22. 13. Mewton L, Andrews G. Cognitive behaviour therapy via the internet for depression: a useful strategy to reduce suicidal ideation. J Affec Disord 2015;170:78-84. 14. Mishara BL, Côté LP. Suicide prevention and new technolo- gies: towards evidence based practice. In: Mishara BL, Kerkhof JFM, eds. Suicide prevention and new technolo- gies: evidence based practice. London: Palgrave Macmillan; 2013. pp 1-23. 15. Quinnett P, Baker A. Web-based suicide prevention educa- tion: innovations in research, training, and practice. In: Sher L, Vilens A, eds. Internet and suicide. Hauppauge: Nova Sci- ence Publishers; 2009. pp 41-61. 16. Alvarez M. Discursive tensions and contradictions: a cultural analysis of an online self-harm forum. In: Bareiss M, ed. Communicating with, about, and through self-harm: scarred discourse. Lanham: Lexington Books; 2020. pp 113-133. 17. Mishara BL, Kerkhof JFM, eds. Suicide prevention and new technologies: evidence based practice. London: Palgrave Macmillan; 2013. 18. Sher L, Vilens A, eds. Internet and suicide. Hauppauge: Nova Science Publishers; 2009. 19. White J, Marsh I, Kral MJ, Morris J, eds. Critical suicidol- ogy: transforming suicide research and prevention for the 21st century. Vancouver: UBC Press; 2016. 20. Katz JE, Rice, RE. Social consequences of Internet use: access, involvement, and interaction. Cambridge: MIT Press; 2002. 21. Giles DC, Newbold J. ‘Is this normal?’: the role of category predicates in constructing mental illness online. JCMC 2013;18:476-90. 22. Markham A. Life online: researching real experience in vir- tual space. Walnut Creek: AltaMira Press; 1998. 23. Moores S. Media/theory: thinking about media and commu- nications. New York: Routledge; 2005. p 169. 24. Willson M. Technically together: rethinking community within techno-society. New York: Peter Lang; 2006. 25. Baym N. Personal connections in the digital age. Malden: Polity; 2010. 26. Meyers E. Dishing dirt in the digital age: celebrity gossip blogs and participatory media culture. New York: Peter Lang; 2013. 27. Hecht M. The promise of communication in large-scale, community-based research. In: Carbaugh D, Buzzanell PM, eds. Distinctive qualities in communication research. New York: Routledge; 2010. pp 53-72. [page 10] [Qualitative Research in Medicine & Healthcare 2022; 6:10437] Article No n- co mm er cia l u se on ly 28. Hymes D. Models of interaction of language and social life. In: Gumperz J, Hymes D, eds. Directions in sociolinguistics: the ethnography of communication. New York: Holt, Rine- hart & Winston; 1972. pp 35-71. 29. Tracy K, Robles JS. Everyday talk: building and reflecting identities. 2nd ed. New York: Guilford Press; 2013. p 25. 30. Carbaugh D. A communication theory of culture. In: Kurylo A, ed. Inter/cultural communication: representation and con- struction of culture. Thousand Oaks: Sage; 2012. pp 69-87. 31. Carbaugh D. Cultural discourse analysis: communication practices and intercultural encounters. J Intercult Commun Res 2007;36:167-82. 32. Philipsen G. The prospect for cultural communication. In: Kincaid DL, ed. Communication theory: Eastern and West- ern perspectives. Thousand Oaks: SAGE; 1987. pp 245-54. 33. Carbaugh D, Gibson T, Milburn T. A view of communication and culture: scenes in an ethnic cultural center and a private college. In: Kovacic B, ed. Emerging theories of human com- munication. Albany: SUNY Press; 1997. pp 1-24. 34. Scollo M, Milburn T, eds. Engaging and transforming global communication through cultural discourse analysis: a tribute to Donal Carbaugh. Lanham: Fairleigh Dickinson Univer- sity Press; 2019. 35. Flanigan J, Alvarez M. Cultural discourse analysis as critical analysis: a view from Twin Oaks and SuicideForum.com. In: Scollo M, Milburn T, eds. Engaging and transforming global communication through cultural discourse analysis: a tribute to Donal Carbaugh. Lanham: Fairleigh Dickinson University Press; 2019. pp 73-90. 36. Stern SR. Encountering distressing information in online re- search: a consideration of legal and ethical responsibilities. New Media Soc 2003;5:249-66. 37. Gergen, K. From mirroring to world-making: research as fu- ture forming. J Theory Soc Behav 2014;45:287-310. 38. Scherr S, Haim M, Arendt F. Equal access to online infor- mation? Google’s suicide-prevention disparities may am- plify a global digital divide. New Media Soc 2019;21: 562-82. 39. Smithson J, Sharkey S, Hewis E, et al. Problem presentation and responses on an online forum for young people who self-harm. Discourse Stud 2011;13:487-501. 40. Sender K. The makeover: reality television and reflexive au- diences. New York: NYU Press; 2012. p 115. 41. Sharkey S, Smithson J, Hewis E, et al. Supportive inter- changes and face-work as ‘protective talk’ in an online self- harm support forum. Commun Med 2012;9:71-82. 42. Marciano A. Living the VirtuReal: negotiating transgender identity in cyberspace. JCMC 2014;19:824-38. 43. Marsh I. Critiquing contemporary suicidology. In: White J, Marsh I, Kral MJ, Morris J, eds. Critical suicidology: trans- forming suicide research and prevention for the 21st century. Vancouver: UBC Press; 2016. pp 15-30. 44. Orgad S. Media representation and the global imagination. Malden: Polity; 2012. 45. Goffman E. On face-work. In: Interaction ritual: an analysis of ritual elements in social interaction. Garden City: Dou- bleday; 1967. pp 5-45. 46. Whitaker R. Mad in America: bad science, bad medicine, and the enduring mistreatment of the mentally ill. 2nd ed. New York: Basic; 2010. 47. Hedtke L, Winslade J. The crafting of grief: constructing aesthetic responses to loss. New York: Routledge; 2017. 48. Atwood GE. The abyss of madness. New York: Routledge; 2012. [Qualitative Research in Medicine & Healthcare 2022; 6:10437] [page 11] Article No n- co mm er cia l u se on ly