Acad Psychiatry 32:136-142, March-April
doi: 10.1176/appi.ap.32.2.136
© 2008 Academic Psychiatry
Suicide and Stigma: A Review of the Literature and Personal Reflections
Howard Sudak, M.D.,
Karen Maxim, M.S., R.N. and
Maryellen Carpenter
Received August 9, 2006; revised January 15 and February 5, 2007; accepted February 16, 2007. Dr. Sudak is affiliated with the Department of Psychiatry at University of Pennsylvania in Philadelphia. Dr. Maxim is affiliated with the Department of Nursing at the University of Medicine and Dentistry of New Jersey. Address correspondence to Howard Sudak, M.D., University of Pennsylvania, Psychiatry, 401 S. Second St., Suite 402, Philadelphia, PA 19147-1612; hsudak{at}afsp.org (e-mail).
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ABSTRACT
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OBJECTIVE: The authors aim to educate mental health practitioners and trainees regarding the issues of stigma and suicide and how stigma impacts this diverse population of suicide attempters, completers, their families, friends, therapists, and others both personally and therapeutically. METHODS: The authors draw upon their own experiences as survivors and review pertinent literature illustrating the history and general impacts of this stigmatization. The authors present suggestions to diminish stigma both for survivors and the general public. RESULTS: Although there appears to have been some diminution in the stigmatization of the mentally ill over the past few decades, there appears to be less diminution in the stigma associated with suicide and suicide-survivorship. CONCLUSION: Mental illness, in general, has become less stigmatized in recent years, but suicide remains nearly as stigmatized as ever.
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INTRODUCTION
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Suicide is a major public health problem, accounting for approximately 30,000 deaths annually in the U.S. (compared to 20,000 for homicides). In older adolescents and young adults it is the second leading cause of death! In this article, the authors specifically address the intense stigma associated with suicide attempts, completions, and being the family, close friend, or therapist of someone who has attempted or completed suicide.
The article is written from three perspectives: those of a psychiatrist/ "suicidologist," another from an experienced therapist who specializes in treating individuals and families bereaved by suicide, and the third from a layperson with long experience organizing and conducting survivors of suicide support groups. Concluding each of their sections are their personal experiences regarding stigma following the suicidal losses in their own lives. An addendum lists resources which may be useful for therapists to provide to their bereaved patients.
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Methods
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Medlines, Ovid, PsycINFO, and other online search engines were reviewed for the last 50 years for relevant articles pertaining to suicide and stigma.
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Results
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Although the word "stigma" indicates something negative or shameful, stigma may also be useful—for instance, stigmatizing smoking helped decrease it. As David Shaffer (personal communication, 2004) has pointed out, "we need to destigmatize mental illness and its treatment...but we do not want to destigmatize suicide and suicide attempts." Shaffer and others (1, 2) have also shown that one of the harmful effects resulting from inappropriate media accounts of suicidal behavior is that they may normalize it and make it appear more reasonable
Over the past 50 years or so, there have been clear reductions in the amount of stigma associated with certain physical illness. Cancer, tuberculosis and "brain illnesses" such as epilepsy and multiple sclerosis are more acceptable. "Mental illness," however, remains stigmatized as apart from brain illnesses and the downward slope of its destigmatization curve appears less steep than for "physical illnesses." Link (3) reported on a study that he and Bernice Pescosolido carried out in 1996, comparing their findings to a 1950 study by Shirley Star. Both studies gave clinical vignettes to representative samples and asked how they felt about the situations (e.g., did they think the persons were mentally ill; were the symptoms due to bad character, chemical imbalances, stress, etc.?). By 1996, people were much more likely to see the vignettes as mental illness rather than bad character.
In addition to stigma, another nearly inevitable legacy of suicide is guilt. This survivors’ guilt compounds and reinforces the stigma either imagined (because of the bereaved’s sense of guilt) or accurately perceived by bereaved friends, family, and therapists. In addition, as A. Salvatore, of the Montgomery County Emergency Services, states (in an unpublished brochure for Survivors of Loved One’s Suicide, 1998), there are entire populations of bereaved individuals who are "marginalized" when it comes to receiving support after a suicidal loss. These marginalized or disenfranchised individuals include common-law spouses, gay and lesbian partners, estranged or divorced spouses, friends of young suicide decedents, and prison inmates.
Suicide attempters may be especially stigmatized, not only dismissed as "merely attention-seeking gesturers," but unable to find survivor-support groups akin to those that friends and families of completed suicides avail themselves of. Attempters technically are also "survivors of suicide" but "survivors of suicide" has come to refer to the family and friends of those who complete suicide, and this latter definition is the one referred to in this article.
Therapists who have lost patients to suicide represent yet another disenfranchised group. They are rarely involved in therapist SOS (Survivors of Suicide) groups and, according to Hendin et al. (4), "institutional responses and case reviews from their institutions for them are rarely helpful, offering either blame or false reassurance that the suicide was inevitable." A notable exception to this policy is the Support Group for Therapists at the University of Medicine and Dentistry in Piscataway, NJ, which was started in 1982 (5).
Are families bereaved by suicide more stigmatized than those bereaved by other causes? Are suicide bereavements harder to bear than those from other deaths? Although there is a sizable literature on stigma (6–8) because of the dearth of evidence-based studies, neither question has been definitively resolved. Kjell Rudestam (9) studied survivors’ perceptions of others’ responses to them and noted that approximately half of his respondents declined to talk with friends and acquaintances about the nature of the death and nearly one third occasionally lied about the cause of death. In a later study, with Imbroll (10), Rudestam looked at public perceptions of survivors of fictitious suicidal and nonsuicidal vignettes of childhood deaths. They found suicidal vignettes more likely to result in parents being blamed and the children viewed as emotionally ill.
Bereavements resulting from suicide may or may not be more difficult than other bereavements. Hauser (11) believes such deaths "carry with them the almost certain likelihood of disturbances in the grief process," citing Calhoun’s (12) generalizations differentiating suicidal grief from other grief: more guilt, more searching for an understanding of what caused the death, and receiving less support. Range (13) also believes these bereavements are uniquely difficult for similar reasons. Pfeffer (14) showed that suicidally bereaved children were more likely to have depressive symptoms (e.g., negative mood, interpersonal problems, anhedonia) than children bereaved by nonsuicidal deaths. Nancy Webb (15) studied children bereaved by a mother’s suicide, stating that "few forms of bereavement present more challenges than that of intervention with a child who has lost a parent to suicide."
Stigma as it Relates to First Author’s Suicidal Bereavement
My survivor status resulted from the suicide of my wife approximately 12 years ago. I belong to the category of the marginalized or disenfranchised survivor since my wife and I were separated, living in different cities, and in the process of divorce when she died. After her death, many of my old friends turned away from me or were noticeably aloof. I felt (and feel) enormous guilt—despite knowing better intellectually. I felt stigmatized (but that may well have been a projection). My relationship to my children, not surprisingly, became much more conflicted than before the separation and the death. I continued my professional interest and activities in suicide and spoke at many survivor’s meetings—but never participated openly as a survivor until Mary Ellen Carpenter encouraged me to attend a group in the role of bereaved person, not a therapist. I found it a relief to be in such a group and partake by opening-up. I have attended some sessions since with similar positive feelings about the experience. At one survivor’s meeting, my current wife asked for a survivor’s ribbon too, since she is also a marginalized survivor—albeit once-removed, a survivor, and also stigmatized.
Recommendations for Helping Families in the Aftermath of Suicide (KM)
In the past 26 years I have worked with a large population of survivor families as they struggled to survive the suicide death of a loved one. I have concluded that the majority of survivors are remarkably resilient.
In 1992 William Worden (16) identified four specific tasks necessary to facilitate healing after losing a loved one:
1. to accept the reality of the loss
2. to work through the pain of the grief
3. to adjust to an environment in which the deceased is missing
4. to emotionally relocate the deceased and move on with life
Many survivors benefit from family, couples, or individual therapy to facilitate their grief. Survivor support groups often provide a path to treatment since seeking counseling is normalized in the group. It is also here that the newly bereaved learn that what they are experiencing is normal and expected. Attending these groups can provide hope because in the groups, they witness the recovery of other survivors who are "further down the road." Perhaps it is the accomplishment of the fourth task that has prompted so many survivors to step forward in order to raise public awareness and funds for suicide research and prevention efforts.
There are predictable emotional reactions experienced by most survivors. These include, shock, denial, a search for the "why," anger, guilt, and anxiety. These reactions can be intensified relative to the amount of stigma the survivor is experiencing. Being mindful of the unique way the sense of stigma intertwines with these reactions can enhance the clinicians’ ability to facilitate a positive outcome.
"Postvention," a term coined by Schneidman (17) for interventions with survivors following a suicide, work has taught me that timely intervention is crucial and a family psychoeducational model provides the best vehicle for this intervention (18).
Although families initially experience grief and shock, they often benefit from an expert’s explanation of the "why of suicide" and the links between suicide and mental illness. We know that 90% of those who die by suicide have a mental illness (19). However, most people with mental illness do not kill themselves. We are learning to better define risk and protective factors. Families with concerns about genetic predispositions to suicide may be relieved to learn that in 87% of identical twinships where one twin has died by suicide, the co-twin does not (20), and that factors such as the absence of alcohol and substance abuse, proper treatment, and a supportive family may be protective. Educating the public about suicide and depression should decrease stigma in general, and providing survivors with such information should decrease internalized stigma, and may also prevent other adverse effects such as blaming other family members, institutions, or treating clinicians for the death.
Helping Parents
Parents who have lost a child to suicide have often been blamed and stigmatized. This scapegoating is similar to the blame formerly placed on parents whose children had autism or schizophrenia. Now, with better understanding of the biological factors associated with such illnesses, parents are blamed less.
Shock is a common reaction experienced by the bereaved immediately after a sudden and traumatic death. After a suicide, this is often accompanied by denial. Individuals refusing to believe that the death was a suicide are often reacting to real or perceived stigma. In the past, some survivors went to great lengths to hide the fact that their loved one died by suicide.
Helping Spouses
Surviving husbands and wives have often been blamed in the suicide death of their spouses. Josephine Pesaresi, a social worker whose psychiatrist husband took his life in 1978, reports that after his death, people suggested she and her children move from their hometown to hide this "shameful" history. The daughter of Supreme Court Justice, Hugo Black, she had the means to do so. Instead, she stayed in Hackensack, N.J., and started one of the first support groups in the nation. She said: "My husband spent his life helping the mentally ill. I am not ashamed that he had a sickness that was like cancer which could not be cured" (21).
Helping Children
Margo Requarth (22), a family psychotherapist, was 4 years old at the time of her mother’s death. She did not learn the true cause of the death until she was 18. She stated she was shocked, hurt, and angered by this revelation. "Because of the stigma of suicide and the needs of the adults in my circle to protect me (and ultimately, themselves) no one ever talked about my mother. That is the part of her death other the fact that she killed herself, that has impacted me the most. I never really knew who she was."
Margo’s experience was not unlike other adults who had lost a parent to suicide. Adults have told us that they learned the truth about a suicide death of a parent from young cousins or from peers on the school playground. (Jane Fonda learned about her mother’s suicidal death in a movie magazine). It is impossible to guarantee that such a secret will not be revealed. Consequently, I believe that children need to be told the truth in a way that is honest and straightforward from the beginning. Clinicians can help parents accomplish this with careful coaching and support. One young father was to tell his children: "Mommy had something like a heart attack except it was a ‘brain attack.’ Some sickness came over her brain and made her thinking mixed-up when she ended her life." Telling children the truth in the presence of loving family members is crucial to their development of trust.
Focus of Clinical Intervention Following a Death by Suicide
Clinicians called upon to work with survivor families after a loss to suicide need to be able to provide guidance and support to them, particularly in the early days and weeks after their loss. A successful intervention at this point should focus on the following seven points:
1. Help the family normalize the mourning process. Encourage them to practice the family’s typical burial rituals and discourage them from doing things that are different from their family’s traditions.
2. Help the family respect the individual grieving styles of its members. Remind them that all people grieve differently and at different paces.
3. Connect the family to other people who have had a loss through suicide. Provide information about support groups as an adjunct to therapy.
4. Encourage the family to break through the silence which often surrounds death by suicide. Suggest that they bring up their loved one in conversations with others.
5. Assist the family to plan ahead for important milestones such as anniversaries, birthdays of the deceased, and for holiday traditions.
6. Provide and encourage education about suicide and its aftermath through reading, the Internet, and accessing the resources of national organizations.
7. Help the family become aware of activities which have helped other survivors such as art, writing, advocacy, fundraising, leading support groups, etc.
Stigma as it Relates to the Second Author’s Bereavement
In 1972, shortly after his sixteenth birthday, my youngest brother, Tim, took his life. At the time of Tim’s death, I was 33 years old and the mother of two young daughters. I was on the faculty of a School of Nursing teaching public health. I remember experiencing a sense of shame about his death. The entire student body knew about it and I perceived that now they thought less of me as an instructor. I was grateful that we were moving to another city.
After the move and obtaining my graduate degree in Advanced Psychiatric Nursing, I started my first position as a clinician in a community mental health center. I made a conscious effort to keep the manner of my brother’s death a secret. I remember thinking that if my colleagues knew the truth, they would assume that I came from a very dysfunctional family and that my competence as a clinician would be called into question; "How could I help others when I could not save my own brother?"
The following year, my family therapy supervisor noticed that I was having difficulty dealing with suicidal adolescents. That is when I told her the "secret." At the time she knew of several other clinicians who had lost family members to suicide and were secretive about it. She put us into a group. Thus started our unofficial "support" group. We formed a task force to review literature on how families react after a suicide.
This supervisor then encouraged us to speak about our experiences at a conference she was planning. Norman Paul was to be the keynote speaker. He was a well known family therapist who was going to be talking about researching his own family history in which he found a murder and a suicide. I remember that coming out about my suicide loss in this very public way caused me several sleepless nights. However, what was so extraordinary was all the clinicians who came up to us afterward to tell us about the "secret" suicide in their own families. We felt as though the silence had been broken.
Fortunately for me, writing and talking about my brother’s suicide has been my path to healing. It is also been important for me to be involved in suicide prevention efforts through the American Foundation for Suicide Prevention and the American Association of Suicidology. Perhaps what sums it up the best are the words written around my brother’s picture on the New Jersey Lifesavers Quilt:
"In Our Dedication to Finding a Cure for Mental illness We Will Remember You."
History of Survivors of Suicide (MC)
Survivors of Suicide, Inc. (SOS) is a volunteer nonprofit organization with the primary goal of offering support to individuals and families suffering from the trauma of losing someone to suicide. SOS is governed by a Board of Directors made up of individuals who have personally experienced a suicide loss. Individual donations, occasional small grants, and in-kind contributions support SOS’s activities. It is not clear when and where the first SOS chapters began. In the Philadelphia area, SOS began in 1983. Two women who experienced a suicide in their families and were independently looking for other individuals who suffered this tragedy connected through the Self-Help Clearing House. They met, shared their stories, advertised, and found many survivors who were alone in their grief. Support for victims of a suicide death was virtually nonexistent in their communities. They decided to start a support group in the communities where they lived. Over the next few years the silence surrounding suicide started to diminish and the need for survivors to share their loss escalated.
SOS believes that the sharing of grief experiences and feelings is the best form of help. SOS feels that those who suffer a suicidal loss can help others comprehend the incomprehensible. SOS is built upon mutual self-help—the process of helping yourself through helping others. The main contribution of SOS is to provide a "safe" place for suicide survivors. SOS is the only place where those new to suicide loss are able to feel normal. While community and religious attitudes about suicide have improved, suicide survivors are still left to cope on their own with a loss for which none are prepared. Being a member of an SOS support group facilitates this process and provides a sense of belonging and acceptance. Participation is empowering and enhances self-esteem and coping ability.
Suicide loss is different than the "normal loss" of a loved one. According to Salvatore (23), it is the most severe loss that anyone can suffer. It is sudden, unexpected, and often violent. The grief it causes is intense and prolonged. Suicide survivors feel responsible for their loss. Those who witness the suicide or find the body may suffer post traumatic stress. Survivors of suicide may feel anger toward the victim, themselves, or others. They may become depressed and are at increased risk of themselves becoming suicidal. SOS groups help survivors realize that the intense emotions they are feeling are normal, they gain knowledge about suicide and depression, and they gain insight into their loss.
In most large U.S. cities, there are now more opportunities than 20 years ago for survivors to reach out for help. Survivors of Suicide (SOS) offers support groups once a month in eight locations in Philadelphia’s surrounding counties. There are surviving suicide conferences twice a year, a quarterly newsletter, yearly walk/runs, yearly candlelight ceremony and the Lifekeeper quilts that put a face on suicide.
Stigma as it Relates to the Third Author’s Bereavement
My son Chris took his life 20 years ago. His method was a bottle of vodka and 17 narcotic pills. He left a note. Chris was 26, married, and the father of two small girls. Chris was diagnosed as an alcoholic at age 21. He had been in rehab clinics three times over that period of 5 years. Chris tried very hard to conquer his disease but to no avail. The last time he crashed was at the death of his father 2 years previous to his own death. My husband had his first heart attack at age 41 with subsequent triple bypass surgery twice in 7 years. After his father’s second open-heart surgery, Chris stayed sober, met his wife, had two girls and managed to get an Associate’s Degree in Computer Science. He had finally accomplished something and did it without alcohol. The morning after his graduation, his father, who was now into congestive heart failure, died in Chris’s apartment and Chris could not save him. The next 2 years were episodes of heavy drinking and the loss of one job after another. The note he left stated that life was too hard for him and he could not make it. He loved us and believed we would be better off without him.
My first reaction was not anger or guilt but an overwhelming sadness. I was so sad that Chris could not stay here. That living was too painful for him. When the guilt came, I felt like a failure as a parent. Was my love not enough to keep him here? I still had four young children living at home—would they do the same thing as Chris?
Eight months after Chris died I knew I was in trouble. There was nobody to talk to who understood what I was going through. Also, at that time the stigma accompanying suicide loss was greater than it is today. Friends told me not to say he took his life; it was not a good thing that he "committed suicide." My priest said, "I do not want to hear how he died." Friends thought it best not to mention his name because I might cry again, and I experienced silence from my neighbors. When I did mention suicide, people could not make eye contact with me. Eventually I went to a different bank, food store, gas station, etc., so I would not be recognized as the mother of a young man who took his life.
There were no support groups for suicide loss in my area. I finally found one in Philadelphia but my energy level was so low I did not want to travel into Philadelphia. I started to spend hours on the phone with the facilitator of the group and she finally encouraged me to start a group at my local hospital which had a Crisis Unit. I was also trying to earn college credits at that time and one of my nursing professors took me under her wing. She introduced me to the right people in the hospital. The Director of the Department of Psychiatry helped me start the group. She left me alone from the beginning because she felt we, as survivors, needed to be together to share our stories and help one another.
I now know that starting the support group was the catalyst that began my healing journey. I had this terrible pain in my soul—an open wound that would not heal. Survivors helped to knit the wound together again. I learned how much helping other people helped me. I am a different person today. My grief has changed shape. My pain and sadness have transformed to the good memories of Chris. My appreciation of life came through my loss. Life is worthwhile and so precious.
Our three personal vignettes are all different and all the same. The newly bereaved survivor is convinced that his or her overwhelming grief will never abate. Although it never vanishes altogether, with time and help it will decrease enough to make life feel worthwhile, even joyous, again.
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This article has been cited by other articles:
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C. I. Ping Tsao, A. Tummala, and L. W. Roberts
Stigma in Mental Health Care
Acad Psychiatry,
April 1, 2008;
32(2):
70 - 72.
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ABSTRACT
INTRODUCTION
