Stigmatizing Suicide and Its Possible Effects on Adolescent Suicide Survivors
Caroline Abbott
When I was 14 years old, my best friend died by suicide. It turned my life, and my friends’ lives, completely upside down. Five years later, we found ourselves in a similar position when two more friends died by suicide within two weeks of each other. We encountered stigmatizing comments made by others, stigmatizing thoughts we ourselves had, guilt, anger, and many unanswerable questions. These additional factors, characteristic of the bereavement of suicide, made the grieving process even more difficult. The stigma surrounding suicide can further complicate the bereavement process of suicide survivors and make an already painful experience more confusing and difficult. This paper seeks to enhance our understanding of the stigma surrounding suicide and how it can impact peer survivors. Although not formal research, this paper reviews the relevant professional literature and presents an investigation of how members of my friendship network experienced the stigmatization of suicide and coped with the death of their friends.
Suicide is the 11th leading cause of death in the United States and accounts for 1.4% of all American deaths (National Center for Injury Prevention and Control, 2008). Adolescents and young adults are at a heightened risk for suicidality with suicide consistently being the second or third leading cause of death among adolescents ages 13 to 18 years old (Bondora & Goodwin, 2005). Adolescent suicide is a common topic in the academic literature and research because it is a persistent problem; suicide rates in the adolescent population have been increasing faster than in any other age group (Johnson, Krug, & Potter, 2000). However, there has been little research on adolescent peer survivors of suicide despite the evidence that “an adolescent suicide may trigger a cluster of subsequent suicides among peers” (Bondora & Goodwin, 2005, p. 6). Stigma and Suicide in the Academic Literature
The first question considered in the literature review was if the bereavement of suicide is different than that of loss by other causes of death. The research overwhelmingly reported that although the grief process overlaps and there are common themes in this process regardless of type of death, grieving a loss by suicide is “further complicated by the societal perception that the act of suicide is a failure by the victim and the family to deal with some emotional issue and ultimately society affixes blame for the loss on the survivors. This individual or societal stigma introduces a unique stress on the bereavement process” (Cvinar, 2005, p. 14). Because of this, suicide survivors feel more blamed and avoided (Ness & Pfeffer, 1990), are viewed more negatively by themselves and others (Jordan, 2001), and experience “more estrangement, anger, and conflict and less openness, support and concern for each other “ than do those bereaved by different forms of death (Nelson & Franz, 1996, p. 142). According to Harvey (1998), stigma, blame, search for meaning, and being misunderstood are four specific bereavement experiences that are unique to suicide survivors.
In his book, Myths about Suicide, Thomas Joiner includes his own theories of suicide that help reduce some of the stigma, especially the myth that it is an act of cowardice and that it is selfish. His first point is that humans’ physiology generally protects them from injury and tries to prevent death. He uses this to make the point that suicide is not an act of cowardice, as a person must go against his/her biological tenants to die by suicide. Joiner explains people’s ability to die by suicide through habituation to the idea of pain and death. One example of this habituation and desensitization is self injury or cutting. Joiner also believes that people who want to die have a “perceived sense of burdensomeness” and a “sense of low belongingness” (Joiner, 2010, p. 7). Joiner’s analysis challenges the misconception that suicide is selfish. Rather, people who die by suicide sincerely believe that their loved ones and the world would be better without them (Joiner, 2010). Joiner argues that our existing stigmatizing attitudes are truly “myths” and are not rooted in truth and understanding.
Although attitudes toward, compassion for, and acceptance of suicide as an act and as a right vary from culture to culture, in the United States, the attitude toward suicide is one of disapproval. The Catholic Church has deemed suicide a sin, and until 1961, suicide was a crime in the U.S. (Sayers, 1949; Suicide Act 1961, 2011). Although it is a common opinion in America that suicide is not a good or rational decision, saying it is sinful makes the victim a sinner. Similarly, saying suicide is illegal makes the victim a criminal. This stigma makes the victim seem bad instead of making the decision alone seem bad. It could be argued that the disapproving stigma could serve to prevent suicide. However, stigmatizing suicide may cause suicidal individuals to feel even worse about themselves and may prevent them from disclosing and seeking help. The stigma is also harmful for the survivors who have lost a loved one to suicide because the stigmatization of suicide can make an already painful experience even harder (Lukas & Seiden, 2007).
Thomas Joiner’s book, Myths about Suicide, lists harmful and stigmatizing common misconceptions about suicide. These myths create stigma toward those who have died by suicide. Joiner’s most harmful myths include suicide is an easy escape, suicide is an act of anger, suicide is selfish, we can’t stop people who want to die by suicide, and suicide is just a cry for help. Another harmful belief about suicide is that it is a sin. In Dante’s Inferno, people who die by suicide are contained in the 7th circle of hell along with those who commit murder, sodomy, and blasphemy (Sayers, 1949). Although it is arguably not harmful to deem suicide a poor decision, saying that suicide is a sin means that those who die by suicide are sinners and are therefore bad. Again, this view can make the individual seem bad instead of making the decision seem bad. The belief that those who die by suicide go to hell makes the grieving process much more difficult, especially for people who are religious and find comfort in thinking that their lost loved ones are in a better place. Stigmatizing myths about suicide can be harmful for the many people who have been affected by suicide personally and interpersonally.
Current Investigation
To examine how the stigmatizations affect peers of those who have died by suicide, I enlisted friends from home who had experienced the death of multiple friends by suicide. In order to understand how these people have felt the stigma, I administered a personal and informal email survey to 23 of my friends (seven men and 16 women) wanted to participate. All questions were optional in order to reduce pressure to answer uncomfortable or emotionally stirring questions. Questions included, “How many friends have you voluntarily told about your friend having passed away?” and “Have you ever witnessed examples of stigma relating to the death of your friends?” The four major themes related to stigma that came from the replies were fear of stigma from others, guilt (self stigma), anger toward the deceased, and blame of others. As a convenience sample of friend networks, it is important to note that this is not a formal study that is representative of all people who experienced these suicides or people who experienced other suicides. Rather, this investigation is about a single case study and one group of friends. It is useful as an exploratory investigation of the possible effects of stigma and of exposure to suicide in adolescent peers.
Fear of stigma from others was a primary focus of the survey. Fifty percent of the people who answered the survey said they were worried others would think less of the person who died or would think less of them as a friend. Sixty six percent said they get nervous when someone asks them how their friend(s) died, and 33.3% even said they have felt ashamed or embarrassed when talking about the suicide(s). Some comments that I collected from open-ended questions were “I feel like they judge our town and my sense of picking friends,” “many people think it is very selfish,” “people judge them, they don’t deserve it,” and “people lose respect for them.” Two people included specific stories of disclosing about the suicides and the reactions they received were that suicide is “the biggest sin you can commit, how selfish and cowardly it is” and “if it were [my] son, [I’d] be pissed at the kid for being such a ‘pussy.’” Unfortunately, this fear of stigmatizing reactions from others can lead to unwillingness to disclose and talk about what happened. Sixty percent of the survey participants said that they have only told a few of their new friends that they have lost friends to suicide. Sixty-two percent said they never or rarely voluntarily include the fact that it was suicide. Their comments included, “I don’t bring it up,” “I avoid the subject altogether,” “I avoid the fact that it was suicide,” “I change the subject,” “I beat around the question,” and “I don’t ever talk about them.” This is obviously problematic and harmful for the bereaved because by choosing to not disclose their grief, they are missing out on the social support that can be so helpful for the grieving process.
Another emphasis revealed in the survey responses was guilt and self stigma. Eight-five percent said they have felt guilty about the deaths, and the comments on this topic were overwhelming. People said “I wish I had reached out, I regret it every day,” “I could have saved him,” “I could have helped him,” “I could have done something,” “I should have said something,” “if I had called him things would have been different,” “I should have known,” and “I should have been more aware”. An interesting finding was that 81% of people who admitted knowing ahead of time that the first friend to die by suicide was struggling emotionally didn’t take it seriously at the time, 43.8% of people who knew something was wrong with the second friend who died by suicide didn’t take it seriously at the time, and 50% of people who knew something was wrong with the third friend didn’t take it seriously at the time. Even after having lost two friends to suicide, 50% of the people still did not take the warning signs seriously. This pattern demonstrates how hard it is to recognize the warning signs, how hard it is to understand what a suicidal friend is going through, and some of the difficult emotions that adolescent suicide survivors may feel when grieving.
Anger and stigma toward the deceased is also a common response during the bereavement period. Seventy-two percent of the people who chose to answer this question said they have been mad at at least one of the three friends who died by suicide at one point. People said “they knew how many people would suffer from this,” “to take his own life was selfish,” and “it was selfish of him to leave all of us behind and hurt.” In this case, suicide survivors can fall prey to the stigmatizing myth that suicide is selfish. Another related theme was stigma, blame, and anger toward others. Sixty-one percent said they have been mad at other friends, 69% said they have been mad at health professionals involved, and 77.7% said they have been mad at the victim’s family. Many of the friends blamed other friends, family, and mental health professionals for not doing enough to help their suicidal friends. Blame can be detrimental for bereaving suicide because it creates hurt feelings, anger, and guilt within an effected social group. These intense emotions can create problems within the social group and diminish the social support that is so important to grieving. Blame tends to move around from blaming oneself, one’s friends, and those close to the person who has died. Understanding the precipitants of suicide and how to intercede will lessen the stigma.
However, destigmatizing suicide is not always viewed as a good idea. Some believe that “we do not want to destigmatize suicide and suicide attempts” (Shaffer, 2004 as cited in Sudak, Maxim, & Carpenter, 2008, p. 136) because we do not want to “normalize it and make it appear more reasonable” (Sudak, Maxim, & Carpenter, 2008, p. 136). This approach is seen as being helpful in preventing suicides, but leaving this stigma intact can be harmful for people who are contemplating suicide, have attempted suicide in the past, or are bereaving suicide currently. We do not want to make suicide seem like a healthy choice, but we also need to be more understanding about what leads a person to do this and how our understanding and compassion could not only help prevent future suicides, but also help those who are currently grieving.
References
Suicide is the 11th leading cause of death in the United States and accounts for 1.4% of all American deaths (National Center for Injury Prevention and Control, 2008). Adolescents and young adults are at a heightened risk for suicidality with suicide consistently being the second or third leading cause of death among adolescents ages 13 to 18 years old (Bondora & Goodwin, 2005). Adolescent suicide is a common topic in the academic literature and research because it is a persistent problem; suicide rates in the adolescent population have been increasing faster than in any other age group (Johnson, Krug, & Potter, 2000). However, there has been little research on adolescent peer survivors of suicide despite the evidence that “an adolescent suicide may trigger a cluster of subsequent suicides among peers” (Bondora & Goodwin, 2005, p. 6). Stigma and Suicide in the Academic Literature
The first question considered in the literature review was if the bereavement of suicide is different than that of loss by other causes of death. The research overwhelmingly reported that although the grief process overlaps and there are common themes in this process regardless of type of death, grieving a loss by suicide is “further complicated by the societal perception that the act of suicide is a failure by the victim and the family to deal with some emotional issue and ultimately society affixes blame for the loss on the survivors. This individual or societal stigma introduces a unique stress on the bereavement process” (Cvinar, 2005, p. 14). Because of this, suicide survivors feel more blamed and avoided (Ness & Pfeffer, 1990), are viewed more negatively by themselves and others (Jordan, 2001), and experience “more estrangement, anger, and conflict and less openness, support and concern for each other “ than do those bereaved by different forms of death (Nelson & Franz, 1996, p. 142). According to Harvey (1998), stigma, blame, search for meaning, and being misunderstood are four specific bereavement experiences that are unique to suicide survivors.
In his book, Myths about Suicide, Thomas Joiner includes his own theories of suicide that help reduce some of the stigma, especially the myth that it is an act of cowardice and that it is selfish. His first point is that humans’ physiology generally protects them from injury and tries to prevent death. He uses this to make the point that suicide is not an act of cowardice, as a person must go against his/her biological tenants to die by suicide. Joiner explains people’s ability to die by suicide through habituation to the idea of pain and death. One example of this habituation and desensitization is self injury or cutting. Joiner also believes that people who want to die have a “perceived sense of burdensomeness” and a “sense of low belongingness” (Joiner, 2010, p. 7). Joiner’s analysis challenges the misconception that suicide is selfish. Rather, people who die by suicide sincerely believe that their loved ones and the world would be better without them (Joiner, 2010). Joiner argues that our existing stigmatizing attitudes are truly “myths” and are not rooted in truth and understanding.
Although attitudes toward, compassion for, and acceptance of suicide as an act and as a right vary from culture to culture, in the United States, the attitude toward suicide is one of disapproval. The Catholic Church has deemed suicide a sin, and until 1961, suicide was a crime in the U.S. (Sayers, 1949; Suicide Act 1961, 2011). Although it is a common opinion in America that suicide is not a good or rational decision, saying it is sinful makes the victim a sinner. Similarly, saying suicide is illegal makes the victim a criminal. This stigma makes the victim seem bad instead of making the decision alone seem bad. It could be argued that the disapproving stigma could serve to prevent suicide. However, stigmatizing suicide may cause suicidal individuals to feel even worse about themselves and may prevent them from disclosing and seeking help. The stigma is also harmful for the survivors who have lost a loved one to suicide because the stigmatization of suicide can make an already painful experience even harder (Lukas & Seiden, 2007).
Thomas Joiner’s book, Myths about Suicide, lists harmful and stigmatizing common misconceptions about suicide. These myths create stigma toward those who have died by suicide. Joiner’s most harmful myths include suicide is an easy escape, suicide is an act of anger, suicide is selfish, we can’t stop people who want to die by suicide, and suicide is just a cry for help. Another harmful belief about suicide is that it is a sin. In Dante’s Inferno, people who die by suicide are contained in the 7th circle of hell along with those who commit murder, sodomy, and blasphemy (Sayers, 1949). Although it is arguably not harmful to deem suicide a poor decision, saying that suicide is a sin means that those who die by suicide are sinners and are therefore bad. Again, this view can make the individual seem bad instead of making the decision seem bad. The belief that those who die by suicide go to hell makes the grieving process much more difficult, especially for people who are religious and find comfort in thinking that their lost loved ones are in a better place. Stigmatizing myths about suicide can be harmful for the many people who have been affected by suicide personally and interpersonally.
Current Investigation
To examine how the stigmatizations affect peers of those who have died by suicide, I enlisted friends from home who had experienced the death of multiple friends by suicide. In order to understand how these people have felt the stigma, I administered a personal and informal email survey to 23 of my friends (seven men and 16 women) wanted to participate. All questions were optional in order to reduce pressure to answer uncomfortable or emotionally stirring questions. Questions included, “How many friends have you voluntarily told about your friend having passed away?” and “Have you ever witnessed examples of stigma relating to the death of your friends?” The four major themes related to stigma that came from the replies were fear of stigma from others, guilt (self stigma), anger toward the deceased, and blame of others. As a convenience sample of friend networks, it is important to note that this is not a formal study that is representative of all people who experienced these suicides or people who experienced other suicides. Rather, this investigation is about a single case study and one group of friends. It is useful as an exploratory investigation of the possible effects of stigma and of exposure to suicide in adolescent peers.
Fear of stigma from others was a primary focus of the survey. Fifty percent of the people who answered the survey said they were worried others would think less of the person who died or would think less of them as a friend. Sixty six percent said they get nervous when someone asks them how their friend(s) died, and 33.3% even said they have felt ashamed or embarrassed when talking about the suicide(s). Some comments that I collected from open-ended questions were “I feel like they judge our town and my sense of picking friends,” “many people think it is very selfish,” “people judge them, they don’t deserve it,” and “people lose respect for them.” Two people included specific stories of disclosing about the suicides and the reactions they received were that suicide is “the biggest sin you can commit, how selfish and cowardly it is” and “if it were [my] son, [I’d] be pissed at the kid for being such a ‘pussy.’” Unfortunately, this fear of stigmatizing reactions from others can lead to unwillingness to disclose and talk about what happened. Sixty percent of the survey participants said that they have only told a few of their new friends that they have lost friends to suicide. Sixty-two percent said they never or rarely voluntarily include the fact that it was suicide. Their comments included, “I don’t bring it up,” “I avoid the subject altogether,” “I avoid the fact that it was suicide,” “I change the subject,” “I beat around the question,” and “I don’t ever talk about them.” This is obviously problematic and harmful for the bereaved because by choosing to not disclose their grief, they are missing out on the social support that can be so helpful for the grieving process.
Another emphasis revealed in the survey responses was guilt and self stigma. Eight-five percent said they have felt guilty about the deaths, and the comments on this topic were overwhelming. People said “I wish I had reached out, I regret it every day,” “I could have saved him,” “I could have helped him,” “I could have done something,” “I should have said something,” “if I had called him things would have been different,” “I should have known,” and “I should have been more aware”. An interesting finding was that 81% of people who admitted knowing ahead of time that the first friend to die by suicide was struggling emotionally didn’t take it seriously at the time, 43.8% of people who knew something was wrong with the second friend who died by suicide didn’t take it seriously at the time, and 50% of people who knew something was wrong with the third friend didn’t take it seriously at the time. Even after having lost two friends to suicide, 50% of the people still did not take the warning signs seriously. This pattern demonstrates how hard it is to recognize the warning signs, how hard it is to understand what a suicidal friend is going through, and some of the difficult emotions that adolescent suicide survivors may feel when grieving.
Anger and stigma toward the deceased is also a common response during the bereavement period. Seventy-two percent of the people who chose to answer this question said they have been mad at at least one of the three friends who died by suicide at one point. People said “they knew how many people would suffer from this,” “to take his own life was selfish,” and “it was selfish of him to leave all of us behind and hurt.” In this case, suicide survivors can fall prey to the stigmatizing myth that suicide is selfish. Another related theme was stigma, blame, and anger toward others. Sixty-one percent said they have been mad at other friends, 69% said they have been mad at health professionals involved, and 77.7% said they have been mad at the victim’s family. Many of the friends blamed other friends, family, and mental health professionals for not doing enough to help their suicidal friends. Blame can be detrimental for bereaving suicide because it creates hurt feelings, anger, and guilt within an effected social group. These intense emotions can create problems within the social group and diminish the social support that is so important to grieving. Blame tends to move around from blaming oneself, one’s friends, and those close to the person who has died. Understanding the precipitants of suicide and how to intercede will lessen the stigma.
However, destigmatizing suicide is not always viewed as a good idea. Some believe that “we do not want to destigmatize suicide and suicide attempts” (Shaffer, 2004 as cited in Sudak, Maxim, & Carpenter, 2008, p. 136) because we do not want to “normalize it and make it appear more reasonable” (Sudak, Maxim, & Carpenter, 2008, p. 136). This approach is seen as being helpful in preventing suicides, but leaving this stigma intact can be harmful for people who are contemplating suicide, have attempted suicide in the past, or are bereaving suicide currently. We do not want to make suicide seem like a healthy choice, but we also need to be more understanding about what leads a person to do this and how our understanding and compassion could not only help prevent future suicides, but also help those who are currently grieving.
References
- Bondora, J. T., & Goodwin, J. L. (2005). The impact of suicidal content in popular media on the attitudes and behaviors of adolescents. Praxis, 5, 5-12.
- Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Schweers, J., Roth, C., Balach, L.
- Canobbio, R., & Liotus, L. (1992). Psychiatric sequelae to the loss of an adolescent peer to suicide. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 509-517. doi:10.1097/00004583-199305000-00004
- Cvinar, J. C. (2005). Do suicide survivors suffer social stigma: A review of the literature. Perspectives in Psychiatric Care, 41, 14-21. doi: 10.1111/j.0031-990.2005.00004.x
- Harvey, J.H. (1998). Perspectives on loss: A sourcebook. Philadelphia : Brunner/Mazel.
- Joiner, T. (2010). Myths about suicide. Cambridge, MA: Harvard University Press.
- Johnson, G., Krug, E., & Potter, L., (2000). Suicide among adolescents and young adults: A crossnational comparison of 34 countries. Suicide & Life-Threatening Behavior, 30, 74–82. doi: 10.1111/j.1943-278X.2000.tb01066.x
- Jordan, J. R., (2001). Is suicide bereavement different?: A reassessment of the literature. Suicide and Life-Threatening Behavior, 31, 91-103. doi: 10.1521/suli.31.1.91.21310
- Lukas, C., & Seiden, H. M. (2007). Silent grief: Living in the wake of suicide. Philadelphia: Kingsley.
- Nelson, B. J., & Franz, T. T. (1996). Family interactions of suicide survivors and survivors of non-suicidal death. Omega, 33, 131-146.
- Ness, D. E., & Pfeffer, C. R. (1990). Sequalae of bereavement resulting from suicide. American Journal of Psychiatry, 147, 279-285.
- Sayers, D. L. (1949). The divine comedy 1: Hell. London, England: Penguin Books.
- Sudak, H., Maxim, K., & Carpenter, M. (2008). Suicide and stigma: A review of the literature and personal reflections. Academic Psychiatry, 32, 136-142. doi: 10.1176/appi.ap.32.2.136
- Suicide Act 1961. Retrieved from http://www.legislation.gov.uk/ukpga/Eliz2/9-10/60