Behind Closed Doors

Background

The impact of suicide is far reaching in society; suicide is the second leading cause of death for those aged 15 to 29 worldwide (World Health Organization [WHO], 2012) and 10th leading cause of death for adults in the United States (Xu, Murphy, Kochanek, & Bastian, 2016). In 2013, there were over 40,000 U.S. deaths due to suicide (Xu et al., 2016), leaving many thousands of family members in bereavement. These family members are more likely to self-harm, be psychologically distressed, consider suicide, and die by suicide when compared with those experiencing natural or nonviolent types of bereavement (de Groot, de Keijser, & Neeleman, 2006; Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2005; Pitman, Osborn, King, & Erlangsen, 2014; Seagal, 2009). Moreover, recent research suggests that families bereaved by suicide experience a grieving process that is qualitatively different from those surviving a nonsuicide death (Maple, Cerel, Jordan, & McKay, 2014). Particularly, beyond the pain of loss, suicide-bereaved families experience negative reactions from the community following a loved ones’ death (Chapple, Ziebland, & Hawton, 2015; Cvinar, 2005). The present study aims to make sense of these negative reactions by identifying social-cognitive components of suicide stigma and mapping these onto a stigma framework.

Social-Cognitive Model of Stigma

The social-cognitive model in Table 1, developed to explain the stigma of mental illness, has been used extensively in the literature to demonstrate how stereotypes, prejudice, and discrimination work together to negatively impact people in varied stigmatized groups (Corrigan & Kosyluk, 2014). Stereotypes are beliefs that the public holds about the stigmatized group (“Depressed people are just lazy”). Prejudice is the emotional response that arises from agreement with public stereotypes (“I agree that depression is just laziness and I despise those people”). Discrimination is the behavior performed in response to stereotypes and prejudices. Discriminatory behavior toward people with mental illness includes refusals to employ or rent apartments to those with a known mental diagnosis (Corrigan & Kosyluk, 2014). Taken together, stereotypes, prejudice, and discrimination comprise public stigma: stigma directed from members of society toward the stigmatized person.

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Table 1.

Social Cognitive Model for Understanding Stigma.

	Public stigma	Self-stigma
Stereotype	People with mental illness are dangerous	People with mental illness are incompetent
Prejudice	Landlord feels they are in danger because Bob has a mental illness	I am a person with a mental illness and am therefore incompetent. Who would want to hire me?
Discrimination	Landlord won’t rent apartment to Bob	I think “why try” and I stop looking for a job

Note. Adapted with permission from “Mental illness stigma: Types, constructs, and vehicles for change. In P. W. Corrigan (Ed.), The stigma of disease and disability: Understanding causes and overcoming injustices (pp. 35–56),” by P. W. Corrigan and K. A. Kosyluk, 2014, Washington, DC: American Psychological Association. Copyright © 2014 by the American Psychological Association. The use of APA information does not imply endorsement by APA.

Self-stigma, in contrast, occurs when stigmatized individuals internalize the public stigma and believe that they conform to the public’s negative perception (I’m lazy and worthless just like everyone says I am”; Corrigan & Rao, 2012). While not all individuals are affected by self-stigma, when stigma is internalized, it threatens self-esteem, leading to depression and loss of self-efficacy (Corrigan, Larson, & Rüsch, 2009). Those who self-stigmatize may become resigned about the fact of their mental illness (or other stigmatized condition) and reduce their efforts to combat stigma and improve their situation.

This social-cognitive model of public stigma and self-stigma was used in an earlier examination of suicide attempt survivor stigma (Sheehan et al., 2017). In the previous qualitative analysis, we focused on identifying stigma directed specifically toward individuals who have attempted or died by suicide. Those data revealed both suicide stigma themes that overlapped with previously established stigmas of mental illness (e.g., people who attempt suicide are dangerous, incompetent, and weak) and those that were more unique to suicide (e.g., people who attempt suicide are selfish, attention-seeking, and immoral). The present analysis qualitatively examines the family stigma of suicide using the social-cognitive model as a framework.

A major strength of this endeavor was the community-based participatory research (CBPR) strategy of including members of the suicide community. In CBPR, community partners work collaboratively with researchers to choose topics and methods that are relevant to local stakeholders and ensure that research is conducted in a way that is sensitive to the particular community (Minkler & Wallerstein, 2008). CBPR team members are not research participants; rather they are full partners in the process, from formulating research questions to dissemination of results. This approach empowers community members, allowing researchers and community members to learn from one another and produce meaningful and externally valid research products (Israel, Eng, Schulz, & Parker, 2005).

Methods

An eight-member CBPR team was first assembled to discuss the research approach and to develop focus group questions. Our team comprised suicide bereavement therapists (n = 4), suicide prevention advocates (n = 2), and researchers (n = 2), many of whom had personally attempted suicide or lost a loved one to suicide (n = 5). A focus group format was used to illicit candidates of stereotypes, prejudice, and discrimination associated with families bereaved by suicide. The CBPR team provided input on the focus group interview guide, strategies for recruitment, and advice on study logistics. The team guided a research protocol sensitive to unique needs and preferences of the community.

Recruitment for seven focus groups was conducted through Chicago mental health and social service agencies, online postings, word-of-mouth, and flyer distribution. As we sought individuals with personal suicide-related experiences, participants were eligible if they had a close family member (usually a child, parent, or sibling) who had died by suicide, had themselves attempted or considered suicide, or had provided services to those bereaved by suicide. The institutional review board from Illinois Institute of Technology approved the project and 62 participants signed a consent document prior to beginning the focus group. The seven focus groups were facilitated by a doctoral student with a state counselor’s license and experience in conducting focus groups. The facilitator was also part of the CBPR team that designed the interview guide and was familiar with both the stigma and suicide literature. A trained research assistant took detailed notes and sessions were also audio recorded. Each focus group lasted approximately 90 minutes and included 6 to 11 participants. Although separate groups were conducted for suicide attempt survivors, suicide-bereaved families, and service providers, several participants fit more than one of these criteria. The facilitator oriented focus group participants to the concepts of stereotypes, prejudice, and discrimination by giving a brief presentation with definitions and examples of each. The interview guide included the following questions: (a) What are stereotypes about families who survive suicide loss or who have a family member who has attempted suicide? (b) What are prejudices about families who survive suicide loss? (c) What discrimination do family survivors experience?

Participants had lost family members to suicide (n = 33), had attempted suicide (n = 28), or had provided services to families bereaved by suicide in the Chicago area (n = 10). There were slightly more males than females in the sample (52% vs. 48%) and most participants were White (55%) or Black (37%). Consistent with the study goal of identifying components of family stigma, transcripts were analyzed by two research assistants who independently coded family stigma responses as stereotypes, prejudice, or discrimination. As we sought to generate a comprehensive pool of stigma items rather than detect differences between suicide stakeholders, items were not coded by respondent characteristics. After coding items as stereotype, prejudice, or discrimination, similar items were combined to develop themes within each component. Responses were coded with the purpose of describing the range of possible stigma-related reactions. Thus, there was no minimum or maximum number of items assigned to each theme, nor was an attempt made to rank themes by importance. Themes were determined based on their distinctiveness from other themes. The CBPR team reviewed items and themes and recommended changes resulting in minor reassignments.

Results

Analyses resulted in distinct themes for stereotypes, prejudice, and discrimination of bereaved family members. We discuss results for each of these public stigma components and then give examples of self-stigma revealed in the data. The seven stereotype themes are presented in Table 2, while the four themes for prejudice and six themes for discrimination are displayed in Table 3.

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Table 2.

Stereotypes of Suicide-Bereaved Families.

Stereotypes	Examples
The family caused the suicide	▪ Family members drove person to suicide  ▪ The family environment was abusive  ▪ The family didn’t love the person enough
The family was in denial	▪ The family didn’t see it [suicide] coming  ▪ The family couldn’t accept that family member needs help
The family failed to help	▪ The family was preoccupied  ▪ The family could have prevented it
Family members are contaminated by the suicide	▪ Family also has mental illness  ▪ Suicide is a generational curse  ▪ The family is now vulnerable to suicide
Family members are victims	▪ The family has been hurt by the person who took their life
Family members are strong	▪ Families have extraordinary strength to go through the pain
The family is harboring a secret	▪ The family looks normal from the outside, but it’s just an act

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Table 3.

Prejudice and Discrimination of Suicide-Bereaved Families.

	Examples
Prejudice
Blame	Feelings of blame and judgment from others
Annoyance	Feelings of annoyance that suicide disrupts their lives or that they have to deal with it
Pity	Feelings of pity for the family
Fear	Fear of suicide contagion
	Feelings of discomfort being around the family after the suicide
Discrimination
Shunning	People won’t talk to you
	People won’t come to the wake/funeral
Shushing	The subject of suicide is “hush-hush”
Shaming	Neighbors gossip
Impatience	People tell you to “get over it” and “move on”
Denial of support	Workplace is unsupportive, few support group available
Mistrust	People judge and are hypercritical of family after the suicide

Discussion

Findings from this study revealed examples of public stigma, including stereotypes, prejudice, and discrimination, thus supporting the social-cognitive model used to describe mental illness stigma. Participant stakeholders said that the bereaved are blamed both for causing events leading to the suicide and for failing to prevent the suicide itself. Family members were also seen as victims, as emotionally strong and as harbors of a family secret. The current study found evidence of public beliefs that the suicide bereaved is contaminated by their loved one’s suicide. Although research suggests a degree of genetic susceptibility to suicide (Brent & Mann, 2005), the contamination stereotype and other overgeneralizations become harmful when they are applied indiscriminately to bereaved family members. Research in mental illness stigma has found that when mental illness is seen as genetic, family stigma increases (Koschade & Lynd-Stevenson, 2011). Future research could determine how biogenetic explanations of suicide impact stigma and ultimately help seeking for families.

Prejudice and discrimination examples in this study often involved members of the public distancing from the bereaved. Prejudices directed at families included blame, annoyance, pity, and fear. Discriminatory reactions of shunning, shushing, shaming, impatience, mistrust, and denial of support were experienced by bereaved families. These results are consistent with past research finding a dearth of professional services and support groups available following a loss (Angermeyer, Schulze, & Dietrich, 2003) and funding of suicide prevention and research programs that lag behind those of other causes of death (Curry, De, Ikeda, & Thacker, 2006). While factors beyond stigma (e.g., economic conditions and health delivery systems) likely also contribute to disparities in suicide-related service availability, a greater understanding of how stigma influences social institutions is valuable. Research on mental health services also shows that care-seeking behavior is dependent not only on availability of services but also on how accessible and culturally relevant these services are (Corrigan, Druss, & Perlick, 2014). These factors are presumably important to consider in the design of suicide bereavement services as well.

These data contained examples of self-stigma that align with research from the mental illness literature. When bereaved family members endorse and internalize the stigma (“I’m to blame and could have prevented this tragedy”), they may put themselves at risk for psychological distress or other problems. For example, people with mental illness who engage in self-stigma risk depression, low self-esteem, and lower rates of care seeking (Corrigan, Kosyluk, & Rüsch, 2013). When engaging in self-stigma, family members may misinterpret the well-intentioned words or actions of others as stigmatizing (“they are only being nice out of pity”). Those family members who hide the suicide can miss out on both formal and informal support networks. Moreover, when family members live in shame and are less open about the suicide, they forego opportunities to educate others and dispel suicide myths.

These results are in line with previous findings that stigma acts as an additional burden for bereaved families (e.g., Chapple et al., 2015; McMenamy, Jordan, & Mitchell, 2008; Östman & Kjellin, 2002; Provini et al., 2000). These findings suggest a similarity to research on mental illness stigma that has described onset and offset responsibility attributed to family members (Corrigan, Watson, & Miller, 2006; van der Sanden et al., 2015). Onset responsibility refers to the belief that the person has a role in causing the stigmatized condition (Weiner, 1995). In contrast, offset responsibility describes the belief that the stigmatized person has control or responsibility over recovery from the stigmatized condition (Weiner, 1995). When the concepts of onset and offset responsibility have been applied to family members of people with mental illness, some family members (in particular mothers) are viewed as responsible for mental illness onset (Corrigan & Miller, 2004; Moses, 2014). Other family members, namely spouses and siblings, are seen as responsible when their loved one fails to recover or contaminated by the illness (Corrigan et al., 2006). While the design of this study precluded identifying the exact nature of onset and offset responsibility in suicide stigma, this study lays the groundwork for future examinations in this research vein.

As a small, qualitative study, this investigation was limited in scope. This study examined general stigma toward families and was not able to illuminate stigma experienced by relationship to the diseased (husband/wife/father/mother) or by ethnicity, age, or gender of the bereaved. While we attempted to achieve a diverse sample of participants within the Chicago area, our urban sample may not have generated the full possible range of suicide-related stigma. Furthermore, we did not specify particular circumstances of the suicide (e.g., physician assisted, murder–suicide, etc.) or differentiate how perceptions of stigma vary by stakeholder group (family member, provider, or person with suicide attempt).

The direct approach to focus group questions (i.e., asking participants for examples of stereotypes, prejudice, and discrimination, rather than asking more open-ended questions) could have minimized discussion of more positive and supportive response of the community to suicide bereaved. While supportive responses were not the focus of the current investigation, understanding affirming attitudes and behaviors toward suicide bereaved is an essential endeavor for subsequent work. Likewise, the use of the social-cognitive framework during data analysis limited the scope of themes to those fitting the specific model. Additional valuable information about suicide such as coping strategies, resilience, and the bereavement process may have emerged through a less structured research protocol. Finally, the qualitative nature of this research introduces the possibility of biased interpretations, particularly considering the double and triple hermeneutics involved. That is, coders were required to interpret both focus group participant’s responses and bereavement providers’ accounts of suicide-bereaved experiences. While a systematic coding system, use of multiple coders, and use of a CBPR team to review code procedures sought to reduce this bias as much as possible, this is an important limitation to acknowledge.

One challenge of this research topic is unpacking the stigma of suicide from the general discomfort people feel when discussing death. When focus group participants recounted stories of stigmatized public reaction, these may have been a perception of stigma rather than a reality. That is, family and friends who merely feel uncomfortable discussing death and are uncertain how to interact with the bereaved are perceived as stigmatizing due to suicide (Ratnarajah & Maple, 2011). The denial of support found in this case might stem from lack of norms regarding the situation (Dyregrov, 2004). Neighbors avoid stopping by the bereaved home out of fear they will offer the wrong words or the misperception that the family wants to be left alone to their grief. In fact, some focus group participants admitted difficulty knowing whether public reactions reflected stigma or not. From a practical standpoint, understanding the perceived stigma is just as important for designing therapeutic interventions as it is for understanding the real stigmatizing treatment (Knieper, 1999). Programs that guide suicide bereaved in reducing social unease of others and initiating social support following their loved ones suicide may encourage more bereaved to be out about the suicide and gain greater formal and informal support.

Cross-cultural research (e.g., Boyd & Chung, 2012) suggests that beliefs about suicide are complex and embedded within the cultural context. In Taiwan, for example, suicide may viewed as disrespect to family and ancestors (Tzeng & Lipson, 2004). In Japan, suicide is generally more accepted than in Western countries and may be seen as a reasonable response to personal shortcomings (Domino, 2005). Specific subgroups (i.e., ex-military) will have unique experiences of stigma that should be examined and addressed within that particular context (Greden et al., 2010). Given that the majority of research on services for suicide bereaved (i.e., postvention services) have been conducted in Western countries (Andriessen, 2014; Dyregrov, 2011), much work on cross-cultural research of suicide stigma remains to be done.

The current research provides a foundation for services that better meet the needs of families bereaved by suicide. Grief complicated by stigma is poorly understood and underresearched, making it difficult for bereaved families to obtain evidence-based supportive resources. Although attention to the issue of suicide bereavement has increased, there is little evidence to guide therapy and counseling interventions for families (Maple et al., 2014; Pitman et al., 2014). Those bereaved by suicide commonly experience psychological problems including anxiety, depression, complicated grief and trauma reactions, sleep disturbances, and suicidal thoughts (McMenamy et al., 2008). According to this and past research, family members also experience social difficulties when they feel unable to talk openly with others because of blame and shame (Jordan, 2001; McMenamy et al., 2008; Ratnarajah & Maple, 2011). Clinicians can enhance bereavement services and programming using the themes uncovered here as a guide. However, our research centered largely on negative aspects of the bereavement experience. More positive, growth-focused examinations of the suicide bereavement process would add greatly to the body of research and provide essential information for designing bereavement services.

This study suggests the need for clinicians to address internalized self-stigma with families grieving a loss. Cognitive-behavioral and disclosure-based approaches to alleviate suicide self-stigma could be adapted from work on mental illness in order to address the specific stigmas relevant for suicide bereaved. In the cognitive-behavioral approach, the therapist facilitates an awareness of self-stigmatizing thoughts and guides the individual to challenge and replace these thoughts with those that might be more adaptive (“My neighbor is avoiding me because she just doesn’t understand suicide and feels uncomfortable around the topic, not because I’ve failed as mother”). In contrast, disclosure-based approaches to challenging self-stigma of mental illness guide individuals in crafting personal stories and strategically seeking out supportive people with whom they can discuss their mental health experiences without the shame. The growing popularity of self-help and peer support groups for suicide bereaved (WHO, 2014) provides another potential vehicle to address the stigma of suicide bereavement. Given the preference of some suicide bereaved to participate in Internet support groups (Feigelman, Gorman, Beal, & Jordan, 2008), online curricula could aid families in navigating social situations.

Future research can use the themes identified here to develop objective measures of suicide-related public stigma and differentiate this suicide stigma from that of mental illness. Such a measure specific to bereaved families could determine the most likely targets for antistigma efforts, which may include health-care providers, religious leaders, employers, or policy makers. Given that the general public lacks a nuanced understanding of suicide, often viewing suicide merely as an extreme outcome of mental illness (Hjelmeland, Dieserud, Dyregrov, Knizek, & Leenaars, 2012), enhanced public knowledge might reduce stigma. Antistigma programs designed to address mental illness stigma have traditionally focused on either providing accurate information about mental illness (myth-busting) or promoting meaningful personal contact between members of the public and individuals who have a mental illness. In terms of suicide stigma, education-based interventions could challenge stereotypes uncovered in this study and encourage the public to examine the prejudice and discrimination that they might unconsciously perpetrate. Contact-based interventions for suicide bereaved might involve families telling their personal stories of coping with stigma following their loved ones’ death and suggesting more supportive responses that the public can utilize. While both education and contact methods produce positive outcomes in terms of stigma change for mental illness, contact-based interventions are generally more powerful in reducing stigma (Corrigan, Morris, Michaels, Rafacz, & Rüsch, 2012) and there is evidence that greater knowledge of the stigmatized condition does not necessarily translate into less stigmatizing attitudes or greater help seeking (Angermeyer, Holzinger, & Matschinger, 2009; Batterham, Calear, & Christensen, 2013a).

Antistigma campaigns and services for suicide bereaved vary greatly by country (WHO, 2014). Thus, policymakers and social institutions may have considerable influence toward changing suicide-related stigma in terms of funding prioritization and national campaigns. Concentrated nationwide efforts to challenge the public stigma of mental illness have been undertaken in several countries to date (Sheehan, 2015). While the full impact of these campaigns may take decades to be realized, similar and complementary efforts toward suicide stigma might work to reduce the stigma experienced by suicide bereaved.