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Teen Suicide: Helping Survivors Make Sense of Sudden Loss
Teen Suicide continuing education social worker CEUs

Section 17
Suicide Survivors and Social Stigma

CEU Question 17 | CEU Test | Table of Contents | Grief
 Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

Suicide Bereavement
There is a consistent criticism in the literature that there have been too few studies to provide meaningful support for a coherent theory of the mechanisms of bereavement following suicide. Studies, when available, attempt to draw generalizations from relatively limited empirical data containing serious design flaws. In spite of these shortcomings, these anecdotal observations and limited studies provide an interesting insight into the interactions between suicide survivors and the community. One of the more striking conflicts in these studies concerns the differences and similarities in social response between bereavement following suicide bereavement and that following natural death. There is a clear body of evidence that suicide bereavement is 'different', there is also a limited body of investigations that argue that, at minimum, it is similar to, if not the same as, that experienced following natural death.

Literature Review
According to the Surgeon General's Report (US Department of Health and Human Services [USDHHS], 1999), stigma is "manifested by bias, distrust, stereotyping, fear, embarrassment, and/or avoidance" (p, 18) of the stigmatized individual or group.

Initial review of literature on the subject of stigma finds that a small number of empirical studies are available relative to bereavement following suicide. Complicating analysis, these studies point to several different conclusions. In addition, prior to 1980, most studies depended on data that are derived from weak study design, poor mechanics, and small populations. Recent review articles of the subject point to a variety of conclusions concerning experiences during suicide bereavement, with a limited number of studies highlighting the role of stigma in shaping the behavior of the suicide survivor. The initial challenge in analysis of suicide bereavement therefore, is to first determine if there is a difference in bereavement following a suicide versus natural death. The task can then move to determining the influence of stigma on behavior.

Suicide Bereavement is Different
In a review of the literature, Knieper (1999) points to findings from several studies that indicate that bereavement following suicide is not the same as that following natural death. Knieper finds that stigma and avoidance continue to be central issues to those who are left to deal with the societal response following suicide. He also points out that there appears to be a complicated set of interactions between the psychological projection of feelings of rejection and the actual social response to the survivor. Knieper's conclusion is that "a discrepancy exists between what support survivors actually receive and what they perceive as receiving from society," (1999, p. 256). A similar view on the difference in suicide bereavement is taken by Worden (1991). He emphatically states: "in our society, there is a stigma associated with suicide," (p. 94).

He goes on to correlate the stigma with the intense experience of shame following suicide. This shame not only places enormous pressure on both the survivor's ability to interact with society, but also alters the relationships within the family unit and with surrounding social structures. The result is often the complete isolation of the bereaved during the period immediately following the suicide event. Worden also provides an interesting anecdote on the stigma experienced by a failed suicide victim. He provides case illustration in which the ensuing stigma by the family and society became so difficult to endure, that a woman ultimately succeeded in ending her life in the same manner as the original attempt (Worden, 1991, p. 94).

There are two additional studies that support the finding that isolation and social stigma are evident after death from suicide. Ness & Pfeffer, in a literature review article in 1990, support the arguments that there are differences between suicide bereavement and other types of mourning following natural death. This is done with some qualifications, however, because the limited results available at the time fail to support a conclusive outcome. Ness & Pfeffer touch on the issue of social stigma by referring to anecdotal reports of isolation and blame by community members. The conclusion is that these reports "collaborate the feelings of suicide victims' family members that they are more blamed and avoided than are the relatives of persons who die under other circumstances," (Ness & Pfeffer, 1990, p. 284). This finding is consistent with the theme presented by Fine (1997) in her collection of personal experiences, conversations with survivors, and interactions with care providers. The tales of survivors provide a tapestry of experiences in which the social stigma and isolation following suicide is initially very strong and only gradually replaced as healing occurs with time. Ultimately, as Fine points out, "as we become more open about our experiences, the stigma of suicide will start to recede," (p. 75).

In a somewhat different approach, Jordan (2001) suggests several underlying reasons why suicide bereavement is different from other mourning following death. In his review of the literature, he finds that suicide "is distinct in three significant ways: the thematic content of grief, the social processes surrounding the survivor, and the impact suicide has on family systems," (p. 91). In reviewing the social processes surrounding suicide, Jordan's analysis supports those of Worden (1991) and Ness & Pfeffer (1990) in that "there is considerable evidence that survivors feel more isolated and stigmatized than other mourners, and may be viewed more negatively by others in their social network," (p. 93). Jordan summarizes that "there is considerable evidence that suicide survivors are viewed more negatively by others and by themselves," (p. 93).

In very different line of thinking, Dunne et al. (1987) use the literature to develop the observation that there may actually be a difference in the way in which survivors believe they are stigmatized versus actually being the object of stigma. Dunne et al. find that the literature provides little in the way of helping sort out this dilemma as nearly all the studies are of the psychological responses not public perception. In this conclusion, Dunne et al. raise the question of how to deal with stigma: is the correct approach to treat the survivor or to educate society?

In a literature review article, Harvey (1998) finds that there are many similarities that exist between persons bereaved by suicide versus other causes. After defining these similarities, Harvey also points out that certain bereavement experience is "more intense or unique to suicide," (p. 213). The article goes on to define four specific bereavement experiences that are unique to the suicide survivors: stigma, blame, search for meaning, and being misunderstood. In assessment, stigma appears to be "an initial global reaction when someone learns of a suicide or suicide attempt," (p. 213).

The intensity of the stigma can be further heightened by a number of factors surrounding the suicide including the use of violence. While Harvey offers no further insight into the mechanism of this reaction, the review does indicate the need for societal action to improve the understanding of suicide and points to the necessity for unique coping mechanisms by the suicide survivor.

An insightful empirical study in the area of suicide bereavement, that coincidentally also looks at the impact of stigma, is from Dunn & Morrish-Videners in 1987. Using interviews with 24 suicide survivors, the authors examined the roles of response to loss, social themes, and personal change as they affected the individual.

In reviewing the social impact of suicide, the interviews reveal a complicated series of responses by the survivor to their social and familial networks. They also provide an insight into the ways in which society handles and responds to this complex problem. In many instances, the survivors distanced themselves from the support mechanisms offered. This seems to have arisen from perceived and expressed changes in attitude by those in the social network surrounding the bereaved. Many of the bereaved felt this was a result of people refusing to accept suicide as a legitimate death. As a result, the bereaved felt that they too were marked with the stigma that is carried by suicide. Dunn & Morrish-Videners point to the fact that society is "culturally and structurally ill-prepared to respond adequately to the emotional and social needs of those in deprived status," (1987, p. 75).

One of the studies that support the notion that suicide grief is different than normal grief and that stigma is an important element in suicide survivors is found in the work of Demi & Howell (1991). In 17 subjects ages 26 to 54, eleven had experienced the suicide of a parent and six the suicide of a sibling. In analyzing the experience of bereavement, it appears that anger and family disintegration were the most dominant themes. Demi & Howell found that "stigma was reported by the majority of the respondents," and was generally "expressed as feeling ashamed or tainted," (p. 353). In reviewing survivor actions taken following suicide, a variety of mechanisms were employed to deal with societal pressure. In a number of cases, survivors disconnected themselves from their existing homes and moved to new environments in an effort to conceal the suicide event and therein relieve the stigmatization (p. 352).

Further corroborating the view that bereavement experiences are different. Reed (1998) points out in a study of 139 survivors, that there are differences between grief from accident and grief from suicide. Reed defines a unique set of predictor variables that helps one to understand the symptomatology of grief. One of the more powerful indicators is the high symptom score associated with the level of social support provided by family and close friends. "Social support from family and close friends play a major and consistent role in alleviating separation anxiety, feelings of rejection, and depression among the suddenly bereaved" (p. 295). Inversely, when social stigma and isolation are the social response to suicide, grief symptomatology is greater.

In a study comparing bereavement following suicide and nonsuicide. Nelson & Franz (1996) draw several conclusions that help define the origin of stigma in immediate family units. A sample of 41 parents and 39 bereaved adolescents were interviewed using a combination of standard instruments and a questionnaire developed by the authors. Of note, is that the dyads studied (parents to surviving children and each other, and siblings to each parent) showed no significant difference in participant perception about the state of their family or indicated the emergence of changes pointing to stigma. The comparisons of large and small families however, show that large families experience "more estrangement, anger, and conflict and less openness, support and concern for each other as they tried to cope with loss," (p. 142). Nelson & Franz speculate that this stigmatization may be a result of "there is not enough energy to go around to all who are suffering," (p. 142).

The study leads one to conclude that social closeness diminishes the likelihood that the bereaved will be stigmatized. This is particularly true within cohesive family units with good support mechanisms in place. The study of social interaction over several periods of grief following suicide is a useful indicator of the effect of social stigma. Sixty widowed survivors were studied by Constantino, Sekula & Rubenstein (2001) to evaluate the effectiveness of two types of group intervention. While not intending to look at social stigmatization, the Grief Experience Inventory reveals a significant reporting of social isolation among survivors.

Of particular note, is the significant reduction in perception of social isolation over 6 months. Constantino et al. found "these results suggest that participants in the combined postinterventions experienced a significant reduction in overall depression, psychological distress, and grief and an increase in social adjustment," (p. 437). The data reveal that the social adjustment issues are the slowest to respond over time. While significant improvement in family interaction was evident in the immediate period following suicide, the nonfamily indicators were not nearly as responsive. They conclude, "these factors may require a longer period of time," (p. 439).

In one of the more specific studies, Fraser (1994) uses a focus group approach to study four families recovering from suicide of a family member. While the numbers of survivors in this study were relatively small, the qualitative data supports some compelling arguments. This exploratory ethnographic-inductive study found that the altered social world surrounding survivors caused them to bear a legacy of stigma. While Frazer concludes that stigma is a significant issue, the focus groups did not reveal people willing to discuss the issue in even this highly supportive format. Frazer found that the group members preferred to internalize their feelings. He offers that, "people did not have to be told to have overt sanctions applied because of previously existing stigmatizing nature of the suicidal act," (p. 3). Frazier concluded that suicide survivors suffer stigmatization, and this stigma is an outcome of the suicide taboo. Further, the taboo remains strong in contemporary society and individuals internalize the attitudes, values and morals that make up the taboo.

In a somewhat tangential approach, Bailley, Krai & Dunham (1999) studied bereavement in a group of 350 university students who had recently suffered natural or suicide loss. Each student completed questionnaires using several standardized methods. There were four subgroups, including 57 suicide survivors. Regression analysis of data suggests that suicide survivors "perceived stigmatization and feelings of shame and embarrassment do set them apart from those who mourn nonsuicidal deaths," (p. 268). In all measurements of outcome variables, including stigmatization, loss of social support, and rejection, students reported significantly different scoring on the Grief Experience Questionnaire.
- Cvinar, J. (2005). Do suicide survivors suffer social stigma: a review of the literature. Perspectives in Psychiatric Care, 41(1), 14-21.

Personal Reflection Exercise #10
The preceding section contained information regarding suicide survivors suffering social stigma.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 17
According to Jordan’s study, how is suicide bereavement different from other mourning following death? Record the letter of the correct answer the CEU Test

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