Friends and Family Perceive Shame and Guilt After Suicide Interview with:

Dr Alexandra Pitman BA MSc(Econ) MBBS MRCPsych FHEA PhD Honorary Research Associate & Consultant Psychiatrist Division of Psychiatry University College London London

Dr. Alexandra Pitman

Dr. Alexandra Pitman BA MSc(Econ) MBBS MRCPsych FHEA PhD
Honorary Research Associate & Consultant Psychiatrist, Division of Psychiatry
University College London
London What is the background for this study? What are the main findings?

Dr. Pitman: We conducted this study to settle a long-standing debate over whether bereavement by suicide is more stigmatising than bereavement due to other causes of sudden death. This is important because the more we understand about the stigma of suicide bereavement, the better equipped we are to design services to support this group. Providing support for people bereaved by suicide is one of five key messages in WHO suicide prevention strategy, and features prominently in the suicide prevention strategies of high income countries such as England, Wales, Northern Ireland, the US, and Australia. The evidence to date suggests that we lack effective interventions to address their known risk of suicide and mental health problems, constituting a failure to tackle an important public health problem.

Although suicide is commonly believed to be highly stigmatising for bereaved relatives and friends, qualitative work suggests that people bereaved by other causes of death also feel stigmatised by their loss. For example, a British study of people bereaved by suicide and other unnatural causes of death found that interviewees in both groups described societal pressure to contain their grief and even to hide it. Our earlier systematic review in the Lancet Psychiatry had identified studies comparing health and mortality outcomes in people bereaved by suicide and other causes of death, among which 7 studies had compared perceived stigma scores using a validated measure. In all cases the measure was the stigmatization subscale of the Grief Experience Questionnaire. Taken together these studies were inconclusive as to whether people bereaved by suicide and other unnatural mortality causes differed in relation to stigma scores. Partly the problem seemed to be one of sample size in having insufficient statistical power to demonstrate score differences, should they exist. We decided to conduct a large-scale British study to compare grief outcomes such as stigma, shame, responsibility and guilt, as well as clinical outcomes such as suicide attempt. Previously published findings from this study, reported in BMJ Open, show an increased risk of suicide attempt in people bereaved by suicide, whether related to the deceased or not. What are the main findings?

Dr. Pitman: When we compared stigma scores we found that people bereaved by suicide reported stigma scores that were statistically higher than those for people bereaved by sudden unnatural deaths, and also higher than those for people bereaved by sudden natural causes. We also found similar relationships for three dimensions of grief linked to stigma – a sense of shame, responsibility and guilt. When we split our sample into relatives and non-relatives we found that these patterns of score differences were the same, effectively signifying that suicide was highly stigmatising for friends as well as for relatives. What should readers take away from your report?

Response: This study is the largest of its kind, and the first to show that people bereaved by suicide report the highest levels of perceived stigma, shame, responsibility and guilt compared with people bereaved by sudden natural or unnatural mortality causes. It suggests that of all groups bereaved due to sudden death, friends and relatives of those dying by suicide are most likely to experience the distress of stigma in addition to the burden of their loss. We can only speculate about the effect of this stigma on their likelihood of asking others for help. Whereas previously the stigma of suicide has been linked to beliefs about inherited traits passing through bloodlines, this study shows that negative attitudes about suicide also extend to those in the friendship group of the person who died. What recommendations do you have for future research as a result of this study?

Response: Whilst this study took a quantitative approach in comparing measures of stigma between groups, there is much more to learn from qualitative research in terms of what it means to feel stigmatised. Of the 3,432 individuals who provided stigma scores for our study, we conducted in-depth interviews with a sub-set of 27 bereaved adults to probe the issues of stigma and support. We are currently analysing this data for publication, to explore how stigma impacts on help-seeking. An important next stage is to apply the results of our work, by designing and evaluating interventions to address perceived stigma in relatives and friends bereaved by suicide. Such interventions might include psychological therapies to enhance coping skills when stigmatising attitudes are encountered, or proactive outreach systems to overcome a reluctance to initiate help-seeking. Is there anything else you would like to add?

Response: We found a hierarchical relationship in our sample, such that stigma scores were highest in people bereaved by suicide, and second highest in people bereaved by non-suicide unnatural causes relative to those bereaved by sudden natural causes. This, and our earlier work, identifies people bereaved by other unnatural deaths as a group who may also be distressed and reluctant to seek help. Further work to explore their vulnerabilities will also help design services to meet their own needs. Thank you for your contribution to the community.


The stigma perceived by people bereaved by suicide and other sudden deaths: A cross-sectional UK study of 3432 bereaved adults
Journal of Psychosomatic Research , Volume 87 , 22 – 29
May 27, 2016

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Last Updated on June 14, 2016 by Marie Benz MD FAAD