1. Introduction

A suicide survivor is defined here as “someone who has lost a significant other to suicide” [1]. Recent estimates indicate that the number of individuals affected by a suicide is considerable. For every suicide, there are approximately 18 individuals experiencing major life disruptions in the course of suicide survivorship [2]. Given an annual rate of 800,000 suicides worldwide [3], up to 14.4 million people might be intimately affected by suicide bereavement every year.

Although suicide bereavement appears to largely resemble grieving after other types of loss in terms of symptom severity [4], there is indication that some suicide survivors are at an increased risk of developing depression, suicide ideation, and a pathological grief reaction, defined as prolonged grief disorder or complicated grief in the bereavement literature [5–7]. Complications occurring in the course of grieving appear to be related to a range of qualitative themes common in suicide bereavement. Thus, suicide survivors face the burden of finding reasons to explain the death and suffer from feelings of shame about the cause of the death, guilt for not being able to prevent the death, blame directed towards self and others and abandonment/rejection by the deceased [7–10]. Another factor that characterizes suicide bereavement and that may greatly complicate the grieving process after suicide is the social stigma attached to suicide survivors [7,10–13].

Stigmatization of suicide survivors can be traced back to early historic periods when family members of suicide were faced with being denied a proper burial of the deceased, property confiscation, and excommunication from the community [1,12]. Although such cultural practices have ceased to exist, there is evidence that negative attitudes towards those bereaved by suicide prevail and that stigmatization has taken more subtle forms of isolation and shunning [8,14–17]. Additionally, the ongoing stigmatization of suicide and associated mental illnesses provides further indication that stigma is a persistent part of the grief experiences of suicide survivors [13,18–21].

In recent years, scientists have come to understand stigma as a social process that involves labeling, stereotyping, and rejecting human differences in order to exert social control [22,23]. Theoretical conceptualizations further distinguish between two interrelated dimensions across which stigma can be assessed: public stigma and self-stigma [24]. Public stigma refers to “the phenomenon of large social groups endorsing negative stereotypes about and acting against a stigmatized group” [25]. Self-stigma describes a process whereby stigmatized individuals perceive social devaluation (perceived stigma), experience actual enactments of stigma in the form of discrimination (enacted stigma), or internalize negative attitudes of others, resulting in an adverse self-image characterized by shame, guilt, maladaptive behaviors, and/or stereotype endorsement (internalized stigma) [24,26].

This conceptualization illustrates how stigma might interfere with the grieving process of suicide survivors. Negative attitudes within the public can be conveyed to the survivors through various pathways, such as attribution of blame by the survivor’s social environment, gossip or negative media portrayal of the deceased [14,27,28]. If suicide survivors internalize these negative attitudes, this could exacerbate existing feelings of shame, self-blame and/or guilt. In order to avoid stigmatization, suicide survivors might also engage in maladaptive behaviors, such as concealment of the cause of death [7]. Research among members of stigmatized groups has shown a multitude of other adverse outcomes of stigma. It has been linked with psychological distress, reduced self-esteem, poor quality of life, a reduction of social support networks, and delays in seeking care from healthcare professionals [29–32].

Although the literature has identified stigma as an important factor in suicide bereavement, so far, it has been only sparsely investigated. While few existing reviews have focused on stigma associated with suicide survivors [12,13], non-systematic modes of data collection limit conclusions and several new studies have been published since the publication date of the most recent review in 2008. Especially the psychological consequences of stigma for affected suicide survivors remain understudied, despite findings from related research fields suggesting serious negative effects of stigma. Thus, this review aims at providing a critical overview on the current state of research on suicide survivor stigma and to investigate the influence of stigma on grief trajectories and survivors’ well-being.

2. Methods

This review was conducted based on PRISMA guidelines [33]. We did a systematic literature search in PubMed, Web of Science, PsycInfo, and PsyArticles of studies indexed up through August 2015. Search terms included variations of the keywords “stigma” and “suicide survivor” using the search strategies described in Table 1.

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Table 1. Database search strategies.

https://doi.org/10.1371/journal.pone.0162688.t001

The database search was restricted to empirical human research articles written in English and published in peer-reviewed journals. After removing duplicates, two independent researchers (FH and FL) identified potentially relevant articles by screening titles and abstracts and then retrieving articles in full-text for a detailed evaluation against inclusion criteria. They also checked reference lists of relevant articles to identify articles not covered by the database search. Both quantitative and qualitative studies were included. Articles were eligible for inclusion if they addressed self-stigma or public stigma related to suicide survivors either by explicitly measuring stigma quantitatively, or by reporting stigma as a major qualitative research finding. If studies involved controls of other bereavement populations, each of those control groups had to be homogenous regarding the type of loss experienced (e.g. natural loss, accidental loss). Studies were excluded if: (1) they investigated the public perception of suicide survivors without explicitly using a measure of stigmatization; (2) focused on bereavement after an assisted suicide or (3) were intervention studies, case studies, reviews, commentaries, theory papers or published as books or book chapters. Data was extracted from eligible studies according to the following scheme: Sample, Design, Participants, Stigma Conceptualization, Main Outcome Measure(s), Main Findings, and Bias.

Due to the high diversity of research designs and methodology applied in the studies included, a narrative synthesis of data was deemed appropriate. Following recent guidelines [34] we did a qualitative assessment of the methodological quality of studies within the text rather than using summary scores of quantitative checklists.

3. Results

3.1 Study characteristics

Fig 1 illustrates the course of the literature search. After removing duplicates, the database search yielded a total of 568 articles. Of these, 22 articles met inclusion criteria. Three of these articles were based on the same study but, for our purposes, were counted as separate studies because the composition of the samples varied [15,35,36]. Three additional studies were identified by searching the reference lists of included articles, resulting in a total of 25 included studies.

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Fig 1. PRISMA Flow Diagram.

https://doi.org/10.1371/journal.pone.0162688.g001

Table 2 and Table 3 provide an overview of the studies’ characteristics. The majority of the studies had been published in 2002 or later (N = 15), while the earliest study dated from 1983. Fourteen studies were quantitative and eleven were qualitative. Most studies provided descriptive data on self-stigma among suicide survivors (N = 15). Other studies investigated associations between stigma and grief, psychosomatic functioning and sociodemographic variables (N = 7). Eight studies compared the stigma experiences of suicide survivors to those of other bereavement populations using controlled study designs. Only one study was found that examined public stigma towards suicide survivors.

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Table 2. Summary of quantitative studies on levels and correlates of self- and public stigma.

https://doi.org/10.1371/journal.pone.0162688.t002

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Table 3. Summary of qualitative studies on subjective experiences of stigma among suicide survivors.

https://doi.org/10.1371/journal.pone.0162688.t003

Sample sizes varied from 55 to 571 participants in the quantitative studies, and from 6 to 97 participants in the qualitative studies. Samples were recruited in 10 different countries, with the majority of samples located in the U.S. (N = 13), the U.K. (N = 4), or other Western countries (N = 6). One study was conducted in Israel and one in Taiwan. In 12 of the 25 studies, participants were spouses or first-degree relatives of the deceased (children, siblings, parents). Other studies included survivors with mixed relationships to the deceased (e.g. parents, friends, second-degree relatives). The vast majority of the studies involved non-representative convenience samples.

4. Discussion

Although the literature has identified stigma as an important factor in suicide bereavement, the results of this systematic review revealed that there is a paucity of research on manifestation and consequences of suicide survivor stigma. The available studies showed considerable variation with regard to study design and stigma measures, making comparison across studies difficult. However, results demonstrate that stigma can be a serious concern for a significant proportion of suicide survivors, as opposed to survivors of a natural loss. Suicide survivors experienced stigma within their social networks as well as from legal and religious institutions in different cultural settings. Stigma went along with social isolation and was internalized as intense feeling of shame by suicide survivors. However, little is known about factors that influence survivors’ experiences of stigma. Previous research has highlighted the role of relationship to the deceased in reactions to a loss, with parents who lost a child usually encountering the greatest difficulties [43]. Contrary to these findings, the included studies found that parent suicide survivors experience less stigmatization than other immediate family members. It is possible that these discrepant finding were produced by differences in quality of the kinship relation, which studies did often not take into account. Further, distinct information regarding feelings of stigma in more distant associates of the deceased such as co-workers were lacking in the included studies. Some suicide survivors had developed strategies to resist stigmatization, but the psychological mechanisms of these strategies remain unknown. Hence, more research is needed to clarify how experiences of stigma vary as a function of individual and contextual factors, in order to identify specific risk populations. A deeper insight into stigma management strategies might help other survivors building up individual resistance and coping with negative feelings in the aftermath of a suicide.

The reviewed studies further revealed that suicide survivors’ experiences of stigma are associated with grief difficulties as well somatic and psychological impairments such as depression and suicide ideation. This evidence tentatively supports the assumption that stigma complicates the grieving process of suicide survivors [8,12]. Moreover, stigma may contribute to heightened suicide risk in survivors of suicidal deaths [5,7]. None of the quantitative studies investigated the underlying mechanisms that mediate the relationship between stigma and complications occurring in the course of grieving. However, the results indicate that suicide survivors frequently conceal the death from others, withdraw from social interactions, and suppress their emotions to manage stigma. Studies involving members of other stigmatized groups have demonstrated that concealment is associated with intrusive thoughts, increased psychological distress, anxiety, and depression [59–61]. There was also some indication that concealment and secrecy deprived suicide survivors of support from others, potentially exacerbating existing grief difficulties. Other studies have shown that suicide survivors who experience a lack of social support are more likely to experience unresolved grief, depression and separation anxiety [62,63]. Given the consistent link between stigma and avoidance behaviors, stigma might also pose a barrier for burdened suicide survivors to seek professional help. Indeed, Wilson and Marshall [64] have shown that there is a significant gap between the need for support in people bereaved by suicide and the provision of professional help.

However, the influence of stigma on grief trajectories and suicide survivors’ support networks needs further methodologically sound research as many of the studies included in this review were flawed due to widespread use of non-validated measures, cross-sectional designs and unadjusted correlational analysis. Especially investigations on the relation between stigma and complicated grief/prolonged grief disorder might advance understanding of the processes that make suicide survivors vulnerable to the development of a pathological grief reaction [6].

This review further provides a differentiated view on the assumption that stigma is a specific characteristic of suicide bereavement, as suggested by some research [4]. While results indicated a tendency for suicide survivors to experience more stigma than natural death survivors, differences disappeared when compared to other traumatic death survivors. These results are converging with a line of research proposing that suicide bereavement and bereavement by other types of traumatic losses produce similar reactions [7,8]. The exact reasons for similarities in experiences of stigma among suicide survivors and survivors of other traumatic deaths remain unclear, but several explanations might apply. It is possible that suicide survivors and other traumatic death survivors evoke fear, avoidance responses, and false attribution of responsibility because they confront others with their own inability to control fundamental issues of life and death [15,55]. In addition, the absence of clear social norms on how to interact with survivors of suicide and traumatic deaths might contribute to similar patterns of insensitivity on the part of the people in survivors’ social networks, which can be perceived as stigmatizing by survivors [15,46].

Understanding the interaction between survivors’ individual emotional reactions to the suicide and surrounding social processes poses another important challenge for future research. Study results suggest that survivors’ emotional reactions to the suicide influence their sense of stigma and strategies for coping with the loss. Suicide survivors have been shown to frequently suffer from negative feelings like shame, guilt, anger and blame [7,8]. While perceived stigma appears to feed into these feelings, it is also possible that suicide survivors project their negative emotions on their social environment, leading to a biased perception of others’ behaviors and attitudes. Some studies further indicate that the social isolation of survivors is not only a reaction to stigma but in part self-imposed to give room for grieving. However, these complex issues cannot be definitely resolved on the basis of the current evidence. The reviewed studies often lacked a clear definition and conceptualization of stigma, which went along with the use of unspecific stigma measures. Such an approach makes it difficult to assess the relationship between more stigma-specific grief components, such as perceived negative judgment, and related emotional and social processes, such as shame, guilt or concealment of the death. The observed lack of stigma conceptualizations also hinders the development of theoretical frameworks that are necessary to systematically advance knowledge on the role of stigma in the context of suicide bereavement.

Assessing the adequacy of suicide survivors’ perception of stigma was further hampered by the absence of studies on stigmatizing attitudes towards suicide survivors within the public. Only one study met inclusion criteria with results indicating that stigmatizing attitudes are indeed common among the general population. This result supports the findings of a larger body of research examining general public perception of and biases towards suicide survivors (see [8], [14], [17] for reviews). These studies suggest that suicide survivors are perceived more negatively than survivors of other modes of death, such as that they are viewed as more psychologically disturbed, are blamed more for the death and are less likeable (e.g. [65–67]). Thus, there is indication that suicide survivors’ perception of stigma might actually be based on adequate evaluation of other’s attitudes, although the limited evidence from this review allows only cautious inference. While more research on negative attitudes and stereotypes among close social circles of suicide survivors, as well as their community and the general population is needed, it is also important to understand how these attitudes translate into direct behavior towards suicide survivors. Observing interactions of suicide survivors within their social network might help to understand how stigma as well as individual emotional reactions to a loss by suicide contribute to the cycle of strained social interactions and isolation experienced by suicide survivors [14,68,69].

Supporting Information