Social Reactions After Disclosing Suicide Loss Among Women

Abstract

Abstract: Background: Suicide loss is often concealed. While initial evidence suggests that disclosure is important for healthy grieving, observed beneficial effects may depend on social reactions. Aim: The current study aimed to identify social reactions and associated consequences experienced by persons who lost a loved one to suicide (i.e., suicide loss survivors). Method: We conducted qualitative interviews with 22 female adult suicide loss survivors focusing on social reactions after suicide loss. Interviews were transcribed and analyzed using qualitative content analysis. Results: When talking about their loss with others, suicide loss survivors experienced a broad range of social reactions including compassionate and supportive responses, speechlessness and insecurity, curiosity and gossip, stigmatization, and grieving expectations. Depending on these social reactions, disclosing suicide loss was associated with both negative and positive long-term effects. Limitations: The findings are limited to the current female sample. Conclusion: Interventions that help suicide loss survivors in finding supportive confidants, combined with public interventions to decrease public suicide stigma and improve the public’s readiness to provide helpful support to suicide loss survivors, could improve grieving outcomes among this group.

Globally, up to 700,000 people die by suicide each year, resulting in great distress among family members, friends, and other close relatives, a group commonly referred to as suicide loss survivors. According to Cerel et al. (2016, 2019), per each suicide, a total of 135 individuals are generally affected, with 25 of them being profoundly impacted and bereaved.

Suicide bereavement is associated with severe mental health outcomes, for example, difficult grief experiences, depressive symptoms, and increased suicide risk (Logan et al., 2018; Pitman et al., 2014). Furthermore, suicide loss survivors are a stigmatized social group due to their association with the deceased (Hanschmidt et al., 2016; Sheehan et al., 2018). In several qualitative studies, suicide loss survivors reported feeling discredited, tainted, and degraded, leading to feelings of shame and embarrassment (Hanschmidt et al., 2016). Such loss-related suicide stigma was found to complicate the grieving process and to be associated with increased psychological distress and suicidality (Hanschmidt et al., 2016; Oexle et al., 2020).

To avoid stigma, many suicide loss survivors withdraw socially and conceal their loss (Azorina et al., 2019; Hanschmidt et al., 2016). However, vast literature among people with other concealable stigmatized identities (e.g., homosexuality, mental illness) showed that secrecy has negative side effects (e.g., fear to be found out, social isolation; Pachankis, 2007) while disclosure can lead to positive consequences (e.g., improved quality of life, increased empowerment; Corrigan et al., 2013; Mayer et al., 2022). In initial studies, loss disclosure was associated with fewer overall grief difficulties both among persons who experienced a sudden loss (e.g., by accident; Feigelman et al., 2018) and suicide loss survivors (Levi-Belz & Lev-Ari, 2019a, 2019b). However, whether loss disclosure is experienced as beneficial or harmful could depend on associated social reactions (Chaudoir & Fisher, 2010). In a qualitative study, suicide attempt survivors reported that positive reactions from family and friends after disclosing led to increased feelings of belongingness and decreased feelings of burdensomeness, and negative reactions were associated with reversed associations (Frey et al., 2017). Several quantitative studies supported these results and showed positive family reactions to mediate the link between disclosure and feelings of belongingness, burdensomeness, and depressive symptoms among this group (Frey & Fulginiti, 2017; Frey et al., 2016). Despite great relevance for suicide postvention, similar studies among suicide loss survivors are lacking.

In summary, existing evidence suggests that disclosing suicide loss is an important determinant of a healthy grieving process. However, beneficial effects could greatly depend on the social reactions experienced when disclosing suicide loss. To contribute to the current evidence base, we conducted a qualitative study among suicide loss survivors aiming to explore social reactions and associated consequences experienced when disclosing suicide loss.

Method

Procedure

Twenty-two semistructured individual interviews with suicide loss survivors were conducted between April 2019 and March 2020 in Germany until theoretical saturation was reached. Inclusion criteria were being at least 18 years old, having lost a significant other by suicide when being older than 13 years, and having experienced significant emotional distress after the loss (score >3 on a scale from 1 [not at all] to 5 [extremely] for the item “To what extent did you experience emotional distress after your loss by suicide?”). We recruited potential participants in regional suicide loss self-help groups as well as by advertisements in regional newspapers and by snowball sampling. Study staff could be reached via phone and e-mail to get detailed study information. After a brief screening interview to determine eligibility, written informed consent was obtained. Interviews were conducted by one researcher (NP) and lasted between 16 and 78 min (face-to-face interviews: n = 7; interviews by telephone: n = 15). An interview guide focusing on social interactions after suicide loss, disclosure of suicide loss, and suicide stigma was used. Participants received 20 € as compensation (plus travel costs). During recruitment, we noted an underrepresentation of male participants. Therefore, we repeated all recruitment efforts as described above specifically addressing men. However, only one male suicide loss survivor participated in this study, and we decided to exclude the single male participant and thus only included female participants in our analysis. While the present article describes findings regarding social reactions and associated consequences after suicide loss disclosure, a second publication focusing on the determinants of disclosing suicide loss is currently being prepared (Oexle et al., 2022).

Data Analysis

All interviews were audio recorded and transcribed verbatim. Qualitative content analysis according to Mayring (2004) was used to analyze the data. Deductive categories were developed based on our research objectives, and inductive categories emerged from the data. Three researchers (LM, NO, NP) independently coded text items and met regularly to discuss discrepancies and inductive codes until reaching consensus. All analyses were conducted within MAXQDA 12. For the current paper, selected text items representing the identified themes were translated from German into English focusing on an accurate reflection of their content.

Results

Participants

Data from 22 women participants were analyzed in this study (see Table 1). They were on average 48 years old with an age range between 24 and 74 years. Nineteen participants reported one suicide loss, and three participants reported several suicide losses. The time since participants first loss by suicide ranged from 0 to 44 years (M = 12 years), and participants were on average 36 years old when they first lost someone by suicide (range between 20 and 63 years). Fifteen or 12 participants indicated that they were seeking professional help or help from a support group, respectively.

Table 1. Sociodemographic variables of female participants.

Participant	Age (years)	Deceased person	Age at loss by suicide (years)
01	40	Friend/son/cousin of husband	20/37/37
02	60	Son	45
03	29	Brother	27
04	26	Partner	25
05	64	Husband	63
06	40	Cousin/godfather	36/39
07	54	Sister-in-law/partner	51/53
08	24	Brother	23
09	64	Son	63
10	67	Son	63
11	74	Husband	30
12	51	Mother	21
13	26	Friend	21
14	53	Son	53
15	53	Brother	32
16	42	Father	31
17	54	Ex-husband	44
18	51	Mother	27
19	51	Father	48
20	58	Father	20
21	24	Grandfather	22
22	49	Mother	21

Social Reactions and Consequences of Disclosing Suicide Loss

Participants in this study described a broad range of behaviors experienced shortly after disclosing, including (a) compassionate and supportive responses, (b) speechlessness and insecurity, (c) curiosity and gossip, (d) stigmatization, and (e) grieving expectations. Depending on these social reactions, participants reported positive and negative long-term effects of disclosing on (f) emotions and (g) social relationships.

Compassionate and Supportive Responses

Almost all participants reported situations in which they observed dismay and compassion among others after disclosing: “My closest friends reacted really well. They just held me and let me cry” (I20). However, for many participants, compassionate and comforting reactions eventually stopped after some time. Additionally, participants described that after their loss, they were supported by family and friends who helped with organizational issues (e.g., funeral planning, apartment liquidation), in everyday life (e.g., preparing meals), and with professional help-seeking. When disclosing suicide loss, participants felt supported by empowering reactions praising openness: “Many people gave us positive feedback that we had decided to talk about it [the suicide] so openly” (I8). However, for some participants, social support did not last long: “Directly afterward everyone in the family came together and supported us […] but then their support declined very quickly” (I3).

Speechlessness and Insecurity

Participants reported that after disclosing suicide loss, they often witnessed distress among the person with whom they shared the information: “Some people just can't understand it […] and I think they are overwhelmed themselves” (I4). One participant reported that when disclosing, she often experienced that others will “freeze […] and usually, the atmosphere of the conversation deteriorates” (I3). Participants also observed general speechlessness and insecurity among others when disclosing suicide loss: “People are very insecure and they don't know what to say” (I17). Another participant described that when disclosing suicide loss, she often has the feeling that others no longer respond authentically but “think about what I might want to hear” (I9). Participants also reported that many people respond with phrases such as “It will get better with time” or “Time is a great healer” (I13). While distress, speechlessness, and insecurity were generally described as unhelpful and hurtful, some participants also expressed their understanding toward such reactions: “I often think that it is not their fault because it is just really a difficult topic” (I9). One participant explained that, when she perceived distress and insecurity among others, she often actively “changed the topic of the conversation” (I21).

Curiosity and Gossip

Participants reported that they were often confronted with significant curiosity after disclosing suicide loss: “Sometimes there were outrageous questions […], for example, some people wanted to know the concrete content of his suicide notes” (I8). Most participants described such reactions as distressing: “It is rude. They do not respect my son’s and my personal boundaries” (I2). When openly communicating suicide loss, participants often experienced or perceived people gossiping about their loss, which was especially prominent in small towns or villages: “It is a small town with 10,000 inhabitants, there is a lot of gossip and we were surely the main topic for a couple of weeks” (I20). For some participants, gossip was experienced as extremely hurtful: “People were gossiping from the start […]. That was actually the worst thing for me” (I14).

Stigmatization

Participants reported stigmatizing attitudes among others toward the deceased person and toward themselves. Stigmatizing attitudes toward people who die by suicide were visible in statements such as: “Others said that he is totally selfish, that he only thinks about himself” (I13). However, whether others expressed their understanding toward those deceased by suicide greatly depended on the particular circumstances of the suicide. Suicide without a seemingly understandable explanation, for example, among younger people and those who had children, generally triggered condemnation: “There is always a lack of understanding and others question […] how he could possibly do such a thing. […] Because he had a daughter and he just got married” (I17). Devaluation also led to strong emotional reactions, including hate and anger: “Quite a lot of people said that if they were me, they would hate him because what he did to me was not fair” (I4). In contrast, people’s understanding toward suicide was higher, when they identified reasons that seemed apparent and comprehensible to them: “Most people could understand him [the deceased person] because they knew about his suffering with mental illness” (I16).

Participants also described stigmatizing attitudes from others toward themselves. For example, many reported that they were stared at (I6), treated as outcasts (I9), and avoided (I1). In addition, participants said that, due to their loss by suicide, others judged them and their family as tainted: “Your family is not perfect. You experienced suicide in both sides of your family, the maternal and the paternal side. So there must be something wrong with you” (I7). Some participants, especially those who lost a child or partner by suicide, reported that they were blamed for the suicide. One woman reported that she was often asked whether she “really didn’t noticed anything,” despite being in close contact (I8). For some participants, accusations by others led to self-blame: “Another person said: ‘Oh my God, you must feel guilty’ […] and only afterwards I started to think: ‘Oh my God, yes, I made great mistakes’” (I2). In contrast, some participants were never blamed for the suicide but were empowered to not feel guilty: “If anything, they encouraged us and told us that we are not to blame” (I14).

Grieving Expectations

When disclosing suicide loss, many participants experienced others to make comments about the general appropriateness, extent, and duration of grieving. This included suggestions that there is no need to grieve at all, for example, when a person’s relationship to the deceased was perceived as not close enough (e.g., ex-husband) or when suicide was perceived as a rational choice: “Why do you feel bad, your son chose this path” (I2). Participants also reported that understanding for their grief decreased with time: “They told me that I have to get over it, and that I cannot go on like this forever” (I9).

Emotions

Independent of social reactions, participants described the disclosure of suicide loss as relieving (I3). Similarly, keeping suicide loss secret was generally described as adding additional distress: “If I had to hide it, I think I would feel under pressure and I also would feel quite stressed from having to hide it” (I4). Many participants reported that disclosing suicide loss was crucial for their grieving process: “One advantage [of disclosing] is that you process trauma better when you talk about it” (I12). Nevertheless, talking about suicide loss was often accompanied by emotional distress: “The sadness always comes back, it comes back every time” (I19). Whether disclosure was experienced as positive greatly depended on reactions from others: “You think if I tell him that, […] he'll surely say something helpful to me. But that never really happened. People are usually quite […] insecure” (I19). When experiencing negative reactions on disclosing suicide loss, participants felt weak and helpless, and reacted with social withdrawal: “When such things happen, I often withdraw. Because I simply do not have the energy to deal verbally with the situation” (I10), and avoided further contact: “If people don’t react the way I hope they do, we aren’t friends anymore” (I9).

Relationships

Many participants reported that some friends and family members avoided them or broke off contact after disclosing, which was experienced as extremely hurtful: “That made me very sad for a long time” (I17). In contrast, for some participants, their relationship with friends and family members became even closer after disclosing suicide loss. Furthermore, openness about suicide loss led to contact with other suicide loss survivors, which was generally described as very helpful: “I was relieved to know that there is someone out there who […] has gone through something similar. […] Simply the certainty that I am not the only one […] was reassuring for me and gave me hope” (I4).

Discussion

This study sought to describe social reactions and associated consequences after disclosing suicide loss. We observed a wide range of social reactions that had both positive and negative long-term effects on participants’ emotions and relationships.

With regard to beneficial social reactions and associated consequences, participants described compassion and support from others and strengthened or new social relationships after disclosing. Suicide loss survivors can benefit from social support after bereavement, for example, by reduced depressive symptoms and suicidality as well as increased personal growth (Oexle & Sheehan, 2020; Spino et al., 2016). Participants in our study also described experienced positive disclosure reactions as relieving and crucial for coping with their loss. These findings are in line with the social–cognitive processing model, which suggests that disclosure is an essential aspect of processing stressful life events (Juth et al., 2015).

However, our findings also showed that suicide loss survivors can experience harmful social reactions after disclosing, including curiosity, stigmatizing behaviors, and inappropriate grieving expectations. In addition to feeling avoided by others, suicide loss survivors withdrew from others to avoid negative social reactions, leading to the degradation of their personal relationships. This is in line with previous research on the impact of suicide bereavement on social relationships (Azorina et al., 2019). Within this context, it is important to note that social isolation can inhibit healthy grieving and contribute to complicated grief (Nam, 2016), a form of prolonged bereavement reaction causing distress and impaired functioning (Horowitz et al., 2003). Furthermore, harmful social reactions in combination with impaired social connectedness due to avoidance and social withdrawal could increase distress and hopelessness and may therefore contribute to suicidal ideation among suicide loss survivors (Klonsky & May, 2015). It is also important to note that suicide loss survivors may also learn from their experiences with disclosure and therefore adapt their disclosure behavior. Over time, they may try to avoid or minimize negative contacts and try to be surrounded by people with whom they can talk openly with and from whom they can gain compassion and support instead.

Our findings indicate that the effects of disclosing suicide loss depend on reactions by other people. To ensure beneficial outcomes of disclosure among suicide loss survivors, interventions supporting suicide loss survivors in finding empathic and supportive confidants are needed. One potential intervention is Honest, Open, Proud (HOP), a program which was originally developed for people with mental illness to support them in their decisions about whether and to whom to disclose their mental illness to. A recent meta-analysis indicated a positive effect of HOP on stigma stress and self-stigma (Rüsch & Kösters, 2021). Currently, there are several adaptations for other social groups such as suicide attempt survivors; however, HOP for suicide loss survivors or a similar program is not yet available. Furthermore, recent research has shown that suicide loss survivors receive less social support than people bereaved by other causes, indicating a need to optimize social support in this vulnerable group (Logan et al., 2018; Pitman et al., 2017). Public interventions can equip members of the general public with the skills to provide helpful support for suicide loss survivors. Such interventions should focus on both knowledge (e.g., duration of grief, symptoms of grief, support strategies) and attitudes toward suicide and suicide loss survivors.

This is one of the first qualitative studies to comprehensively investigate social reactions experienced after suicide loss. As social experiences after suicide loss may vary depending on various aspects such as the type of relationship to the deceased and time passed since the loss occurred, we included a diverse sample of suicide loss survivors. Furthermore, we could reach people who tend not to talk about their loss with others (i.e., people with low help-seeking behavior).

However, some limitations need to be considered. As usual in qualitative research, we investigated a nonrepresentative sample. Furthermore, we only analyzed data from female suicide loss survivors, and therefore, transferability to male and nonbinary loss survivors are limited. As grief-related social experiences might differ among men, future research should identify strategies to successfully recruit male participants.

In conclusion, suicide loss survivors experience various beneficial and harmful social reactions when disclosing suicide loss, which are associated with both positive and negative disclosure outcomes. Therefore, our findings suggest that the beneficial effects of disclosing suicide loss may depend on experienced social reactions. Interventions to support suicide loss survivors in finding supportive confidants and to equip members of the general population with the skills to provide helpful social support could improve grieving outcomes after suicide loss. Finally, to better understand social support after suicide loss and develop effective interventions, future research should also investigate specific social support needs among suicide loss survivors as well as public knowledge and attitudes toward suicide and suicide loss survivors and their impact on the general public’s readiness to provide social support.

Biographies

Author Biographies

Lea Mayer, MSc, is a research assistant and doctoral student at the Department of Psychiatry II, Ulm University and BKH Günzburg, Germany. She is currently working on several projects focusing on suicide stigma and the disclosure of suicide-related experiences.

Nadja Puschner, BSc, is a research assistant at the Department of Psychiatry II at Ulm University and BKH Günzburg, Germany. Her research interests are in the field of mental health care and suicide prevention.

Nicole Votruba is a postdoctoral researcher at the Nuffield Department of Women's & Reproductive Health at the University of Oxford, UK, and at the George Institute for Global Health, London, UK. Dr. Votruba is interested in global health/mental health, women's mental health, implementation science, stigma/discrimination, gender, and science–policy interrelationships.

Nicolas Rüsch, MD, MSt, is a professor of public mental health and a consultant psychiatrist at the Department of Psychiatry II, Ulm University and BKH Günzburg, Germany. Dr. Rüsch works on mental illness stigma, (un)employment and mental health, stigma and care-seeking, and the evaluation of antistigma interventions.

Nathalie Oexle, MSc, PhD, is an assistant professor at the Department of Psychiatry II, Ulm University and BKH Günzburg, Germany. Her research is focused on the identification, development, and evaluation of innovative approaches to suicide prevention, with a particular interest in interventions targeting societal attitudes about suicide.

Funding Statement

Funding: Open access publication enabled by Ulm University, Germany.