The inter-relationship between suicide risk, mental illness, and stigma against mental illness is multi-faceted and strong. Both mental illness and suicide are highly stigmatized. The American Foundation for Suicide Prevention (AFSP) identifies mental illness as a significant risk factor for suicide. The Centers for Disease Control and Prevention (CDC) cite stigma associated with mental illness as a risk factor for suicide. When stigma provokes suicidality it becomes more potent and dangerous by joining with the stigma attached to suicide.
Suicide research and suicide prevention give considerable attention to mental illness as a suicide risk factor. This association is so robust that the World Health Organization (WHO) noted that it underlies one of the most prevalent myths of suicide, namely that “only people with mental disorders are suicidal.” This widely accepted misconception is itself stigmatizing to both persons with mental illness and those struggling with suicidality. Overstating the correlation between mental illness and suicide distorts public perceptions and may leave some feeling that their disorder has doomed them to suicide.
Stigma towards mental illness may be a significant contributor to the emergence of suicidal ideation, to the progression from thoughts of suicide to suicidal behavior, and, in some cases, to dying by suicide. The most compelling effects of mental health stigma that drive suicide risk are:
- The internalization of negative beliefs
- Social exclusion and isolation
- Loss of autonomy and community living
- Reduced social connections and support
- Diminished self-esteem and self-efficacy
- Avoiding treatment of both health and behavioral health problems
- Inhibiting engagement with providers and treatment
- Exacerbation of mental illness symptoms
These factors affect persons with mental illness at the individual psychological level. In his text, Why People Die by Suicide, psychologist Thomas Joiner presents a theoretical model of suicide that show how these factors combine and interact to set the stage for a potentially lethal suicide attempt. Joiner’s model posits two conditions that contribute to such an outcome. One is an intense desire to die. The other is the capability to take one’s life.
Intent to die may be brought on by an individual’s belief that he or she is a burden to those they care about and who would be better off if he or she were dead. Intent also originates in the feeling that someone is socially disconnected from family or friends. Neither of these feelings need necessarily be true to generate a desire to die leading to suicidal intent. Mental health stigma may directly produce a sense of burdensomeness and disconnectedness to one’s support system that can lead to suicidal ideation and, in some cases, to suicidal intent.
Concerning suicide risk, self-stigma may be the most pernicious consequence of mental health stigma. Internalizing public stigma with the stereotyping, discrimination, and prejudice it entails amplifies shame, guilt, and other negative feelings. The resulting self-assessment further confirms beliefs that one’s life has no value, meaning or purpose and that ending it would relieve others of the heavy emotional load it places on them.
The effects of mental health stigma can also extenuate the other component of Joiner’s model, the capability to die by suicide. In order to complete suicide, one must overcome the inborn resistance to lethal self-harm. The capability for suicide is acquired gradually through adverse life experiences that enhance an individual’s tolerance to circumstances that may cause pain or harm. This lessens the aversion to danger to self that deters suicidal behavior.
Mental health stigma can put an individual with mental illness in positions that weaken their resistance to self-harm. Chief among these is discouraging treatment adherence, which can cause emotional, psychological, and physical harm. Repeated and extended episodes of treatment nonadherence can gradually increase vulnerability to other forms of self-harm, including suicidal behavior.
Stigma can further the onset of the ability to end one’s life by impeding crisis intervention help seeking. If ongoing suicidal ideation is not checked, it can progress from vague thoughts of suicide to the specifics of how to suicide. Ruminating on a suicide plan lowers resistance to self-harm. Once the threshold from suicidal thinking to suicidal action is crossed, the risk of dying by suicide rises significantly. This occurs because the stigma accruing to suicide merges with mental health stigma and creates a risk multiplier for more dangerous self-injurious behavior.
Protective factors against suicide may be another casualty of mental health stigma. These are personal characteristics that moderate risk and make it less likely that individuals will become suicidal or die by suicide. Mental health wellness, the state of wellbeing that enables individuals to manage stress and effectively function in their lives and community, is an example of a suicide protective factor. Wellness is also an example of a personal defense against suicide that the corrosive action of stigma can undermine.
Other protective factors that may serve as buffers against suicidality in individuals with mental illness include:
- A sense of purpose, optimism, and self-esteem
- Good coping and problem-solving skills
- Strong connections to friends, family, and community support
- Access to mental health care and treatment adherence
- Supportive relationships with care providers
- Resilience and being adaptive to change
Each of these factors is susceptible to the negative impact of mental health stigma. Of course, at the same time the presence of these factors, particularly in combinations of two or more, can counteract the influence of stigma as well as the possible emergence of suicidality.
Recovery is another powerful personal suicide prevention resource negatively affected by stigma, which undoes everything that is gained. Stigma compromises wellness, overrides good coping mechanisms, and causes extreme stress. It brings anxiety, depression, and panic. It generates emotional pain and shatters feelings of control and safety. Stigma can substantially impede recovery and the obstruct the benefits it offers as a disincentive to suicidal thinking.
Ameliorating suicide risk must be a more prominent part of the rationale for combating stigma towards mental illness. Anti-stigma efforts may have a number of positive objectives and outcomes, but they can go further. They can help blunt suicide risk by addressing the suicidogenic aspects of mental health stigma. This would show the full measure of the debilitating influence of stigma on those with mental illness, their family members, their providers, and on the community as a whole.
Tony Salvatore is Director of Suicide Prevention for Montgomery County Emergency Services in Norristown, PA.