In this study of trait shame in attempted suicide, three findings add to previous knowledge on the connection between shame and suicidal behavior: male and female suicide attempters differed in the disposition to shame, female suicide attempters with BPD were highly shame-prone, and male non-BPD suicide attempters reported relatively low shame-proneness.
These results, with the highest and
lowest shame levels found in subgroups of suicide attempters, were unexpected. Previous research has reported increased
shame only, in relation to suicidal behavior
]. In the studies by Lester
] and by Hastings and coworkers
], the relationship was demonstrated by correlations between shame and suicide ideation (Beck Depression Inventory, item 9
]; Symptom Checklist 90, item 16
]), assessed by questionnaires to college students. In contrast, we examined individuals who were psychiatric patients and had actually attempted suicide. A similar difference between populations may explain the discrepancy between our findings and Tangney and Dearing
], who found that childhood shame-proneness predicted suicide attempts in adolescence or early adulthood. Even though the young participants in their study reported that they had attempted suicide in their late teens, their degree of psychopathology was likely lower than in our subjects, who were recruited to the study after a suicide attempt severe enough to call for a psychiatric emergency consultation, or referred for treatment of chronic suicidal behavior. The finding of relatively low shame-proneness in male suicide attempters in the present study also challenges findings from a previous qualitative study by our research group, where several male suicide attempters expressed feelings of shame or described shame reactions after their suicide attempt
]. Though both groups were relatively small and more research is needed to draw any definite conclusions, it is still worth reflecting on the possible meaning of these seemingly contradictory results. The interviews in our qualitative study focused on specific experiences in connection with the suicide attempt, and the shame descriptions could thus be conceptualized as state shame in a desperate situation. The TOSCA inventory, on the other hand, captures propensity to shame in less extreme situations. Low shame-ratings on TOSCA could also be due to difficulties in recognition or acknowledgement of shame feelings. Denial or unawareness of shame is well-known in the theoretical shame literature
], but the phenomenon has rarely been described in empirical research
]. Our previous interview study also included respondents’ reports of non-verbal shame behaviors (e.g., wanting to hide). Therefore, the respondents themselves did not have to conceptualize their experiences as shame. Furthermore, some suicidal men may be genuinely less shame-prone in everyday life, but still experience shame in connection with a suicide attempt. If these men are unfamiliar with shame experiences or tend to repress such feelings, the shame experience of surviving a suicide attempt might be especially painful. It would thus be important to cautiously help these patients endure the aftermath of the suicide attempt by making psychiatric care easily accessible even if the patients do not express their feelings or communicate their need for help. A respectful and non-demanding stance from the psychiatric personnel may reduce the shame experience of the patient
High levels of shame-proneness were seen among the attempted suicide BPD patients. There were only three men with BPD in the study and more research on shame in this population is thus needed. The finding of high shame-proneness in attempted suicide BPD women is consistent with previous research on shame in BPD
]. It has not been clear whether the shame-proneness in this group is related to the high rates of suicidality in BPD. The results of the present study, with less elevated levels of shame-proneness in attempted suicide women other than BPD, suggest that the shame-proneness is related to the BPD psychopathology and not a reflection of high shame-proneness in suicidal individuals in general. This hypothesis has to be investigated in future studies, which also include non-suicidal BPD participants. Being aware of the high shame-proneness in BPD women can be clinically important. These patients often have difficulties in identifying and expressing their emotions. Shame should be considered when patients exhibit behaviors like non-attendance, silence, and anger
]. However, patients’ emotions should always be assessed, not assumed
]. The present study also confirmed the previously described connection between shame-proneness and depression
This study has several limitations. Firstly, both the attempted suicide patients and the non-suicidal patients were convenience samples from different clinical research projects. This resulted in a high proportion of women with BPD, relatively few attempted suicide men and only three attempted suicide men with BPD. Thus, future research should include larger groups of attempted suicide men and could also benefit from investigating shame-proneness in diagnostically homogeneous groups of attempted suicide patients other than BPD. The non-suicidal patients were all employees on long-term sick leave for depressive disorders and work related stress. These patients represent only a subgroup of psychiatric outpatients, and their levels of shame-proneness might not be representative for other groups of patients. Thus, shame-proneness in other non-suicidal psychiatric comparison groups should be investigated. Secondly, shame-proneness was measured by self-ratings on a scenario-based instrument. The scenarios in TOSCA might not be appropriate for all populations. For example, several of the scenarios in TOSCA depict work-related situations. However, TOSCA has been used in other studies of psychiatric patients (e.g.
]) and the patients in our study were outpatients with educational and vocational experiences broadly comparable with non-patients (e.g., more than 95% of the patients had some work experience). A more important concern is if some TOSCA response alternatives may be difficult to acknowledge for groups of respondents, e.g. men who attempt suicide may be less aware of feelings of incompetence or smallness, or hesitate to admit such feelings. One article has also argued that the TOSCA instrument might be less appropriate for male respondents in general
]. Therefore, future research on shame in suicidal individuals should benefit from investigating shame with several different methods. It must also be remembered that TOSCA measures recognized and admitted propensity to shame in everyday life and that shame-proneness is not a measure of the absolute capacity to experience shame.