Levels of grief

Losing a loved to suicide is one is one of life's most painful experiences. The feelings of loss, sadness, and loneliness experienced after any death of a loved one are often magnified in suicide survivors by feelings of quilt, confusion, rejection, shame, anger, and the effects of stigma and trauma. Furthermore, survivors of suicide loss are at higher risk of developing major depression, post-traumatic stress disorder, and suicidal behaviors, as well as a prolonged form of grief called complicated grief. Added to the burden is the substantial stigma, which can keep survivors away from much needed support and healing resources. Thus, survivors may require unique supportive measures and targeted treatment to cope with their loss. After a brief description of the epidemiology and circumstances of suicide, we review the current state of research on suicide bereavement, complicated grief in suicide survivors, and grief treatment for survivors of suicide.

Keywords: suicide bereavement, complicated grief, grief, bereavement, suicide Introduction Nearly 1 million people die by suicide globally each year.1 Suicide is one of the top ten leading causes of death across all age groups. Worldwide, suicide ranks among the three leading causes of death among adolescents and young adults. During 2008-2009, 8.3 million people over age 18 in the United States (3.7% of the adult US population) reported having suicidal thoughts in the last year, and approximately 1 million people (0.5% of the adult US population) reported having made a suicide attempt in the last year. There were just under 37 000 reported deaths by suicide (completed suicides) during the same time period, and almost 20 times that number of emergency room visits after nonfatal suicide attempts.2 Rates of suicidal thoughts and behaviors vary by age, gender, occupation, region, ethnicity, and time of year. According to a 2011 report2 released by the CDC, in 2008, the highest prevalence of suicidal thoughts, plans, and attempts among those surveyed in the US was reported by adults aged 18 to 29 years, non-Hispanic white males, people who were unemployed, and people with less than a high school education. There were no reported differences in the rates of suicide attempts by geographical region, though people living in the Midwest region of the US were most likely to have made a suicide plan in the last year, and those in the Midwest and Western region of the US reported the highest prevalence of suicidal ideation. While rates of completed suicides tend to be higher among men than women and higher among middle aged or older adults than among younger people, rates of nonfatal suicidal behavior are higher among females and adolescents and young adults.1

The most commonly employed methods of suicide are by gunshot, hanging, drug overdose or other poisoning, jumping, asphyxiation, vehicular impact, drowning, exsanguination, and electrocution. There are other indirect methods some attempters may employ, such as behaving recklessly or not taking vitally required medications. Many suicides go unreported, as it can be difficult to identify indirect suicide attempts as suicide, and even some of the more direct methods of suicide may not be clearly identifiable attempts. For example, drug overdoses or vehicular impact attempts are more passive methods, and it may be difficult to determine whether an event was an attempt or accident. Conversely, accidental drug overdoses can often be confused with suicide attempts. If the deceased left behind a note or told someone about their plans or intent to take their own life, this can help those left behind, the suicide survivors, to distinguish between an attempt and an accident, but often no such explanation exists.

Nearly 90% of all suicides are associated with a diagnosable mental health or substance-abuse disorder.3 The underlying vulnerability of suicidal behavior is the subject of intense research scrutiny, and includes biological, social, and psychological underpinnings.4-8 While depression and bipolar disorder are the most common disorders among people who attempt suicide, suicide attempters may also suffer from substance abuse disorders, other psychiatric disorders such as schizophrenia, and may feel that suicide is the only way to end an unbearable pain they may be feeling as the result of their mental illness, trauma, or a significant loss, rejection, or disappointment. Additionally, a past history of suicide attempts is the best predictor for future attempts.9 Common themes among suicide attempters are feelings of hopelessness, despair, and isolation from family and friends. Despite loved ones' and professionals' best efforts to support them in their suffering, suicide attempters are often unable to think clearly and rationally through their pain.

It is estimated that 85% of people in the United States will know someone personally who has completed suicide.3 For each suicide completed, at least 6 loved ones are directly affected by the death.While not everyone exposed to a suicide will be acutely affected by the death, this is likely an underestimation as reported figures may not account for the emergency responders, health care providers, coworkers, and acquaintances also affected by the suicide. That said, individuals most closely related to the deceased are usually those most adversely affected by the death.

Grief reactions and characteristics Grief is the universal, instinctual and adaptive reaction to the loss of a loved one. It can be subcategorized as acute grief, which is the initial painful response, integrated grief, which is the ongoing, attenuated adaptation to the death of a loved one, and finally complicated grief (CG), which is sometimes labeled as prolonged, unresolved, or traumatic grief. CG references acute grief that remains persistent and intense and does not transition into integrated grief.

Acute grief After the death of a loved one, regardless of the cause of death, bereaved individuals may experience intense and distressing emotions. Immediately following the death, bereaved individuals often experience feelings of numbness, shock, and denial. For some, this denial is adaptive as it provides a brief respite from the pain, allowing time and energy to accept the death and to deal with practical implications: interacting with the coroner's office, planning a funeral, doing what is necessary for children or others affected by the loss and settling the estate of the deceased. But, for most, the pain cannot be put off indefinably. It may not be until days, weeks, or even months following the death that the reality is fully comprehended, both cognitively and emotionally, and the intense feelings of sadness, longing, and emptiness may not peak until after that recognition sets in. Indeed, grief has been described as one of the most painful experiences an individual ever faces. Shock, anguish, loss, anger, guilt, regret, anxiety, fear, intrusive images, depersonalization, feeling overwhelmed, loneliness, unhappiness, and depression are just some of the feeling states often described.

Feelings of anguish and despair may initially seem everpresent but soon they occur predominantly in waves or bursts—the so-called pangs of grief—brought on by concrete reminders of or discussions about the deceased. Once the reality of the loss begins to sink in, over time, the waves become less intense and less frequent. For most bereaved persons, these feelings gradually diminish in intensity, allowing the individual to accept the loss and re-establish emotional balance. The person knows what the loss has meant to them but they begin to shift attention to the world around them.

Integrated grief Under most circumstances, acute grief instinctively transitions to integrated grief within several months. However, as described later, this period may be substantially extended for those who have lost a loved one to suicide. The hallmarks of “healing” from the death of a loved one are the ability of the bereaved to recognize that they have grieved, to be able to think of the deceased with equanimity, to return to work, to re-experience pleasure, and to be able to seek the companionship and love of others. For many, new capacities, wisdom, unrecognized strengths, new and meaningful relationships, and broader perspectives emerge in the aftermath of loss. However, a small percentage of individuals are not able to come to such a resolution and go on to develop a “complicated grief” reaction.16

Complicated grief CG is a bereavement reaction in which acute grief is prolonged, causing distress and interfering with functioning. The bereaved may feel longing and yearning that does not substantially abate with time and may experience difficulty re-establishing a meaningful life without the person who died. The pain of the loss stays fresh and healing does not occur. The bereaved person feels stuck; time moves forward but the intense grief remains. Symptoms include recurrent and intense pangs of grief and a preoccupation with the person who died mixed with avoidance of reminders of the loss. The bereaved may have recurrent intrusive images of the death, while positive memories may be blocked or interpreted as sad, or experienced in prolonged states of reverie that interfere with daily activities. Life might feel so empty and the yearning may be so strong that the bereaved may also feel a strong desire to join their loved one, leading to suicidal thoughts and behaviors. Alternatively, the pain from the loss may be so intense that their own death may feel like the only possible outlet of relief.

Some reports suggest that as many as 10% to 20% of bereaved individuals develop CG. Notably, survivors of suicide loss are at higher risk of developing CG. CG is associated with poor functional, psychological, and physical outcomes. Individuals with CG often have impairments in their daily functioning, occupational functioning, and social functioning. They have increased rates of psychiatric comorbidity, including higher rates of comorbid major depression and posttraumatic stress disorder (PTSD). Furthermore, individuals with CG are at higher risk for suicidal ideation and behavior. Additionally, CG is associated with poor physical health outcomes. Overall, untreated CG results in suffering, impairment, and poor health outcomes, and will persist indefinitely without treatment.

Bereavement after suicide Suicide survivors often face unique challenges that differ from those who have been bereaved by other types of death. In addition to the inevitable grief, sadness, and disbelief typical of all grief, overwhelming guilt, confusion, rejection, shame, and anger are also often prominent. These painful experiences may be further complicated by the effects of stigma and trauma. For these reasons, grief experienced by suicide survivors may be qualitatively different than grief after other causes of death. Thus, while found no significant differences in rates of comorbid psychiatric disorders and suicidality among suicide bereaved individuals compared with other bereaved individuals across studies, they did find higher incidences of rejection, blaming, shame, stigma, and the need to conceal the cause of death among those bereaved by suicide as compared with other causes of death. certain characteristics of suicide bereavement that are qualitatively different from other forms of bereavement may lead to delays in survivors' healing.

Need to understand, guilt, and responsibility Most suicide survivors are plagued by the need to make sense of the death and to understand why the suicide completers made the decision to end their life. A message left by the deceased might help the survivors understand why their loved one decided to take his or her own life. Even with such explanations there are often still unanswered questions survivors feel they are left to untangle, including their own role in the sequence of events.

Another common response to a loved one's suicide is an overestimation of one's own responsibility, as well as guilt for not having been able to do more to prevent such an outcome. Survivors are often unaware of the many factors that contributed to the suicide, and in retrospect see things they may have not been aware of before the event. Survivors will often replay events up to the last moments of their loved ones' lives, digging for clues and warnings that they blame themselves for not noticing or taking seriously enough. They might recall past disagreements or arguments, plans not fulfilled, calls not returned, words not said, and ruminate on how if only they had done or said something differently, maybe the outcome would have been different.

Parents who have lost a child to suicide can be especially afflicted with feelings of guilt and responsibility.40 Parents who have lost a child to suicide report more guilt, shame, and shock than spouses and children. They often think “If only I had not lost my temper” or “If only I had been around more.” The death of child is arguably the most difficult type of loss a person can experience, particularly when the death is by suicide. Parents feel responsible for their children, especially when the deceased child is young. Indeed, age of the suicide deceased has been found to be one of the most important factors predicting intensity of grief.

While guilt is not a grief response specific to death by suicide, it is not uncommon for a survivor to view the suicide as an event that can be prevented. Therefore, it is easy for survivors to get caught up in self-blame. Understanding that most suicide completers were battling a psychiatric illness when they died helps some survivors make sense of the death and can decrease self-blame.

Rejection, perceived abandonment, and anger Survivors of suicide may feel rejected or abandoned by the deceased because they see the deceased as choosing to give up and leave their loved ones behind. They are often left feeling bewildered, wondering why their relationship with the person was not enough to keep them from taking their lives. One survivor told us that when she had shared her own suicidal ideation with her sister, her sister made her promise to never act upon her suicidal thoughts. When her sister took her own life, this survivor not only felt abandoned, but she also felt deceived. She felt angry about this perceived deception, she felt angry for being left behind to deal with life's stresses without her sister, and she felt angry that her sister put her and her family through the pain of dealing with her death by suicide. She was now alone.

Suicide bereaved spouses often struggle because the marriage may be the most intimate relationship an individual ever experiences, and to be left by a self-inflicted death can feel like the ultimate form of rejection.Children who lose their parents to suicide are left to feel that the person whom they count on the most for the most basic needs has abandoned them. Results of one study suggest that children whose parents completed suicide and had an alcohol-use disorder were less likely to feel guilty or abandoned, and suicide bereaved spouses whose partners had an alcohol-use disorder were more likely to react with anger than other suicide bereaved spouses.

Anger is a common emotion among many survivors of suicide. It can be experienced as anger at the person who died, at themselves, at other family members or acquaintances, at providers, at God, or at the world in general. Often survivors feel angry at themselves for feeling angry, as they also recognize that the deceased was suffering greatly when deciding to die. Survivors may also feel angry towards other family members or mental health providers for not doing more to prevent the death and angry towards the deceased for not seeking help. A few survivors told us that their loved ones took their lives after a shameful behavior was revealed and/or in the midst of strained relationships. Survivors under these circumstances often feel anger at the deceased for depriving them of the opportunity to work through the difficult time or for not taking responsibility for their behavior