Nature of grief

Grief is the normal internal feeling one experiences in reaction to a loss, while bereavement is the state of experiencing that loss. Although people often suffer emotional pain in response to loss of anything that is very important to them (for example, a job, a friendship or other relationship, one’s sense of safety, a home), grief usually refers to the loss of a loved one through death.

Complicated grief

Although not a formal medical diagnosis, prolonged or complicated grief refers to a reaction to loss that lasts more than one year. It is characterized by the grief reaction intensifying to affect the sufferer’s close relationships, disrupting his or her beliefs, and it tends to result in the bereaved experiencing ongoing longing for their deceased loved one. About 15% of bereaved individuals will suffer from complicated grief, and one-third of people already getting mental-health services have been found to suffer from this extended grief reaction.

Anticipatory grief

Anticipatory grief is defined as the feelings loved ones have in reaction to knowing that someone they care about is terminally ill. It occurs before the death of the afflicted loved one and can be an important part of the grieving process since this allows time for loved ones to say goodbye to the terminally ill individual, begin to settle affairs, and plan for the funeral or other rituals on behalf of the person who is dying.

Mourning

Mourning is the outward expression of that loss. It usually involves culturally determined rituals that help mourners make sense of the end of their loved one’s life and give structure to what can feel like a very confusing time. Therefore, while the internal pain of grief is a more universal phenomenon, how people mourn is influenced by their personal, familial, cultural, religious, and societal beliefs, and customs.

Everything from how families prepare themselves and their loved ones for death, and understand and react to the passing to the practices for preserving memories of the deceased, their funeral or memorial, burial, cremation, or other ways of handling the remains of the deceased is influenced by internal and external factors.

Mourning period

The length of time for a formal mourning period and sometimes the amount of bereavement leave people are allowed to take from work is determined by a combination of personal, familial, cultural, religious, and societal factors. Mourning customs also affect how bereaved individuals may feel comfortable seeking support from others as well as the appropriate ways for their friends and family to express sympathy during this time.

For example, cultures may differ greatly in how much or how little the aggrieved individual may talk about their loss with friends, family members, and coworkers and may determine whether or not participating in a bereavement support group or psychotherapy is acceptable.

What are the effects of losing a loved one?

The potential negative effects of a grief reaction can be significant. For example, research shows that about 40% of bereaved people will suffer from some form of anxiety disorder in the first year after the death of a loved one, and there can be up to a 70% increase in death risk of the surviving spouse within the first six months after the death of his or her partner.

For these reasons, questionnaires that assess how much stress a person is experiencing usually place the loss of a loved one at the top of the list of the most serious stresses to endure. When considering the death of a loved one, the effects of losing a pet should not be minimized.

Pets are often considered another member of the family, and therefore their loss is grieved as well. Making the decision to euthanize (painlessly put to death) the family pet once a family works with their veterinarian to determine that the pet is suffering as a result of their age, specific illness, and/or general declining health can add stress to the bereavement process by leaving family members feeling guilty initially, but if done properly, can help families understand that they spared their beloved pet unnecessary suffering.

In addition to grief as an initial reaction to loss, the process can be aggravated by events that remind the bereaved individual of their loved one or the circumstances surrounding their loss. Such events are often referred to as grief triggers.

For instance, the beginning of the school year may cause the parent who has lost a child (or a child who has lost a parent) to feel distraught. A shared song, television show, or activity can cause anguish by reminding the widower of the wife he lost or the child of the grandparent who is no longer living. Watching another child play with a pet may reduce a child whose pet has died to tears.

Stages of grief

In 1969, a Swiss-American psychiatrist named Elizabeth Kübler-Ross wrote in her book “On Death and Dying” that grief could be divided into five stages. Her observations came from years of working with terminally ill individuals. Her theory of grief became known as the Kübler-Ross model. While it was originally devised for people who were ill, these stages of grief have been adapted for other experiences with loss, too.

The five stages of grief may be the most widely known, but it’s far from the only popular stages of grief theory. The five stages of grief are denial, anger, bargaining, depression and acceptance. Not everyone will experience all five stages, and you may not go through them in this order. Grief is different for every person. Some people may begin coping with loss in the bargaining stage and find themselves in anger or denial next. Other people may remain for months in one of the five stages but skip other stages entirely.

Stage 1: Denial

Grief is an overwhelming emotion. It’s not unusual to respond to the intense and often sudden feelings by pretending the loss or change isn’t happening. Denying it gives time to more gradually absorb the news and begin to process it. This is a common defense mechanism and helps numb the intensity of the situation. As people move out of the denial stage, however, the emotions they have been hiding will begin to rise. They will be confronted with a lot of sorrow they have denied. That is also part of the journey of grief, but it can be difficult.

Stage 2: Anger

Where denial may be considered a coping mechanism, anger is a masking effect. Anger is hiding many of the emotions and pain that you carry. This anger may be redirected at other people, such as the person who died, partner or an old boss. Anger may be aimed at inanimate objects.

Though the rational brain knows that the object of anger is not to be blamed, the feelings at that moment are too intense to feel that Anger may mask itself in feelings like bitterness or resentment. It may not be clear-cut fury or rage. Not everyone will experience this stage, and some may linger here. As the anger subsides, however, people may begin to think more rationally about what’s happening and feel the emotions they have been pushing aside.

Stage 3: Bargaining

During grief, persons may feel vulnerable and helpless. In those moments of intense emotions, it’s not uncommon to look for ways to regain control or to want to feel that one can can affect the outcome of an event. In the bargaining stage of grief, people may find themselves creating a lot of “what if” and “if only” statements.

It’s also not uncommon for religious individuals to try to make a deal or promise to God or a higher power in return for healing or relief from the grief and pain. Bargaining is a line of defense against the emotions of grief. It helps postpone the sadness, confusion, or hurt.

Stage 4: Depression

Whereas anger and bargaining can feel very “active,” depression may feel like a “quiet” stage of grief. In the early stages of loss, people may be running from the emotions, trying to stay a step ahead of them. By this point, however, they may be able to embrace and work through them in a more healthful manner.

They may also choose to isolate themselves from others in order to fully cope with the loss. That doesn’t mean, however, that depression is easy or well defined. Like the other stages of grief, depression can be difficult and messy. It can feel overwhelming. People may feel foggy, heavy, and confused.

Depression may feel like the inevitable landing point of any loss. However, if people feel stuck here or can’t seem to move past this stage of grief, they must talk with a mental health expert. A therapist can help them work through this period of coping.

Stage 5: Acceptance

Acceptance is not necessarily a happy or uplifting stage of grief. It doesn’t mean people have moved past the grief or loss. It does, however, mean that they have accepted it and have come to understand what it means in their life now. People may feel very different in this stage. That’s entirely expected. They have had a major change in their life, and that upends the way they feel about many things. Look to acceptance as a way to see that there may be more good days than bad, but there may still be bad — and that’s OK.

The 7 stages of grief

The seven stages of grief are another popular model for explaining the many complicated experiences of loss. These seven stages include:

• Shock and denial. This is a state of disbelief and numbed feelings.
• Pain and guilt. People may feel that the loss is unbearable and that they are making other people’s lives harder because of their feelings and needs.
• Anger and bargaining. People may lash out, telling God or a higher power
• that they will do anything they ask if they’ll only grant them relief from these feelings.
• Depression. This may be a period of isolation and loneliness during which
• you process and reflect on the loss.
• The upward turn. At this point, the stages of grief like anger and pain have
• died down, and people are left in a more calm and relaxed state.
• Reconstruction and working through. People can begin to put pieces of
• their life back together and carry forward.
• Acceptance and hope. This is a very gradual acceptance of the new way of
• life and a feeling of possibility in the future.

As an example, this may be the presentation of stages from a breakup or divorce:

• Shock and denial: “She absolutely wouldn’t do this to me. She’ll realize she’s wrong and be back here tomorrow.”
• Pain and guilt: “How could she do this to me? How selfish is she? How did I mess this up?”
• Anger and bargaining: “If she’ll give me another chance, I’ll be a better boyfriend. I’ll dote on her and give her everything she asks.”
• Depression: “I’ll never have another relationship. I’m doomed to fail everyone.”
• The upward turn: “The end was hard, but there could be a place in the future where I could see myself in another relationship.”
• Reconstruction and working through: “I need to evaluate that relationship and learn from my mistakes.”
• Acceptance and hope: “I have a lot to offer another person. I just have to meet them.”

What are the causes and risk factors of prolonged grief?

The risk factors for experiencing more serious symptoms of grief for a longer period of time can be related to the physical and emotional health of the survivor before the loss, the relationship between the bereaved and their loved one, as well as to the nature of the death. For example, it is not uncommon for surviving loved ones who had a contentious or strained relationship, or otherwise unresolved issues with the deceased to suffer severe feelings of sorrow.

Parents who have lost their child are at a significantly higher risk of divorce compared to couples that have not. They are also at increased risk for a decline in emotional health, including being psychiatrically hospitalized following the loss. This is a particular risk for mothers who have lost a child.

What are the signs and symptoms of grief?

In addition to the emotional pain, symptoms of grief can be physical, social, cultural, or religious in nature. Physical symptoms can range from mild sleep or appetite problems to heart attack. Social symptoms of bereavement include isolation from other loved ones and difficulty functioning at home, school, and/or at work.

For children and adolescents, reactions to the death of a parent or other loved one tend to be consistent with their reaction to any severe stress. Such reactions usually reflect the particular developmental stage of the child or adolescent.

For example, since infants up to about 2 years of age cannot yet talk, their reaction to the loss of a loved one tends to involve crying and being more irritable or clingy. They further show physical symptoms of sleep or appetite problems, changes in activity level, and
being more watchful of (vigilant toward) their surroundings.

Since preschoolers from 3 to 5 years of age begin to be able to remember the one who died but have not yet developed the ability to understand the permanence of death, they may believe they somehow magically caused the death and can make the person come back. In addition to showing signs of grief that are similar to infants, they may have more difficulty separating from caregivers.

Early school-aged children, from 6 to 8 years of age, more likely understand that death is permanent compared to younger children, often feel guilt about the death of the loved one, become preoccupied with memories about the departed, and try to master the loss they have suffered by talking about it frequently.

While symptoms of grief in school-aged children from 9 to 11 years of age are quite similar to those of early school-aged children, this older group is more vulnerable to a decrease in self-esteem because they feel different from their peers if they have experienced the loss of a loved one. They are also more prone to defend against their feelings of sorrow by becoming engrossed in school, social, and/or extracurricular activities.

In keeping with their budding need for independence, young adolescents 12 to 14 years of age may experience mixed feelings about the deceased individual and exhibit a wide range of emotions. They may avoid talking about the loss.

Older teens usually experience grief similarly to adults, enduring sadness,  anxiety, and anger. They tend to deny their feelings of loss to parents but discuss them in detail with peers. For children, adolescents, and adults, as with any major stress, grief may cause a person to regress emotionally, in that they go back to former, often less mature ways of thinking, behaving, and coping.

How do health care professionals assess grief?

Although practitioners sometimes use paper and pencil survey tests to determine if a person is suffering from grief, the assessment is usually made by the health-care professional asking questions to assess what symptoms an individual is experiencing, then considering whether he or she is suffering from normal grief, complicated grief, or some other issue.

Those questions tend to explore whether there are emotional, physical, and/or social symptoms of grief, and if so, how severe and how long the symptoms have been present. The practitioner may also try to determine what stages of the grief process the person has experienced and what stage currently dominates their feelings at the time of the assessment.

How can people cope with grief?

There remains some controversy about how to best help people survive the loss of a loved one. While many forms of support are available and do help certain individuals, little scientific research has shown clear benefits for any particular approach for grief reactions in general. That is thought to be because each approach to support is so different that it is hard to scientifically compare one to another, intervention procedures are not consistently reported in publications, and the ways these interventions have been studied are flawed.

Although there has been some concern that grief counseling for uncomplicated grief sufferers works against bereavement recovery, there is research to the contrary. One approach to treating grief is the dual process model, which endorses the bereavement process as being the dynamic struggle between the pain of the death of the loved one (loss-oriented) and recovery (restoration-oriented). This model of treatment recommends that bereaved individuals alternate between directly working on their loss (confrontation) and taking a break from (avoidance) that process when appropriate. For couples that are grieving the occurrence of a miscarriage, brief professional counseling has been
found to be helpful.

Journaling can be an effective way of management of bereavement rather than just stirring up painful feelings. Though there are not strict rules to the process of journaling, some of the ideas encouraged include limiting the time journaling to 15minutes per day or less to decrease the likelihood of worsening grief, writing how one imagines his or her life will be a year from the date of the loss, and clearly identifying feelings to allow for easier tracking of the individual’s grieving process.

To help children and adolescents cope emotionally with the death of a friend or family member, it is important to ensure they receive consistent caretaking and frequent interaction with supportive adults. For children of school age and older, appropriate participation in school, social, and extracurricular activities is necessary to a successful resolution of grief. For adolescents, maintaining positive relationships with peers becomes important in helping teens figure out how to deal with grief.

Depending on the adolescent, they even may find interactions with peers and family more helpful than formal sources of support like their school counselor. All children and teens can benefit from being reassured that they did not cause their loved one to die, and such reassurance can go a long way toward lessening the developmentally appropriate tendency children and adolescents have for blaming themselves and any angry feelings they may have harbored against their lost loved one for the death.

Effective coping tips for grieving are nearly as different and numerous as there are bereaved individuals. The bereaved individual’s caring for him/herself through continuing nutritious and regular eating habits, getting extra rest, and communicating with surviving friends and families are some ways for grief sufferers to ease the grief process. The use of supportive structure can also go a long way to helping the aggrieved individual come to terms with their loss.

Anything from reciting comforting prayers or affirmations, to returning to established meal and bedtimes, as well as returning to work or school routines can help grieving individuals regain a sense of normalcy in their lives. As death involves the loss of an imperfect relationship involving imperfect individuals, forgiveness of the faults of the lost loved one and of the inherently imperfect relationship between the bereaved and the deceased can go a long way toward healing for the bereaved. While the painful aspects of dealing with death are clear, bereavement sometimes also leads to enhanced personal development.

Overview

Grief is universal. At some point in everyone’s life, there will be at least one
encounter with grief. It may be from the death of a loved one, the loss of a job, the end of a relationship, or any other change that alters life as you know it.

Grief is also very personal. It’s not very neat or linear. It doesn’t follow any timelines or schedules. People may cry, become angry, withdraw, feel empty. None of these things are unusual or wrong. Everyone grieves differently, but there are some commonalities in the stages and the order of feelings experienced during grief. The key to understanding grief is realizing that no one experiences the same thing. Grief is very personal, and people may feel something different every time. They may need several weeks, or grief may be years long.

If people decide they need help coping with the feelings and changes, a mental health professional is a good resource for vetting their feelings and finding a sense of assurance in these very heavy and weighty emotions.