Introduction to Grief and Bereavement Issues

Kathryn Patricelli, MA, edited by Mark Dombeck, Ph.D.


While it is true that people require "air, food, water, clothing, and shelter,” in order to survive, we must also add "relationships" to this list because it is a rare person who is able to thrive in the absence of intimate relationships with other people, places, and things.

Grief is the process and emotions that we experience when our important relationships are significantly interrupted or (more frequently) ended, either through death, divorce, relocation, theft, destruction, or some similar process. A related term, “bereavement”, has different meanings for different people, but all meanings refer to the grieving process. While some view bereavement as a specific subtype of grief that occurs when a loved one (usually a spouse) dies, others think of the term as referring to the period of time during which grief is felt and losses are dealt with.

Grief starts when someone or something we care about is lost to us. We do not grieve for all lost relationships; instead, we grieve only for those that have become important to us over time. These can be relationships with people that we have strong connections to, such as family members, spouses, significant others, and friends; places we feel attached to, such as the house we grew up in or our hometown; or things that are important to us, such as love letters, a watch that a grandparent gave us, etc. We may have loved or hated that person, place, or thing, but we feel grief when they (or it) are gone.

There are two types of losses that we may grieve. The first is the actual loss of the person or thing in our lives. The second is the symbolic loss of the events that can no longer occur in the future because of that actual loss. For example, if a child is lost to parents, those parents lose not only their actual child, but also all the many events they expected to share with that child, including birthdays, graduations, wedding days, and other shared events large and small that make up the ongoing relationship with the lost child that is no longer possible because that child has died.

In many ways, we live our lives through our important relationships. Our relationships define us and who we are; they become intimately intertwined into our sense of self (or self-concept) and are thus a living part of us. It is terribly painful to lose one of these key relationships, because with the loss of such an important relationship, we also lose an important part of ourselves. For this reason, grief is not something that happens 'out there' in the world. Instead, it happens inside each grieving person's sense of self which is personally wounded and damaged by such losses. The work of grief is thus the personal work of healing and regrowing the sense of self.

Grief ends when we have gotten past the acute need for the lost other person or thing in our lives and are able to function normally without them. This doesn't mean that we stop feeling sad when we think about older losses; it only means that we are no longer significantly crippled by them.

Grief is a normal and natural process that takes work to get through. It is not easy to let go of close relationships that have existed in our lives. Dealing with the emotions that occur in the grieving process takes much time and energy, and is usually both physically and emotionally demanding. It is normal for people to grieve in very different ways. Some people grieve openly, while others hide their feelings of distress. Some people grieve quickly, while others take a long time to "finish." There is no "right way" to grieve. Each individual comes up with a method of grieving that fits them and their particular loss.

There are a number of conditions that can make it harder for a person to successfully make it through the grief process. For example, sudden losses are harder to deal with than ones that have been anticipated. With anticipated losses, the knowledge that a loss will occur allows people to prepare, both by feeling grief before the fact of the loss and also by planning ways to minimize the negative impact of the loss when it does occur.

The loss of a spouse, lover, child, parent, or best friend is usually more deeply felt than the loss of more distant relations and friends. This is because such central relationships have long and deeply felt histories and an intensity of attachment that does not occur with more distant relationships. Central relationships are more deeply and significantly intertwined into the grieving person's sense of self, and thus leave a bigger hole in the grieving person's sense of self when they are lost.

The amount of support a grieving person can draw upon is critical to how successfully he or she will cope with grief. The more that friends, family and community are present and supportive, and the more that the grieving person is able to accept offered support, the better the outcome tends to be. Isolated people tend to have a harder time.

The "fairness" of the loss is also important. Losses that challenge a grieving person's ability to believe that the world is predictable are harder to manage. It is easier to accept the loss of an aged parent who has lived a full life than it is to accept the loss of a child. Death by disease tends to be easier to accept than death by a random, senseless accident.


Stages and Process of Grief

Even though everyone grieves losses in slightly different ways, there are some regular patterns or stages of grieving that people usually experience. These patterns describe the emotions and mental processes that may be felt at different stages of the grief process.

Horowitz’s Model of Loss/Adaptation

Psychiatrist Mardi Horowitz divides the process of normal grief into the following "stages of loss." These stages are typical, but they don't occur for everyone or always in this exact order.

• Outcry. People often get upset when they first realize that they have lost someone important. They may publicly scream and yell; cry and collapse. Alternatively, they may hold their distress inside and not share it with others. Outcry feelings may be suppressed by the person who is feeling them so that the feelings are not felt too strongly, or they may spill out uncontrollably. In any event, initial outcry feelings take a lot of energy to sustain and tend to not last too long.
  
• Denial and Intrusion. As people move past the initial outcry, they will often enter a period characterized by movement between 'denial' and 'intrusion'. This means that people will experience periods where they distract themselves so thoroughly in other activities and thoughts they don't think about the loss, and also periods where the loss is felt very strongly and acutely, perhaps even as intensely as during the initial outcry stage. It is normal for people to bounce between these opposites of engagement and disengagement. People may feel guilty when they realize they are no longer constantly feeling their loss and are able to engage in other activities and emotions, but it is a good thing that this happens. Distraction and disengagement break up the intensity of feeling characteristic of the acute pain of loss so it is more manageable and less overwhelming.
  
• Working Through. As time goes by (days, weeks, months), the movement between denial (not thinking about or feeling the loss) and intrusion (thinking about and feeling the loss very intensely) tends to slow down and becomes less pronounced, with people spending more time not thinking about or feeling the loss, and less time being overwhelmed by it. During the working through stage, people think about and feel their loss, but also start to figure out new ways to manage without the lost relationship. Such new ways of managing might include making preparations to date again (or just starting to think about it), developing new friendships and strengthening existing ones, finding new hobbies, engaging in new projects, etc.
  
• Completion. At some point in time (months, years), the process of grieving is completed or rather, "completed enough", so that life has started to feel normal again. While memories remain of what has been lost, the feeling attached to the loss is less painful and no longer regularly interferes with the person's life. Temporary reactivation of grief feelings may occur on anniversaries important to the lost relationship (marriage and engagement dates, etc.), but such upwellings of hurt feeling tend to be temporary in nature.

Probably the most famous formulation of the stages of grief was developed by Dr. Elizabeth Kubler-Ross in her book "On Death and Dying". Dr. Kubler-Ross actually wrote about the stages that dying people tend to go through as they come to terms with the realization that they will soon be dead. However, her stages have since been borrowed by the larger grief community as a means of describing the grief process more generally. Coming to terms with dying is certainly a loss experience and an occasion for grief, so there is merit to this borrowing and reason to become familiar with Dr. Kubler-Ross' stages. Again, not everyone will experience all of these stages, or, if all are experienced, they won't necessarily occur in this particular order.

Kubler-Ross' first stage is Denial. In this stage, grieving people are unable or unwilling to accept that the loss has taken (or will shortly take) place. It can feel as though they are experiencing a bad dream, that the loss is unreal, and they are waiting to "wake up" as though from a dream, expecting that things will be normal.

After people have passed through denial and accepted that the loss has occurred (or will shortly occur), they may begin to feel Anger at the loss and the unfairness of it. They may become angry at the person who has been lost (or is dying). Feelings of abandonment may also occur.

Next comes Bargaining. In this stage, people beg their "higher power" to undo the loss, saying things along the lines of, "I'll change if you bring her (or him) back to me". This phase usually involves promises of better behavior or significant life change which will be made in exchange for the reversal of the loss.

Once it becomes clear that Anger and Bargaining are not going to reverse the loss, people may then sink into a Depression stage where they confront the inevitability and reality of the loss and their own helplessness to change it. During this period, grieving people may may cry, experience sleep or eating habit changes, or withdraw from other relationships and activities while they process the loss they have sustained. People may also blame themselves for having caused or in some way contributed to their loss, whether or not this is justified.

Finally (if all goes according to Dr. Kubler-Ross's plan), people enter a stage of Acceptance where they have processed their initial grief emotions, are able to accept that the loss has occurred and cannot be undone, and are once again able to plan for their futures and re-engage in daily life.



Therese Rando's Six R's

Researcher and Clinical Psychologist Therese Rando also has contributed a stage model of the grief process that she observed people to experience while adjusting to significant loss. She called her model the "Six R's":

• Recognize the loss: First, people must experience their loss and understand that it has happened.

• React: People react emotionally to their loss.

• Recollect and Re-Experience: People may review memories of their lost relationship (events that occurred, places visited together, or day to day moments that were experienced together).

• Relinquish: People begin to put their loss behind them, realizing and accepting that the world has truly changed and that there is no turning back.

• Readjust: People begin the process of returning to daily life and the loss starts to feel less acute and sharp.

• Reinvest: Ultimately, people re-enter the world, forming new relationships and commitments. They accept the changes that have occurred and move past them.

Though different in approach and ordering of stages, each of these three models of the grief process share common similarities. They all understand grief to involve an often a painful emotional adjustment which necessarily takes time and cannot be hurried along. This much appears to be universally true, although each person's grief experience will be unique.

Though each person grieves in unique ways, there are common behavioral, emotional, and physical signs and symptoms that people who are grieving typically experience.

• Physically, persons affected by grief may experience:
  • Fatigue and exhaustion alternating with periods of high alertness and energy
  • Temporary hearing loss or vision impairment (possibly associated with dissociation)
  • Difficulty sleeping
  • Disturbed appetite (either more appetite or less appetite than normal)
  • Muscle tremors
  • Chills and/or sweating
  • Difficulty breathing or rapid respiration
  • Increased heart rate or blood pressure
  • Stomach and/or intestinal problems
  • Nausea and/or dizziness
• Mentally, persons affected by grief may experience:
  • Confusion (memory, concentration, judgment and comprehension difficulties)
  • Intrusion (unwanted thoughts, arousal, nightmares)
  • Dissociation (feeling of detachment and unreality, disorientation, denial)
• Emotionally, persons affected by grief may experience:
  • Shock
  • Fear, anxiety or apprehension
  • Anger, irritability or agitation
  • Guilt
  • Numbness, remoteness, depression

• There are many ways that people can choose to cope with grief and loss in their lives, some constructive and some destructive. Among the more destructive coping methods are people's choice to turn to alcohol or other drugs to dull their pain and/or provide a illusory means of escape from the pressing demands of grieving. Heavy use of either drugs or alcohol may actually extend and prolong the grief period and lead to other serious problems such as substance abuse or dependence (otherwise known as addiction). Additionally, alcohol, and several other drugs and medicines including the benzodiazapines (like Valium, Atavan, Xanax and Klonapin), and the barbiturates have a depressant effect on the brain that can actually lead a person towards serious depression when misused. Magnified feelings of hopelessness and even suicidal thoughts may occur in such circumstances when they otherwise would not. Mixing alcohol with these depressant drugs can be fatal. For these reasons, if alcohol and drugs are to be used at all during a time of grief, their use should be limited, or they should be used as directed by a physician.
  Fortunately, there are many constructive and healthy ways to deal with grief. These can include:
  
  • Journaling – Many people find comfort in writing out their thoughts and feelings during the grieving period. Some even decide to write letters to the deceased or lost person. This can be a very good way to express feelings that people may not feel comfortable sharing with others and to avoid bottling up of emotions, which can extend the grief process or lead to other physical/emotional problems.
  • Talking with an Intimate – Others find that talking with a close family member or friend is beneficial and allows them to share memories about the lost relationship or emotions that they are feeling.
  • Getting Professional Help – Some people decide that they are not comfortable sharing their feelings with close friends and family. Alternatively, they may feel that they do not wish to burden those around them who are also suffering. In these cases, many choose to speak with a professional grief therapist. In a typical psychotherapy intervention, the therapist will both encourage the person to share feelings and thoughts about the loss and will encourage and challenge them to do things (such as to be a part of social activities, to exercise, etc.) that will help themselves to reengage life and get better. It can be an empowering process to speak with someone that understands the grief process and can help to normalize the emotions or reactions that are being felt.
    
  • Medication - Grief therapists and other doctors that might be consulted during times of grief may suggest that a prescription for anti-depressant or anti-anxiety medications would be helpful. When taken as directed by a doctor, such medicines can be extremely helpful for managing extreme grief symptoms (such as unremitting sadness, anxiety, or confusion, etc.). Since grief is not an illness so much as it is a life process, it is unwise to rely purely on medicines as a way to manage grief related pain. Properly used medicines can take the edge off the worst grief symptoms. They cannot speed the process of recovery and regrowth that must inevitably occur for grief to resolve.
  • Support Groups – For those that don’t want to speak to an intimate friend or family member or a counselor one-on-one, a community-based or internet-based support group is an option. Many people find it comforting to speak with others who are experiencing similar types of loss and who are at different stages of the grieving process. As is the case with individual therapy, support group support can help to normalize what grieving people are feeling.