Definition

Grief, which is also known as bereavement, is a term used to describe the intense and painful emotions experienced when someone or something a person cares about either dies or is lost. The emotional pain from losing a loved one, whether it is a spouse, child, parent, sibling, friend, or pet, can be the most severe suffering a person must endure. At its most intense, grief can dominate every facet of a person's life, making the carrying out of ordinary responsibilities impossible. Loss and subsequent grief, however, are an inevitable part of life and loving other people or companion animals. Painful as it is, grief is a normal response to loss and generally resolves with the passage of time.

Description

Grief is usually characterized by numbness, tearfulness, physical feelings of emptiness in the pit of the stomach, weak knees, shortness of breath, a tendency to sigh deeply, a sense of unreality, and overall emotional distress. Anxiety and longing may alternate with depression and despair. Insomniaand loss of appetite are common. Initially, people often feel numb and unable to accept their loss. Numbness is followed by shock as reality begins to penetrate.

There is generally a disorganization of normal behavior patterns that may make it impossible for a bereaved person to return to work immediately or take social initiatives. Such acute symptoms usually begin to subside after several months, with emotional balance being regained within a year. Studies using instruments developed to measure symptoms of grief and bereavement demonstrate wide individual variations in specific symptoms and their intensity. Long after the immediate period of mourning, bereaved persons may continue to feel upset, empty, or tearful. In addition, further losses, additional stressors, or dates of such important anniversaries as a wedding, birthday, or the date of death can reactivate the acute symptoms of grief.

Dimensions of grief

Grief and mourning are important life experiences in that they permit a bereaved person to accept the reality of loss and begin to find ways of filling the resultant emptiness. Loss is a significant part of the aging process and can contribute to emotional problems in older people. The impact of loss and resulting grief and mourning is not limited to the death of a loved one. It is also present to a lesser extent in the loss of physical acuity and agility and the loss of social of status as a result of retirement and/or growing older.

Unfortunately, people in the United States do not generally receive cultural support for the losses they experience and the need to mourn those losses. Unlike other cultures with specific rituals for grief and mourning, there is often subtle but insistent pressure on Americans— particularly males— to stop crying and move forward with resumption of regular activities. Onlookers may try to divert the mourner's attention to other topics or discourage crying or talking about the loved one. These responses suggest that grief isn't healthy or that it should be minimized or avoided. If the grief is associated with the loss of a pet, the person may be shamed for grieving because "it was just an animal." Women who have had a pregnancy ended by miscarriage also encounter responses that minimize or trivialize the loss of their expected child. Social insensitivity may drive the mourner to grieve in secret or feel guilty because of continued intense feelings of loss.

Stages of grief

Elizabeth Kubler-Ross, the noted researcher on death and dying, identified five stages of acceptance in the process of dying. While her work initially referred to the person who is dying, the five stages are also applied to people who are grieving a loss. The stages are sometimes collapsed into three, but the general grieving process includes these components:

• Shock/denial. This stage comprises the initial period after receiving news of the loss. The affected person may say, "There must be a mistake," "This can't be true," or similar expressions of disbelief. People often describe feeling numb or cold in this stage.
• Bargaining. This stage represents an attempt to persuade God or a higher power to change the reality of loss in exchange for improved behavior or some sacrifice on the part of the bereaved person. The mourner may offer, for example, to take better care of their relationship with the loved one if God will only bring them back.
• Anger. This emotion may be directed toward the medical establishment, family members, God, or even the person who has died.
• Depression. In this stage, the person's body begins to absorb the reality of the loss. The bereaved person may be unable to eat, sleep, or talk normally with people. They may have episodes of spontaneous crying and such physical symptoms as nausea, headaches, chills or trembling.
• Acceptance. This is the phase in which the mourner comes to terms with the loss and begins to look ahead once more. Energy returns and the bereaved person is able to reconnect with others, engage in enjoyable activities, and make plans for the future.

There is, however, no "normal" pattern for grief; it is a highly variable experience. People pass through the stages outlined by Kubler-Ross at their own rate, depending on the significance of the loss, number of previous losses, individual resiliency, presence of a support system, and permission to grieve from those around them. Grieving is not a linear process. There is movement back and forth between the stages until acceptance is reached. Occasionally, a person may remain "stuck" in one stage, particularly anger or depression, and may benefit from professional help in order to move on. Remaining in one of the stages indefinitely can create emotional and occupational difficulties.

Bereavement and marriage

Studies show that some widowed people have hallucinations or delusionsof contact with the lost spouse that may last for years. These hallucinations are more likely to occur in people who were happily married. The most common hallucination reported is a sense of the dead spouse's presence. Others report seeing, hearing, or being touched by or spoken to by the spouse.

The interplay of grief and marital quality has led to research findings that contradict earlier widespread beliefs. A study by Deborah Carr and her colleagues in 2000 found that anxiety was greater in those who had been highly dependent on their spouses than in those who were less dependent. People who had been in conflicted relationships reported lower levels of yearning for the spouse than those who had enjoyed high levels of marital closeness. Women who had relied on their husbands to do the driving and perform other similar tasks had much higher levels of yearning than men who depended on their wives. This finding contradicts the common belief that grief is more severe if the marriage was conflicted, suggesting a more complex relationship between bereavement and characteristics of the marriage.

Another suggestion of the complex relationship between bereavement and marriage is reflected in studies of sudden and anticipated loss among older widowed people. The sudden death of a spouse was associated with slightly higher levels of yearning among women, but significantly lower yearning among men. Forewarning of the death (extended illness, advancing age) did not affect depression, anger, shock or overall grief six or 18 months after the loss. Prolonged forewarning was associated with increased anxiety at sixand 18-month follow-up interviews after the death.

Grief and mourning may also occur when the loss of a partner occurs through divorce or the end of a dating relationship. Some researchers think that moving to the stage of acceptance is more difficult in such cases because the partner can still be contacted, especially if there are children involved. Seeing a former partner involved in a new relationship can cause the partner mourning the loss to re-experience acute symptoms of grief. Some research evidence suggests that grief related to the breakup of an intimate relationship is more intense for the individual who was left behind than for the person who ended the relationship.

Grieving may be particularly prolonged and intense when certain unexpected losses occur that are outside the ordinary progression of life events. The loss of a parent before a child reaches adulthood or a parent's loss of a child inflict deep emotional wounds for an extended period of time. Similarly, the loss of a loved one to murder, terrorism, or other acts of intentional violence is harder to bear than death resulting from natural causes or accidents. Death from suicidecomplicates grief by adding shame to the other painful emotions associated with bereavement. The opportunity to fully grieve such significant losses, however, enables survivors to move forward despite the magnitude of their loss.

See also Adjustment disorder; Suicide

Resources

BOOKS

Butler, Robert N., Myrna I. Lewis and Trey Sunderland. Aging and Mental Health.5th edition. Boston: Allyn and Bacon, 1998.

Harris, Maxine, Ph.D. The Loss That Is Forever: The Lifelong Impact of the Early Death of a Mother or Father.New York: Dutton, 1995.

Kubler-Ross, Elizabeth, and David Kessler. Life Lessons.New York: Simon and Schuster and the Elizabeth Kubler-Ross Family Partnership, Ltd. 2000.

Vaughan, Diane, Ph.D. Uncoupling: Turning Points in Intimate Relationships.New York: Oxford University Press, 1986.

PERIODICALS

Carr, Deborah, James S. House, Ronald C. Kessler, Randolph M. Nesse, John Sonnega and Camille Wortman. "Marital Quality and Psychological Adjustment to Widowhood Among Older Adults." Journals of Gerontology Series B: Psychological Sciences and Social Sciences55 (2000): S197-S207.

Carr, Deborah, James S. House, Camille Wortman, Randolph Nesse and Ronald C. Kessler. "Psychological Adjustment to Sudden and Anticipated Spousal Loss Among Older Widowed Persons." Journals of Gerontology Series B: Psychological Sciences and Social Sciences56 (2001): S237-S248.

Zisook, S., R. A. Devaul, and M. A. Click Jr. "Measuring Symptoms of Grief and Bereavement." American Journal of Psychiatry 139 (1982): 1590-1593.

ORGANIZATIONS

The Compassionate Friends, Inc. P.O. Box 3696, Oak Brook, IL 60522. .

GROWW [Grief Recovery Online (founded by) Widows & Widowers]. 931 N. State Road 434, Suite 1201-358, Altamonte Springs, FL 32714. .

Judy Leaver, M.A.

Grief is a multi-faceted response to loss. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social and philosophical dimensions. Common to human experience is the death of a loved one, whether it be a friend, family, or other close companion. While the terms are often used interchangeably, bereavement often refers to the state of loss, and grief to the reaction to loss. Losses can range from loss of employment, pets, status, a sense of safety, order or possessions to the loss of loved ones. Our response to loss is varied and researchers have moved away from conventional views of grief (that is, that people move through an orderly and predictable series of responses to loss) to one that considers the wide variety of responses that are influenced by personality, family, culture, and spiritual and religious beliefs and practices.

Bereavement, while a normal part of life for us all, carries a degree of risk when limited support is available. Severe reactions to loss may carry over into familial relations and cause trauma for children, spouses and any other family members: there is an increased risk of marital breakup following the death of a child, for example. Issues of personal faith and beliefs may also face challenge, as bereaved persons reassess personal definitions in the face of great pain. While many who grieve are able to work through their loss independently, accessing additional support from bereavement professionals may promote the process of healing. Grief counseling, professional support groups or educational classes, and peer-led support groups are primary resources available to the bereaved. In the United States, local hospice agencies may be an important first contact for those seeking bereavement support.

Stage theories and processes

Some researchers such as Dr. Elisabeth Kübler-Ross and others have posited sequential stages including denial, anger, bargaining, depression and acceptance, which are commonly referred to as the "grief cycle". As research progressed over the past 40 years, many who worked with the bereaved found stage models too simplistic and instead began to look at processes, dynamics, and experiences common to all. John Bowlby, a noted psychiatrist, outlined the ebb and flow of processes such as Shock and Numbness, Yearning and Searching, Disorganization and Despair, and Reorganization. Bowlby and Parkes both note psychophysiologic components of grief as well. Included in these processes are:

Shock and denial (disbelief)

Feelings of unreality, depersonalization, withdrawal, and an anesthetizing of affect. The person feels unable to come to terms with what just occurred.

Volatile reactions

"Whenever one's identity and social order face the possibility of destruction, there is a natural tendency to feel angry, frustrated, helpless, and/or hurt. The volatile reactions of terror, hatred, resentment, and jealousy are often experienced as emotional manifestations of these feelings." (see the article entitled The Grieving Process by Michael R. Leming and George E. Dickinson)

Disorganization and despair

These are the processes commonly associated with bereavement: the mourning and severe pain of being away from the loved person or situation.

Reorganization

Reorganization is the assimilation of the loss of something or someone and redefining of life and meaning without the deceased.

Risks

Many studies have looked at the bereaved in terms of increased risks for stress-related illnesses. Colin Murray Parkes in the 1960s and 1970s in England noted increased doctor visits, with symptoms such as abdominal pain, breathing difficulties, and so forth in the first six months following a death. Others have noted increased mortality rates (Ward, A.W. 1976) and Bunch et al found a five times greater risk of suicide in teens following the death of a parent. Grief puts a great stress on the physical body as well as on the psyche, resulting in wear and tear beyond what is normal.

Normal and complicated grief

Complicated grief can be differentiated from normal grief. Normal grief typically involves at least two of Elisabeth Kubler-Ross' five grief stages, though not necessarily in any order. While the experience of grief is a very individual process depending on many factors, certain commonalities are often reported. Nightmares, appetite problems, dryness of mouth, shortness of breath, sleep disorders and repetitive motions to avoid pain are often reported by people experiencing normal grief. Even hallucinatory experiences may be normal early in grief.

Complicated grief typically cycles through these five stages and then some, processing them out of order and often much more rapidly. Examples of complicated grief can often be found in those who have survived a suicide attempt (Hsu, 2002). Complicated grief responses almost always are a function of intensity and timing: a grief that after a year or two begins to worsen, accompanied by unusual behaviors, is a warning sign. Complicated grief is usually grief where the story of the loss is in some ways difficult to tell. Deaths such as suicides, murders, accidents, and other sudden and unexpected deaths can result in complicated grief due to the sudden shock. The surprise makes it difficult to integrate the "story" of the loss, so the person struggles with an initial task of simply believing that the loss has occurred. Variables surrounding the death such as expectedness, naturalness, presence of violence, ambivalence, degree of attachment, and others play into the presence of complicated grief. All too often complicated grief can last for years and most people (friends of the mourner) will recoil when hearing that this sort of grief may still be present after several years.

Additionally, there is a clinical problem of becoming "identified" with the grief. In this situation, mourners are reluctant to release the grief because grieving has been integrated as part of their identity.

Types of bereavement

Differing bereavements along the life cycle may have different manifestations and problems which are age related, mostly because of cognitive and emotional skills along the way. Children will exhibit their mourning very differently in reaction to the loss of a parent than a widow would to the loss of a spouse. Reactions in one type of bereavement may be perfectly normal, but in another the same reaction could be problematic. The kind of loss must be taken under consideration when determining how to help.

Childhood bereavement

When a parent or carer dies or leaves, children may have symptoms of psychopathology, but they are less severe than in children with major depression (Cerel, 2006). The loss of a parent, grandparent or sibling can be very troubling in childhood, but even in childhood there are age differences in relation to the loss. A very young child, under one or two, may be felt to have no reaction if a carer dies, but this is far from the truth. At a time when trust and dependency are formed, a break even of no more than separation can cause problems in wellbeing; this is especially true if the loss is around critical periods such as 8-12 months when attachment and separation are at their height in formation and even a brief separation from a carer can cause distress. (Ainsworth 1963) A change in carers can have lifelong consequences, which may become so blurred as to be untraceable.

As a child grows older, death still difficult to assimilate and that fact affects the way a child responds. For example, younger children will find the 'fact' of death a changeable thing: one child believed her deceased mother could be restored with 'band-aids', and children often see death as curable or reversible, more as a separation. Reactions here may manifest themselves in 'acting out' behaviors: a return to earlier behaviors such as sucking thumbs, clinging to a toy or angry behavior: they do not have the maturity to mourn as an adult, but the intensity is there. As children enter pre-teen and teen years, there is a more mature understanding. Adolescents may respond by delinquency, or oppositely become 'over-achievers': repetitive actions are not uncommon such as washing a car repeatedly or taking up repetitive tasks such as sewing, computer games etc. It is an effort to stay 'above' the grief. Childhood loss as mentioned before can predispose a child not only to physical illness but to emotional problems and an increased risk for suicide, especially in the adolescent period.

Death of a child

Death of a child can take the form of a loss in infancy such as miscarriage, stillbirth or neonatal death, SIDS, or the death of an older child. In all cases, parents find the grief almost unbearably devastating and while persons may rate the death of a spouse as first in traumatic life events, the death of a child is still perhaps one of the most intense forms of grief, and holds greater risk factors. This loss also bears a lifelong process: one does not get 'over' the loss but instead must assimilate and live with the death. Intervention and comforting support can make all the difference to the survival of a parent in this type of grief but the risk factors are great and may include family breakup or suicide. Because of the intensity of grief emotions irrational decisions are often made. In the event of a miscarriage or abortion it is important for friends and family members to acknowledge the loss of the pregnancy, and not to attempt to minimalize the significance of a pregnancy that did not come to term. Feelings of guilt, whether legitimate or not, are pervasive, and the dependent nature of the relationship disposes parents to a variety of problems as they seek to cope with this great loss. Parents that suffer miscarriage or abortion may experience resentment towards others who experience successful pregnancies.

Death of a spouse

Although the death of a spouse may be an expected change, particularly as we age, it is a particularly powerful loss of a loved-one. A spouse, though, often becomes part of the other in a unique way: many widows and widowers describe losing 'half' of themselves, and after a long marriage, at older ages, the elderly may find it a very difficult assimilation to begin anew. Further, most couples have a division of 'tasks' or 'labor', e.g. the husband mows the yard, the wife pays the bills, etc. which in addition to dealing with great grief and life changes means added responsibilities for the bereaved. Social isolation may also become imminent as many groups composed of couples find it difficult adjust to the new identity of the bereaved. When queried about what in life is most troubling, most rate death of a spouse first, although the death of a child presents more risk factors.

Death of a parent

As a child the death of a parent without support to manage the effect of the grief may result in long term psychological harm and it is important that the emotions involved are worked through completely and discussed openly. While as an adult one may be expected to cope with the death of a parent in a less emotional way it is an extremely powerful emotion, especially when the death occurs at important or difficult times in life such as becoming a parent as well, graduation or at a time of emotional stress. It is important to recognise the effects that the loss of a parent can cause and address these. As an adult the williness to be open to grief is often diminished and a failure to accept and deal with loss will only result in further pain and suffering.

Death of a sibling

Responses and reactions of older children or adults to the death of a sibling. There is a saying (Compassionate Friends} that if you have lost your parents, you have lost your past; if you lost your children, you have lost your future; if you have lost your spouse, you have lost your present; and if you have lost your sibling, then you have lost a part of your past, present and future.

Loss of children through divorce or kidnapping

Responses of parents accepting permanent loss of children through the reality of the divorce system, or through kidnapping. This loss differs from the death of a child in that the grief process is prolonged or denied because of hope that the relationship will be restored. This is often not the case.

Other losses

Many other losses predispose persons to these same experiences, although often not as severely. Loss reactions may occur after the loss of a romantic relationship (i.e. divorce or break up), a vocation, a pet (animal loss), a home, children leaving home (empty nest), a friend, a favored appointment or desire, a faith in one's religion, etc. While the reaction may not be as intense, experiences of loss may still show in these forms of bereavement. Those who have experienced a loss of trust, will also experience some form of grief. For example, people that have been physically or sexually abused as a child may have issues around trust as an adult.

See also

• Grief counseling
• Grief therapy
• Mourning sickness
• List of counseling topics

References

External links

• The Emotions of Grief During A Breakup

. Listing of support and self help groups and other resources.