Grief is a natural stress response to bereavement that is unique to the individual and evolves over time. With adequate support, most people adapt to the death of a loved one without clinical intervention. There are highs and lows, but grief usually becomes integrated into a person’s mindset within about six to twelve months. That said, grief responses vary based on culture, religion, personal coping strategies and support systems, the nature of the loss, and the relationship to the deceased.
Depending on the severity and duration of symptoms, grief can become acute or prolonged to the degree that it causes undue distress or impairment to important areas of functioning. This is when natural grief can develop into prolonged grief disorder.
How to Help Patients to Adjust to the Death of a Loved One
There are important ways for clinicians and other health care providers to help their patients to integrate grief and adapt to their new life situation after the death of a loved one.
First, it is important to normalize grief as a process – a matter of adapting to the changes in a person’s life brought about by the death of a significant person. A key step is to recognize that cultural meanings mediate people’s experiences of pain and suffering, including how we interpret our lives, impending deaths, and conceptions of dignity. Attending to the values, beliefs and practices associated with an individual’s (and family’s) cultural background and spiritual and/or religious preferences is vital for offering meaningful support in times of grief. From that lens, clinicians can help patients to recognize and reflect on their grief in constructive ways. To learn more about how people with different cultural backgrounds view grief and bereavement, see this synopsis by certified grief counselor, Dr. Alejandra Vasquez.
Second, providing information at appropriate times about common grief symptoms can help patients to realize that their responses are normal. Let patients know that the intense shock, separation distress, and emotional pain following death of a loved one is a common part of the grieving process. Grief symptoms (psychological, behavioral, and physiological) can vary in intensity over time, often increasing on occasions such as birthdays, holidays, the anniversary of the death, or sporadically with an incidental reminder of the person, an experience, or the circumstances of their death. Acknowledging that these emotions can range from sadness to anger to joy and other feelings, can help patients to give themselves grace if they feel like they are “doing grief” the wrong way.
Third, acknowledge that the grief process is not predictable and does not occur in a linear way. Over time, there is usually a gradual progression toward acceptance of the loss and adjustment to life without the deceased person. Helping patients to reflect on their thoughts and behaviors to identify any that may be maladaptive (such as, excessive counterfactual thoughts or worries about the future, avoidance, and compulsively wanting to feel close to the deceased) can facilitate the integration of grief.
When Natural Grief Becomes Prolonged Grief Disorder
In patients with grief responses that exceed the duration and severity of the individual's sociocultural and religious context, consider a psychiatric referral to screen for prolonged grief disorder.
The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. text revision (DSM-5-TR) considers prolonged grief disorder for a specific set of symptoms lasting longer than 12 months in bereaved adults and longer than 6 months in bereaved children. Notably, these symptoms occur almost daily during the last month, or longer, and to a clinically important degree. They include:
- When a person experiences either intense yearning for the deceased person or preoccupation with thoughts or memories of the deceased person.
- And at least three of the following:
- Identity disruption (feeling as though part of oneself has died)
- Strong sense of disbelief about the death
- Avoidance of reminders of the loss
- Severe emotional pain such as anger, bitterness, or sorrow
- Difficulty reintegrating into life such as reengaging with friends, personal interests, or plans
- Emotional numbness or feeling stunned
- Feeling that life has no meaning
- Intense loneliness or detachment from others
If patients have experienced this array of symptoms for the duration identified and the symptoms are not better explained by another psychiatric disorder (such as, major depressive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorders, or substance use disorders), then prolonged grief disorder may be the diagnosis.
Risk factors associated with prolonged grief disorder include pre-loss factors such as preexisting psychological trauma, prior loss, poor physical health, suddenness of the death or being unprepared for the death, insecure attachment with the deceased, and others. Risk factors at the time of or after the death include maladaptive dependency, family-related challenges, limited resources, poor understanding of the circumstance of the death, intense emotional pain and preoccupation, and interference with natural grieving processes.
Helping patients to understand the range of responses to grief can help them to know that they are not alone. Working with them to get appropriate support and medical care if they need it can facilitate bereavement adjustment and prevent prolonged grief disorder.
For patient information, see the National Cancer Institute handout on Grief, Bereavement, and Loss and the National Institutes of Health handout on Coping with Loss.
