Grief and Bereavement

Grief and bereavement refer to the emotional responses and psychological processes experienced following the death of a loved one. Bereavement is marked by feelings of desolation and loss, often accompanied by grief, which can manifest as deep mental anguish, separation anxiety, and physical symptoms of distress. The grieving process is highly individual and varies widely across cultures, with many people experiencing a range of emotional reactions that may not follow a set pattern. Commonly discussed stages of grief include denial, anger, bargaining, depression, and acceptance; however, not everyone experiences these stages in the same order or at all. While grief is a natural response and typically less intense than clinical depression, extreme cases can lead to complicated grief, which may require professional intervention. Cultural rituals and support from friends and family can significantly aid individuals in navigating their grief. It is also essential for those grieving to accept their loss over time and to gradually move forward in life, honoring their loved ones while recognizing the necessity of living without them.

Published in: 2021

By: Wienclaw, Ruth A.

Subject Terms

Grief and bereavement

Abstract

Following the death of a loved one, most people experience bereavement, a feeling of desolation or loss, grief, and deep mental anguish. This is more than a purely emotional experience; however, extreme experiences of grief can become life-threatening. Although there are a number of widely reported reactions to the loss of a loved one among individuals and cultures alike, not everyone experiences the same stages or the same order. Eventually, most people come to a point of resolution and the willingness to go on with their lives without the other person. Working through the grieving process is neither a short-term activity nor one that can be rushed. However, if complicated grief is suspected, it is important that the individual receive professional help.

Overview

Everyone experiences a period of bereavement a some point during their lives following the death of a friend or loved one. Bereavement may be marked by grief; a deep mental anguish whose symptoms may include physiological distress, separation anxiety, confusion, yearning, obsessive dwelling on the past, and apprehension about the future. Although grief may seem like a purely emotional or psychological response to bereavement, extreme experiences of grief can become life-threatening not only if the grieving person neglects him/herself or has suicidal ideation, but also because the immune system may become disrupted during the grieving process. Whether or not grief is expressed publicly, the bereaved person typically goes through a period of mourning during which s/he may experience feelings of apathy and dejection, loss of interest in the outside world, and decreased activity and initiative. Although these symptoms are similar to those of depression, mourning and clinical depression are not the same. Symptoms of mourning are of shorter duration than those of clinical depression, and are not considered pathological. Grief is considered to be a normal and natural reaction to the death of a close friend or loved one.

Five Stages of Death

Based on her work with terminal patients, Kübler-Ross identified a general pattern of five reactions to impending death:

Denial;
Anger;
Bargaining;
Depression;
Acceptance.

Frequently, people who have been given a terminal diagnosis first go through a stage of denial and isolation in which they question their prognosis and then attempt to avoid reminders of the situation. Many people also become angry and rail against their fate and may direct their rage toward the living including family, friends, and caregivers. Another common reaction to a terminal diagnosis is bargaining with God (or fate) and promising to mend their ways in exchange for a few more years. Many people may also become depressed, particularly as they realize that their death is inevitable and will come in the foreseeable future. In the end, however, many people are able to resolve the issues surrounding their death and come to terms with their mortality, accepting it with peace and dignity.

Kübler-Ross noted that people who have lost a loved one similarly go through these stages. Because of the individuality of the grieving process and the fact that the reaction of each person is not necessarily the same, there is some disagreement in the literature as to where to draw the lines between the stages of the grieving process, what they should be called, or even whether such "stages" exist at all. The manner in which grief is experienced may depend on a number of factors including the personality of the bereaved and how that person typically deals with stressful situations, the relationship of the person to the one who has died, whether the loss was sudden or lingering, whether or not the death was painful, or whether or not the person had unresolved issues with the one who died.

Stages of Bereavement

Despite the individuality of the grieving process, most theorists do recognize a variety of reactions that are commonly experienced in bereavement. Initially, many people go through a state of denial in which they cannot seem to believe that the person is gone or shock in which they appear dazed, numb, or show little emotion. Emotional shock may last anywhere from a few minutes or hours to a few days. (However, if the period of shock lasts for weeks, it is best to seek professional help.) During this time, most people find it very difficult to accept the reality of their loss. For most people, however, emotional release eventually comes as the person realizes that the loved one is gone for good. The end of shock usually comes about the time of the funeral, which often can be a catalyst for the release of unexpressed tears and emotion. This may be accompanied by acute pangs of grief in which the person experiences an intense and anguished yearning for the person who has died. During this time, one may continue to feel as if the deceased is still alive, thinking that one hears the other person's voice, sees him/her out of the corner of one's eye, or have vivid dreams about the person. Such feelings are often accompanied by tears and other outward expressions of their distress. The grieving person may experience alternating episodes of agitated distress and silent despair during this time. Many people also feel apathetic, dejected, depressed, or lonely as they grieve, particularly if the loved one played a significant part in their lives. This is a time when the support of nonjudgmental friends and family can be particularly important. Some people may also experience psychosomatic symptoms of distress or episodes of panic in response to the death of a loved one and are unable to think of how they can go on with their lives without the other person. If there were unresolved issues between the deceased and the person in mourning, the latter may also experience feelings of guilt over things that were said and done or left unsaid or undone. As the person overcomes the natural depressive reaction to the death of the loved one, s/he may also experience anger or resentment, whether at the loved one for dying and leaving the person to go on without him/her or at God, fate, or someone else for having taken the loved one away.

Eventually, the grieving person will come to the realization (either on his/her own or with the help of a counselor or support group) that life must continue to be lived. During this phase of resolution, the person comes to an acceptance of the loss of a loved one and the recognition of the need to build a new life without that person. At first, however, many people are resistant to picking up their lives again. But gradually, hope typically breaks through and they struggle to move on and live without their loved one. Resolution occurs gradually, as the bereaved person slowly learns to accept that the other person is out of his/her life forever. The person may continue to experience pangs of grief during this period, but they become increasingly less frequent. Although for many people it takes six months to a year to reach the point of resolution, it can take two or three years for some. Mourning at a low level of intensity may even continue indefinitely (Coon, 2002). However, grief can also be complicated by adjustment disorders, major depressive disorder, substance abuse, or post-traumatic stress disorder. In this type of complicated grief, the symptoms of grieving last significantly longer, cause greater interference with normal functioning, or express themselves in more intense symptoms (e.g., suicidal ideation) than in normal grief. If complicated grief is suspected, it is important to seek professional help.

Discrepancies

However, although reactions in grief appear to be universal, the five stages of grief are not so. Although the five stages are commonly observed reactions to death and dying, it is important to note that not every terminally ill person exhibits all these reactions nor do those who do necessarily go through them in the same order. Not everyone experiences all five stages of grief and some people experience one or more stages multiple times. There has been much misunderstanding over these stages, and Kübler-Ross was quick to point out that the grieving process is not the same for every individual just as the relationship between the grieving person and the deceased are different in each case. Although many people have these responses and may even have them in the order listed, not every does. Further, not everyone goes through all the stages. In addition, for some people, the grieving process may be cyclic, and the individual might experience one stage more than one time before resolution is finally reached.

Helping with the Grieving Process

Clinical practitioners recommend a number of actions to help someone successfully go through the grieving process. First, it is important for the grieving person to acknowledge his/her loss and accept that the person is gone. Although shock and denial are part of the initial reaction to a loss, eventually the death of the other person needs to be faced and accepted. During this process it is important not to isolate oneself from those individuals who will be willing to listen and not judge, and will help one go through whatever process is necessary. It is particularly important to discuss one's feelings with friends and relatives who are also going through their own grieving process over the loss of the deceased. Knowing that one is not alone and that others are feeling the loss can be helpful during this time. However, it is also important not to hurry the grieving process: One must go through this process at one's own pace. It is also important to not to try to mask one's feelings through alcohol or drugs. Alcohol is in itself a depressant and will only make depressive symptoms worse, not better. Further, alcohol and drugs will only mask the symptoms, not alleviate them. Eventually, one will have to deal with one's feelings and the reality of one's loss. Finally, although it can be helpful to honor the memory of the deceased as a way to come to terms with the loss, it is also important not to dwell in the past, but to come to terms with the need to move on with one's life without the person.

As noted above, to work through one's grief, it is important not to suppress it since, in the end, one must come to terms with the death of the loved one before one can move on with one's life. Because of this fact, many people have assumed that suppressing one's grief may result in more severe and lasting depression and other symptoms of mourning. However, as noted above, everyone reacts to bereavement in their own way. Researchers have found that lack of intense grief typically does not predict later, more intense problems (Coon, 2001). Just because someone does not show a great deal (or any) reaction in public does not mean that s/he is not going though the grieving process and working through his/her grief. Many people also find it helpful to join a grief support group or to talk to a counselor or clergyperson. However, although the depressive symptoms associated with the grieving processes of many individuals are typically not cause for concern, if they become prolonged, interfere with the individual being able to perform the daily activities of living, or if the individual talks about suicide, s/he should be diagnosed and treated by a doctor.

Cultural Rituals & Grief

The various symptoms of grief discussed above have been found to be consistent across cultures. However, bereavement practices and the way that persons express their grief do differ from culture to culture. These differences are important. Health care practitioners who deal with grief and bereavement have noted the importance of cultural rituals in helping the bereaved reach resolution in the grieving process. Failure to perform these rituals can have a devastating effect on the family of the deceased and lead to unresolved loss. The cultural rituals associated with death can be instrumental in helping the family or other grieving individuals through the grieving process by enabling them adjust to the fact of the death and loss. For example, in African American culture, both religion and culture play an important role in helping individuals work through their grief. Although African Americans may appear stoic when dealing with people outside the culture, within people from their own culture, they often respond differently. The mourning practices of Hispanics, on the other hand, vary. However, Hispanics often express their emotions through tears and consider crying to be a healthy emotional response to the death of a loved one. As in the African American culture, religion is important to most Hispanics. In both cultures, this means both the comfort of one's religious beliefs in helping resolve one's grief and the religious rituals that can help one gain closure and come to terms with one's loss.

Applications

Pre-Loss & Post-Loss Actions & Reactions. Although death may come suddenly, particularly with older persons, it often does not. This means that hypothetically there is time to prepare for the loss of a loved one and resolve any issues before the person's death. However, the research literature shows inconsistent findings on this issue. Although some studies suggest that open communication may help a surviving individual to remain close to his/her spouse while accepting the impending death and preparing for life without the spouse, other studies have not supported this conclusion. Metzger and Gray (2008) performed a study to investigate the impact of pre-loss communication on post-loss adjustment of the survivor. Participants in the study were recruited from online bereavement support groups; a total of 123 subjects participated in the study. Data collected included measures of the actual and desired amount of communication that they had with the deceased person before his/her death; measures of depression, grief, complicated grief, and posttraumatic growth; and demographic data. The results of the analysis indicated that most forms of distress following the death of a loved one were not significantly related with the levels of communication before the death.

The results of the study indicated that individuals who had come to terms with the impending death of a loved before the fact were more likely to report less distress following the death than were individuals who were unable to come to do so. The findings further suggest that the relationship between pre-loss acceptance and post-loss distress is independent of time elapsed and the closeness of the relationship. In other words, the ability to accept the immanent death of a loved one following a terminal diagnosis may be beneficial towards the surviving person's well-being following the death. The study also found that pre-loss acceptance was associated with post-traumatic personal growth. However, for most measures of communication used in the study, it was not found that the level of communication between the individual and the dying person were related to the individual's experience during bereavement. In fact, the study findings indicated that increased communication with the dying person was associated with higher reports of distress after the death. Further, the difference between the actual levels of communication before the death and the desired levels of communication were generally not related to the experience of the bereaved after the loss.

Conclusion

Although there are a number of widely reported emotional reactions to the loss of a loved one among individuals and cultures alike, in the end each person works through the process in his/her own way in order to come to a point of resolution and the willingness to go on with his/her life without the other person. The support of understanding friends and family can be particularly helpful during this time, as can support groups or counseling. Working through the grieving process is neither a short-term activity nor one that can be rushed. It can take many months or even several years to work through one's feelings after the loss of a loved one, and mourning may even continue indefinitely at a low level of intensity. If complicated grief is suspected, however, it is important that the individual receive professional help.

Terms & Concepts

Bereavement: A feeling of desolation or loss, particularly following the death of a close friend or loved one. The bereaved person may experience emotional pain and distress (grief) and may or may not express this distress to others (mourning). Not all bereavements result in a strong grief response.

Complicated Grief: Grief that is accompanied by adjustment disorders, major depressive disorder, substance abuse, or post-traumatic stress disorder. Because of these additional emotional factors, grief may last significantly longer, cause greater interference with normal functioning, or express itself in more intense symptoms (e.g., suicidal ideation). Complicated grief is also referred to as unresolved grief.

Culture: A complex system of meaning and behavior that is socially transmitted and that defines a common way of life for a group or society. Culture includes the totality of behavior patterns, arts, beliefs, institutions, and other products of human work and thought of the society or group.

Dejection: Feelings of demoralization and discouragement that occur during the grieving process.

Demographic Data: Statistical information about a given subset of the human population such as persons living in a particular area, shopping at an area mall, or subscribing to a local newspaper. Demographic data might include such information as age, gender, or income distribution.

Depression: A mood primarily characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that were once pleasurable. Disturbance in sleep patterns, appetite, and mental processes are a common accompaniment to depression. The depression experienced during the grieving process differs from clinical depression in terms of duration (with clinical depression being more long-term).

Grief: A deep mental anguish experienced after bereavement or other significant loss, in particular the death of a loved one. Symptoms of grief may include physiological distress, separation anxiety, confusion, yearning, obsessive dwelling on the past, and apprehension about the future. Intense grief may become life-threatening through disruption of the immune system, self-neglect, and suicidal thoughts. Grief is distinguished from bereavement and mourning.

Mourning: Feelings or expressions of grief following bereavement. Mourning often is experienced through feelings of apathy and dejection, loss of interest in the outside world, and decreased activity and initiative. Although these symptoms are similar to those of depression, they are of shorter duration and not considered pathological. Expressions of grief and mourning responses vary from individual to individual and not all grief is given expression in public mourning. The term mourning is also used to describe the period during which these feelings or expressions occur.

Pangs of Grief: Episodes in which the bereaved person experiences an intense and anguished yearning for the person who has died.

Panic: A sudden, uncontrollable experience of fear in reaction to a perceived threat. Panic symptoms may include terror, confusion, or irrational behavior.

Psychosomatic Disorder: A physical disorder in which psychological factors are believed to play an important part in either the cause or course of the disorder.

Resolution: An acceptance of the loss of a loved one and the recognition of the need to build a new life without that person.

Shock: During the grieving process, shock is a period of time in which the bereaved person appears dazed, numb, or shows little emotion.

Subject: A participant in a research study or experiment whose responses are observed, recorded, and analyzed.

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