Grief, Bereavement, and Mourning

Grief is the psychological, physical, and emotional experience and reaction to loss. People may experience grief in various ways, but several theories, such as Kübler-Ross’ stages of loss theory, attempt to explain and understand the way people deal with grief. Kübler-Ross’ famous theory, which we’ll examine in more detail soon, describes five stages of grief: denial, anger, bargaining, depression, and acceptance.^[1]

Grief reactions vary depending on whether a loss was anticipated or unexpected, (parents do not expect to lose their children, for example), and whether or not it occurred suddenly or after a long illness, and whether or not the survivor feels responsible for the death. Struggling with the question of responsibility is particularly felt by those who lose a loved one to suicide. ^[2] These survivors may torment themselves with endless “what ifs” in order to make sense of the loss and reduce feelings of guilt. And family members may also hold one another responsible for the loss. The same may be true for any sudden or unexpected death, making conflict an added dimension to grief. Much of this laying of responsibility is an effort to think that we have some control over these losses; the assumption being that if we do not repeat the same mistakes, we can control what happens in our life. While grief describes the response to loss, bereavement describes the state of being following the death of someone (Figure 1).

As we’ve already learned in terms of attitudes toward death, individuals’ own lifespan developmental stage and cognitive level can influence their emotional and behavioral reactions to the death of someone they know. But what about the impact of the type of death or age of the deceased or relationship to the deceased upon bereavement?

Anticipatory grief

Anticipatory grief occurs when a death is expected and survivors have time to prepare to some extent before the loss. Anticipatory grief can include the same denial, anger, bargaining, depression, and acceptance experienced in loss one might experience after a death; this can make adjustment after a loss somewhat easier, although a person may then go through the stages of loss again after the death. A death after a long-term, painful illness may bring family members a sense of relief that the suffering is over or the exhausting process of caring for someone who is ill is over.

Complicated grief

Complicated grief involves a distinct set of maladaptive or self-defeating thoughts, emotions, and behaviors that occur as a negative response to a loss.^[6] From a cognitive and emotional perspective, these individuals tend to experience extreme bitterness over the loss, intense preoccupation with the deceased, and a need to feel connected to the deceased. These feelings often lead the grieving individual to engage in problematic behaviors that further prevent positive coping and delay the return to normalcy. He or she may spend excessive amounts of time visiting the deceased person's grave, talking to the deceased person, or trying to connect with the deceased person on a spiritual level, often forgoing other responsibilities or tasks to do so. The extreme nature of these thoughts, emotions, and behaviors separate this type of grief from the normal grieving process.

Disenfranchised grief

Disenfranchised grief may be experienced by those who have to hide the circumstances of their loss or whose grief goes unrecognized by others. Loss of an ex-spouse, lover, or pet may be examples of disenfranchised grief.

It has been said that intense grief lasts about two years or less, but grief is felt throughout life. One loss triggers the feelings that surround another. People grieve with varied intensity throughout the remainder of their lives. It does not end. But it eventually becomes something that a person has learned to live with. As long as we experience loss, we experience grief.

There are layers of grief. Initial denial, marked by shock and disbelief in the weeks following a loss may become an expectation that the loved one will walk in the door. And anger directed toward those who could not save our loved one's life, may become anger that life did not turn out as we expected. There is no right way to grieve. A bereavement counselor expressed it well by saying that grief touches us on the shoulder from time to time throughout life.

Grief and mixed emotions go hand in hand. A sense of relief is accompanied by regrets and periods of reminiscing about our loved ones are interspersed with feeling haunted by them in death. Our outward expressions of loss are also sometimes contradictory. We want to move on but at the same time are saddened by going through a loved one's possessions and giving them away. We may no longer feel sexual arousal or we may want sex to feel connected and alive. We need others to befriend us but may get angry at their attempts to console us. These contradictions are normal and we need to allow ourselves and others to grieve in their own time and in their own ways.

The "death-denying, grief-dismissing world" is often the approach to grief in our modern world. We are asked to grieve privately, quickly, and to medicate our suffering. Employers grant us 3 to 5 days for bereavement, if our loss is that of an immediate family member. And such leaves are sometimes limited to no more than one per year. Yet grief takes much longer and the bereaved are seldom ready to perform well on the job. It becomes a clash between life having to continue, and the individual being ready for it to do so. One coping mechanism that can help smooth out this conflict is called the fading affect bias. Based on a collection of similar findings, the fading affect bias suggests that negative events, such as the death of a loved one, tend to lose their emotional intensity at a faster rate than pleasant events. ^[7] This is believed to help enhance pleasant experiences and avoid the negative emotions associated with unpleasant ones, thus helping the individual return to his or her normal daily routines following a loss.

Grief: Loss of Children and Parents

Loss of a Child: According to Parkes and Prigerson,^[8] the loss of a child at any age is considered “the most distressing and long-lasting of all griefs” (p. 142). Bereaved parents suffer an increased risk to both physical and mental health and exhibit an increased mortality rate. Additionally, they earn higher scores on inventories of grief compared to other types of bereavement. Of those recently diagnosed with depression, a high percentage had experienced the death of child within the preceding six months, and 8 percent of women whose child had died attempted or committed suicide. Archer^[9] found that the intensity of grief increased with the child’s age until the age of 17, when it declined. Archer explained that women have a greater chance of having another child when younger, and thus with added age comes greater grief as fertility declines. Certainly, the older the child the more the mother has bonded with the child and will experience greater grief.

Even when children are adults, parents may experience intense grief, especially when the death is sudden. Adult children dying in traffic accidents was associated with parents experiencing more intense grief and depression, greater symptoms on a health check list, and more guilt than those parents whose adult children died from cancer.^[10] Additionally, the deaths of unmarried adult children still residing at home and those who experienced alcohol and relationship problems were especially difficult for parents. Overall, in societies in which childhood deaths are statistically infrequent, parents are often unprepared for the loss of their daughter or son and suffer high levels of grief.

Loss of Parents in Adulthood: In contrast to the loss of a child, the loss of parents in adult life is much more common and results in less suffering. In their literature review, Moss and Moss (1995) found that the loss of a parent in adult life is “rarely pathological.” Those adult children who appear to have the most difficulty dealing with the loss of a parent are adult men who remain unmarried and continue to live with their mothers. In contrast, those who are in satisfying marriages are less likely to require grief assistance (Parkes & Prigerson, 2010). To determine the effects of gender on parental death, Marks, Jun and Song^[11] analyzed longitudinal data from the National Survey of Families and Households that assessed multiple dimensions of psychological well-being in adulthood including depression, happiness, self-esteem, mastery, psychological wellness, alcohol abuse, and physical health. Findings indicated that a father’s death led to more negative effects for sons than daughters, and a mother’s death lead to more negative effects for daughters.

Loss of Parents in Childhood: Parental deaths in childhood have been associated with adjustment problems that may last into adulthood. Ellis, Dowrick and Lloyd-Williams^[12] identified several negative outcomes associated with childhood grief including increased chance of substance abuse, greater susceptibility to depression, higher chance of criminal behavior, school underachievement, and lower employment rates. Typically, professional help is not required in helping children and teens who are dealing with the death of a loved one. However, Worden^[13] identified ten “red flags” displayed by grieving children that may indicate the need for professional assistance:

• Persistent difficulty in talking about the dead person
• Persistent or destructive aggressive behavior
• Persisting anxiety, clinging, or fears
• Somatic complaints (stomachaches, headaches)
• Sleeping difficulties
• Eating disturbance
• Marked social withdrawal
• School difficulties or serious academic reversal
• Persistent self-blame or guilt
• Self-destructive behavior

As parents may also be dealing with funeral arrangements and other end of life matters, they may not always have the time to address questions and concerns that children may have. When explaining death to children it is important to use real words, such as died and death.^[14] Children do not understand the meanings of such phrases as “passed away”, “left us”, or “lost”, and they can become confused as to what happened. Saying a loved one died of a disease called cancer, is preferable to saying he was “very sick”. The child may become worried when others become sick that they too will die. Consequently, it is important that children have someone who will listen to, and accurately address their concerns.

Mourning

As a society, are we given the tools and time to adequately mourn? Not all researchers agree that we do. The "death-denying, grief-dismissing world" is the modern world (p. 205).^[15] We often grieve privately, quickly, and medicate our suffering with substances or activities. Employers grant 3 to 5 days for bereavement, if the loss is that of an immediate family member, and such leaves are sometimes limited to no more than one per year. Yet grief takes much longer and the bereaved are seldom ready to perform well on the job after just a few days. Obviously life does have to continue, but we need to acknowledge and make more caring accommodations for those who are in grief.

Four Tasks of Mourning

Worden^[16] identified four tasks that facilitate the mourning process. Worden believes that all four tasks must be completed, but they may be completed in any order and for varying amounts of time. These tasks include:

• Acceptance that the loss has occurred
• Working through the pain of grief
• Adjusting to life without the deceased
• Starting a new life while still maintaining a connection with the deceased

Support Groups

Support groups are helpful for grieving individuals of all ages, including those who are sick, terminal, caregiving, or mourning the loss of a loved one. Support groups reduce isolation, connect individuals with others who have similar experiences, and offer those grieving a place to share their pain and learn new ways of coping.^[17] Support groups are available through religious organizations, hospitals, hospice, nursing homes, mental health facilities, and schools for children.

Viewing death as an integral part of the lifespan will benefit those who are ill, those who are bereaved, and all of us as friends, caregivers, partners, family members and humans in a global society.

Stages of Loss

The complex construct of death is associated with a variety of thoughts, emotions, and behaviors, that vary between individuals and groups. To some, death is the final end, when the body ceases to function, with nothing occurring next. To others, death is the start of a new journey, and is its own beginning. These varying viewpoints are shaped by numerous factors related to culture, religion, social norms, personal experiences, and more. It is no surprise then that multiple theories have been created to understand the occurrence of death on cognitive, emotional, and behavioral levels; each offering different explanations for what individuals go through during death.

Kübler-Ross' Stages of Loss

Kübler-Ross^[18] described five stages of loss experienced by someone who faces the news of their impending death (based on her work and interviews with terminally ill patients; Figure 2). These "stages" are not really stages that a person goes through in order or only once; nor are they stages that occur with the same intensity. Indeed, the process of death is influenced by a person's life experiences, the timing of their death in relation to life events, the predictability of their death based on health or illness, their belief system, and their assessment of the quality of their own life. Nevertheless, these stages provide a framework to help us to understand and recognize some of what a dying person experiences psychologically. And by understanding, we are more equipped to support that person as they die.

1. Denial is often the first reaction to overwhelming, unimaginable news. Denial, or disbelief or shock, protects us by allowing such news to enter slowly and to give us time to come to grips with what is taking place. The person who receives positive test results for life-threatening conditions may question the results, seek second opinions, or may simply feel a sense of disbelief psychologically even though they know that the results are true.
2. Anger also provides us with protection in that being angry energizes us to fight against something and gives structure to a situation that may be thrusting us into the unknown. It is much easier to be angry than to be sad or in pain or depressed. It helps us to temporarily believe that we have a sense of control over our future and to feel that we have at least expressed our rage about how unfair life can be. Anger can be focused on a person, a health care provider, at God, or at the world in general. And it can be expressed over issues that have nothing to do with our death; consequently, being in this stage of loss is not always obvious.
3. Bargaining involves trying to think of what could be done to turn the situation around. Living better, devoting self to a cause, being a better friend, parent, or spouse, are all agreements one might willingly commit to if doing so would lengthen life. Asking to just live long enough to witness a family event or finish a task are examples of bargaining.
4. Depression is sadness and sadness is appropriate for such an event. Feeling the full weight of loss, crying, and losing interest in the outside world is an important part of the process of dying. This depression makes others feel very uncomfortable and family members may try to console their loved one. Sometimes hospice care may include the use of antidepressants to reduce depression during this stage.
5. Acceptance involves learning how to carry on and to incorporate this aspect of the life span into daily existence. Reaching acceptance does not in any way imply that people who are dying are happy about it or content with it. It means that they are facing it and continuing to make arrangements and to say what they wish to say to others. Some terminally ill people find that they live life more fully than ever before after they come to this stage.

In some ways, these five stages serve as cognitive defense mechanisms, allowing the individual to make sense of the situation while coming to terms with what is happening. They are, in other words, the mind's way of gradually recognizing the implications of one's impending death and giving him or her the chance to process it. These stages provide a type of framework in which dying is experienced, although it is not exactly the same for every individual in every case.

Since Kübler-Ross presented these stages of loss, several other models have been developed. These subsequent models, in many ways, build on that of Kübler-Ross, offering expanded views of how individuals process loss and grief. While Kübler-Ross' model was restricted to dying individuals, subsequent theories tended to focus on loss as a more general construct. This ultimately suggests that facing one's own death is just one example of the grief and loss that human beings can experience, and that other loss or grief-related situations tend to be processed in a similar way.

Other Models on Grief

One such model was presented by Worden,^[19] which explained the process of grief through a set of four different tasks that the individual must complete in order to resolve the grief. These tasks included: (a) accepting that the loss has occurred, (b) working through and experiencing the pain associated with grief, (c) adjusting the changes that the loss created in the environment, and (d) moving past the loss on an emotional level.^[20]

Another model is that of Parkes (1998), which broke down grief into four stages, including: (a) shock, (b) yearning, (c) despair, and (d) recovery. Although comprised of somewhat different stages than those of Kübler-Ross' model, Parkes' stages still reflected an ongoing process that the individual goes through, each of which was characterized by different thoughts, emotions, and behaviors. Throughout this process, the individual gradually moves closer to accepting the situation, and being able to continue with his or her daily life to the greatest extent possible.^[21]

A different approach was proposed by Strobe and Schut,^[22] which suggested that individuals cope with grief through an ongoing set of processes related to both loss and restoration. The loss-oriented processes included: (a) grief work, (b) intrusion on grief, (c) denying or avoiding changes toward restoration, and (d) the breaking of bonds or ties. The restoration-oriented processes included: (a) attending to life changes, (b) distracting oneself from grief, (c) doing new things, and (d) establishing new roles, identities, and relationships. Since each individual experiences grief and loss differently, in light of personal, cultural, and environmental factors, these processes often occur simultaneously, and not in a set order.^[23]

We no longer think that there is a "right way" to experience grief and loss. People move through a variety of stages with different frequency and in different ways. The theories that have been developed to help explain and understand this complex process have shifted over time to encompass a wider variety of situations, as well as to present implications for helping and supporting the individual(s) who are going through it. Stroebe et al.^[24] cautions health-care professionals working from a grief stage model. Such models can attempt to categorize, or assign, people to a stage. Alternatively, abnormality in grief stage progression may suggest the need to wrongly diagnosis with a mental health disorder. They make points to suggest that grieving is not stage-like, varies largely by individual and cultural factors, and individuals, or groups, will adjust to the loss in their own way in their own time. The American Psychological Association^[25]. suggests the following strategies have been identified as effective in the support of healthy grieving:

• Talk about the death. This will help the surviving individuals understand what happened and remember the deceased in a positive way. When coping with death, it can be easy to get wrapped up in denial, which can lead to isolation and lack of a solid support system.
• Accept the multitude of feelings. The death of a loved one can, and almost always does, trigger numerous emotions. It is normal for sadness, frustration, and in some cases exhaustion to be experienced.
• Take care of yourself and your family. Remembering to keep one's own health and the health of their family a priority can help with moving through each day effectively. Making an conscious effort to eat well, exercise regularly, and obtain adequate rest is important.
• Reach out and help others dealing with the loss. It has long been recognized that helping others can enhance one's own mood and general mental state. Helping others as they cope with the loss can have this effect, as can sharing stories of the deceased.
• Remember and celebrate the lives of your loved ones. This can be a great way to honor the relationship that was once had with the deceased. Possibilities can include donating to a charity that the deceased supported, framing photos of fun experiences with the deceased, planting a tree or garden in memory of the deceased, or anything else that feels right for the particular situation.

Criticisms of Kübler-Ross’s Five Stages of Grief

Some researchers have been skeptical of the validity of there being stages to grief among the dying.^[26] As Kübler- Ross notes in her own work, it is difficult to empirically test the experiences of the dying. “How do you do research on dying,…? When you cannot verify your data and cannot set up experiments?” (p. 19).^[27] She and four students from the Chicago Theology Seminary in 1965 decided to listen to the experiences of dying patients, but her ideas about death and dying are based on the interviewers’ collective “feelings” about what the dying were experiencing and needed.^[28] While she goes on to say in support of her approach that she and her students read nothing about the prior literature on death and dying, so as to have no preconceived ideas, a later work revealed that her own experiences of grief from childhood undoubtedly colored her perceptions of the grieving process.^[29] Kübler-Ross is adamant in her theory that the one stage that all those who are dying go through is anger. It is clear from her 2005 book that anger played a central role in “her” grief, and did so for many years.^[30]

There have been challenges to the notion that denial and acceptance are beneficial to the grieving process.^[31] Denial can become a barrier between the patient and health care specialists, and reduce the ability to educate and treat the patient. Similarly, acceptance of a terminal diagnosis may also lead patients to give up and forgo treatments to alleviate their symptoms. In fact, some research suggests that optimism about one’s prognosis may help in one’s adjustment and increase longevity.^[32]

A third criticism is not so much of Kübler-Ross’s work, but how others have assumed that these stages apply to anyone who is grieving. Her research focused only on those who were terminally ill. This does not mean that others who are grieving the loss of someone would necessarily experience grief in the same way. Friedman and James^[33] and Telford et al.^[34] expressed concern that mental health professionals, along with the general public, may assume that grief follows a set pattern, which may create more harm than good.

Lastly, the Yale Bereavement Study, completed between January 2000 and January 2003, did not find support for Kübler-Ross’s five stage theory of grief.^[35] Results indicated that acceptance was the most commonly reported reaction from the start, and yearning was the most common negative feature for the first two years. The other variables, such as disbelief, depression, and anger, were typically absent or minimal.