Grief and Bereavement

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The term grief can be defined as a type of stress reaction, a highly personal and subjective response that an individual makes to a real, perceived, or anticipated loss. Grief reactions may occur in any loss situation, whether the loss is physical or tangible, such as a death, significant injury, or loss of property; or symbolic and intangible such as the loss of a dream. The intensity of grief will vary, depending on many variables such as the meaning of a loss to the individual experiencing it. It should be recognized that loss does not inevitably create grief. Some individuals may be so disassociated from the loss object that they experience little or no grief, or their response may be characterized by intense denial.

This definition of acute grief distinguishes it from other terms such as bereavement or mourning. Bereavement refers to an objective state of loss. If one experiences a loss, one is bereaved. Bereavement refers to the fact of loss, whereas grief is the subjective response to that state of loss. Mourning has had two interrelated meanings within the field. On one hand, it has been used to describe the intrapsychic process through which a grieving individual gradually adapts to the loss, a process that has also been referred to as "grieving" or "grief work." The term has also been used to refer to the social aspect of grief, the norms and patterned behaviors and rituals through which an individual is recognized as bereaved and socially expresses grief. For example, in the United States, wearing black, sending flowers, and attending funerals are common illustrations of appropriate mourning behaviors.

Paradigms of Grief

Grief was first empirically described in 1944 by Eric Lindemann, a psychiatrist who studied survivors of the Coconut Grove Fire, a 1942 Boston fire that swept through a nightclub, killing many. Lindemann described grief as a syndrome that was "remarkably uniform" and included a common range of physical symptoms, such as tightness of throat, shortness of breath, and other pain, as well as emotional and other responses. It should be recognized that Lindemann's research was based on a sample of primarily young survivors of sudden and traumatic loss.

This medical model of grief was continued most clearly in the work of George Engel (1961). Engel believed that grief could be described as a disease, one having a clear onset in a circumstance of loss; a predictable course that includes an initial state of shock; a developing awareness of loss characterized by physical, affective, cognitive, psychological, and behavioral symptoms; and a prolonged period of gradual recovery, with the possibility that this recovery may be complicated by other variables. He noted that other disease processes also are influenced by psychological and social variables. Even the fact that grief is universal and rarely requires treatment, Engel argued, is not unlike other diseases. Engel also noted that whether or not a disease requires medical treatment or is even recognized as a disease is a social convention. Epilepsy, alcoholism, and many forms of mental illness are recognized as diseases but were not at other times in human history or in other cultures.

Another paradigm that attempts to offer insight into the nature of acute grief is the psychological trauma model. This model, based on the work of the Austrian neurologist Sigmund Freud (1917), views grief as a response to the psychological trauma brought on by the loss of a love object. Acute grief is a normal defense against the trauma of loss. To Freud, grief is a crisis, but one that will likely improve over time and that generally does not require psychiatric intervention.

Perhaps one of the more influential models to account for acute grief is the attachment model developed by John Bowlby (1980). This approach emphasizes that attachment, or bonding, is a functional survival mechanism, an instinct found in many of the higher animals. Given the prolonged periods of infancy and dependency, attachment is necessary for the survival of the species. When the object of that attachment is missing, certain behaviors arise that are instinctual responses to that loss. These behaviors, including crying, searching, and clinging, were seen by Bowlby as biologically based responses that seek to restore the lost bond and maintain the attachment. When these bonds are permanently severed, as in death, these behaviors continue until the bond is divested of emotional meaning and significance. These behaviors also serve a secondary purpose. By expressing distress, they engage the care, support, and protection of the larger social unit. This psychobiological model sees grief as a natural, instinctual response to a loss, a response that continues until the bond is restored or the grieving person detaches and divests of the bond.

These early approaches continue to influence under-standings of grief, though more contemporary models emphasize that grief is a natural response to major transitions in life and that bonds between the grieving individual and the lost object continue, albeit in different forms, after the loss (Klass, Silverman, and Nickman). In addition, more recent approaches emphasize that a significant loss may shatter assumptions, causing grieving individuals to reconstruct their sense of self, their spirituality, and their relationship to others and the world at large. While this may be a painful process, it also may be a catalyst for growth.

Manifestations of Grief

Individuals can experience acute grief in varied ways. Physical reactions are common. These includes a range of physical responses such as headaches, other aches and pains, tightness, dizziness, exhaustion, menstrual irregularities, sexual impotency, breathlessness, tremors and shakes, and oversensitivity to noise.

Bereaved individuals, particularly widows, do have a higher rate of mortality in the first year of loss (Osterweis, Solomon, and Green). There may be many reasons for this—the stress of bereavement, the change in lifestyle that accompanies a loss, and the fact that many chronic diseases have lifestyle factors that can be shared by both partners. It is important that a physician monitor any physical responses to loss.

There are affective manifestations of grief as well. Individuals may experience a range of emotions such as anger, guilt, helplessness, sadness, shock, numbing, yearning, jealousy, and self-blame. Some bereaved persons experience a sense of relief or even a feeling of emancipation. This, however, can be followed by a sense of guilt. As in any emotional crisis, even contradictory feelings, such as sadness and relief, can be experienced simultaneously.

There can be cognitive manifestations of grief. Included here is a sense of depersonalization in which nothing seems real. There can be a sense of disbelief and confusion, an inability to concentrate or focus. Bereaved individuals can be preoccupied with images or memories of the loss. These cognitive manifestations can affect functioning at work, school, or home. Many persons also report experiences in which they dream of the deceased or have a sense of the person's presence, even sense-based experiences of the other.

Grief has spiritual manifestations. Individuals may struggle to find meaning and to reestablish a sense of identity and order in their world. They may be angry at God or struggle with their faith.

Behavioral manifestations of grief can also vary. These behavioral manifestations can include crying, withdrawal, avoiding or seeking reminders of the loss, searching behaviors, over activity, and changes in relationships with others.

The reactions of persons to loss are highly individual and influenced by a number of factors. These include the unique meaning of the loss, the strength and nature of the attachment, the circumstances surrounding the loss such as the presence of other crises, reactions and experiences of earlier loss, the temperament and adaptive abilities of the individual, the presence and support of family and other informal and formal support systems, cultural and spiritual beliefs and practices, and general health and lifestyle practices of the grieving individuals.

The Course of Grief

There have been a number of approaches to understanding the process or course of acute grief. Earlier approaches tended to see grief as proceeding in stages or phases. Colin Murray Parkes (1972), for example, described four stages of grief: shock, angry pining, depression and despair, and detachment. Recent approaches have emphasized that grief does not follow a predictable and linear course, stressing instead that it often proceeds in a roller-coaster-like pattern, full of ups and downs, times when the grief reactions are more or less intense. Some of these more intense periods are predictable—holidays, anniversaries, or other significant days—but other times may have no recognizable trigger.

More recent approaches have emphasized that grief involves a series of tasks or processes. J. William Worden (1992) described four tasks to grief: recognizing the reality of the loss, dealing with expressed and latent feelings, living in a world without the deceased, and relocating the deceased in one's life. Therese A. Rando (1993) suggested that grieving individuals need to complete six "R" processes: recognize the loss, react to the separation, recollect and reexperience the deceased and the relationship, relinquish the old attachments to the deceased and the old assumptive world, read-just to the new world without forgetting the old, and reinvest. (While the language of both Worden and Rando is specific to death-related loss, their models can be adapted to other losses as well.) These and other similar models reaffirm the very individual nature of grief, acknowledging that these tasks or processes are not necessarily linear and that any given individual may have difficulty with one or more processes or tasks.

The critical point to remember is that the course of grief is not linear. Nor is there any inherent timetable to grief. Grief reactions can persist for considerable time, gradually losing intensity after the first few years. Recent research as well emphasizes that one does not "get over the loss." Rather, over time, the pain lessens, and the grief becomes less disabling as individuals function at levels comparable to (and sometimes better than) preloss levels. Bonds and attachments to the lost object continue, however, and periods of intense grief can occur years after the loss (Klass, Silverman, and Nickman). For example, the birth of a grandchild can trigger an experience of grief in a widow who wished to share this event with her deceased spouse.

Help and Grief

Persons experiencing acute grief can help themselves in a number of ways. Because grief is a form of stress, lifestyle management including adequate sleep and diet, as well as other techniques for stress reduction, can be helpful. Bibliotherapy or the use of self-help books can often validate or normalize grief reactions, suggest ways of adaptation, and offer hope. Self-help and support groups can offer similar assistance as well as social support from others who have experienced loss. Others may benefit from counselors, particularly if their health suffers or their grief becomes highly disabling, impairing functioning at work, school, or home, or if they harbor destructive thoughts toward self or others. Parkes (1980) particularly stressed the value of grief counseling when other support is not forthcoming.

Pharmacological interventions also may be helpful particularly when the grief is disabling, that is, severely compromising the individual's health or ability to function. Such interventions should be focused on particular conditions, such as anxiety or depression, that are precipitated or exacerbated by the bereavement. Pharmacological interventions should be accompanied by psychotherapy.

Most individuals seem to ameliorate grief in that, over time, they can remember the loss without the intense reactions experienced earlier. Nevertheless, anywhere from 20 to 33 percent seem to experience more complicated grief reactions (Rando).

Complicated Grief

While models of complicated grief vary (Rando; Worden), complicated grief reactions generally involve intensifications and exaggerations of the earlier described responses to grief that effectively impair the individual's ability to function. Complicated grief can also be evident in masked reactions—that is, the grief is masked by another problem such as substance abuse.

One factor that can complicate grief is disenfranchisement. The term disenfranchised grief refers to a grief that results when a loss is not socially sanctioned, publicly acknowledged, or openly mourned. Grief may be disenfranchised because a loss is not recognized (e.g., the loss of an animal companion), a relationship is not recognized (e.g., a friend or therapist), the griever is not acknowledged (e.g., a very young child or a person with developmental disabilities), the death evokes shame or censure (e.g., an execution), or the way the person expresses grief is considered inappropriate or unacceptable. In such cases, the person has experienced a loss, but has "no right to grieve," no expectation of public acknowledgement or support (Doka, 1989, 2002).

Ethical Issues in Grief

Ethical issues in grief may emerge from three sources. First are general issues for counselors. Grieving persons can be highly vulnerable. Counselors have to have personal integrity and follow the ethical standards of their profession, including maintaining confidentiality, preventing harm to the client or others, assuring competence, and upholding standards of professional behavior. Counselors should familiarize themselves with their respective codes of ethics. They may wish to review as well the Code of Ethics of the Association for Death Education and Counseling.

In addition to the normal standards of professional conduct, counselors should be aware of two other ethic-related issues that might arise in grief counseling. Ethical issues within the course of the medical treatment of the deceased person may affect responses to grief. For example, a person who decided to terminate treatment may struggle with that issue within the grief process. In similar ways, ethical decisions made after the death—such as the disposition of the remains or inheritance—may also be reviewed in the grieving process. For example, the deceased may make requests regarding the disposition of remains or property that families may be reluctant to follow. Such situations can exacerbate grief—intensifying guilt or anger and causing conflicts that lessen mutual support and add concurrent stresses.

kenneth j. doka

SEE ALSO: Care; Death; Dementia; Healing; Health and Disease; Medicine, Anthropology of; Mental Health, Meaning of Mental Health; Mental Health Therapies; Pain and Suffering; Palliative Care and Hospice


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