11.6: Grief, Bereavement, and Mourning

The terms grief, bereavement, and mourning are often used interchangeably, however, they have different meanings. Grief is the normal process of reacting to a loss. Grief can be in response to a physical loss, such as a death, or a social loss including a relationship or job. Bereavement is the period after a loss during which grief and mourning occurs. The time spent in bereavement for the loss of a loved one depends on the circumstances of the loss and the level of attachment to the person who died. Mourning is the process by which people adapt to a loss. Mourning is greatly influenced by cultural beliefs, practices, and rituals (Casarett, Kutner, & Abrahm,2001). Grief can take many forms.

Dual-Process Model of Grieving

The dual-process model takes into consideration that bereaved individuals move back and forth between grieving and preparing for life without their loved one (Stroebe & Schut, 2001; Stroebe, Schut, & Stroebe, 2005). This model focuses on a loss orientation, which emphasizes the feelings of loss and yearning for the deceased and a restoration orientation, which centers on the grieving individual reestablishing roles and activities they had prior to the death of their loved one. When oriented toward loss, grieving individuals look back, and when oriented toward restoration they look forward. As one cannot look both back and forward at the same time, a bereaved person must shift back and forth between the two. Both orientations facilitate normal grieving and interact until bereavement has completed.

Grief Reactions

Typical grief reactions involve mental, physical, social and/or emotional responses. These reactions can include feelings of numbness, anger, guilt, anxiety, sadness and despair. The individual can experience difficulty concentrating, sleep and eating problems, loss of interest in pleasurable activities, physical problems, and even illness. Research has demonstrated that the immune systems of individuals grieving is suppressed and their healthy cells behave more sluggishly, resulting in greater susceptibility to illnesses (Parkes & Prigerson, 2010). However, the intensity and duration of typical grief symptoms do not match those usually seen in severe grief reactions.

Complicated Grief

After the loss of a loved one, some individuals experience complicated grief, which includes atypical grief reactions (Newson, Boelen, Hek, Hofman, & Tiemeier, 2011). Symptoms of complicated grief include: Feelings of disbelief, a preoccupation with the dead loved one, distressful memories, feeling unable to move on with one’s life, and an intense and sustained yearning for the deceased. Additionally, these symptoms may mirror those seen in major depressive disorder (Youdin, 2016).

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013), distinguishing between major depressive disorder and complicated grief requires clinical judgment. The psychologist needs to evaluate the client’s individual history and determine whether the symptoms are focused entirely on the loss of the loved one and represent the individual’s cultural norms for grieving, which would be acceptable. Those who seek assistance for complicated grief usually have experienced traumatic forms of bereavement, such as unexpected, multiple and violent deaths, or those due to murders or suicides (Parkes & Prigerson, 2010).

Disenfranchised Grief

Grief that is not socially recognized is referred to as disenfranchised grief (Doka, 1989). Examples of disenfranchised grief include death due to AIDS, the suicide of a loved one, perinatal deaths, the death of a pet, or ex-spouse, and psychological losses, such as a partner developing Alzheimer’s disease. Due to the type of loss, there is no formal mourning practices or recognition by others that would comfort the grieving individual.

Consequently, individuals experiencing disenfranchised grief may suffer intensified symptoms due to the lack of social support (Parkes & Prigerson, 2010).

Anticipatory Grief

Grief that occurs when a death is expected and survivors have time to prepare to some extent before the loss is referred to as anticipatory grief. This expectation can make adjustment after a loss somewhat easier (Kübler-Ross & Kessler, 2005). A death after a long-term, painful illness may bring family members a sense of relief that the suffering is over, and the exhausting process of caring for someone who is ill is also completed.

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.

Mixed Emotions

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.

"Modern" Grief

The “death-denying, grief-dismissing world” is the modern world (Kubler-Ross & Kessler, 2005, p. 205). We are asked to grieve privately, quickly, and to medicate our suffering. Employers usually 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. Obviously life does have to continue. But Kubler-Ross and Kessler suggest that contemporary American society would do well to acknowledge and make more caring accommodations to those who are in grief.

Four Tasks of Mourning

Worden (2008) 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 (Lynn & Harrold, 2011). Support groups are available through spiritual 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.

Five Stages of Grief

There are several theoretical models of grief, however, none is all encompassing (Youdin, 2016). These models are merely guidelines for what an individual may experience while grieving. However, if individuals do not fit a model, it does not mean there is something “wrong” with the way they experience grief. It is important to remember that there is no one way to grieve, and people move through a variety of stages of grief in various ways.

The most well-known module of grief was developed by Swiss psychiatrist Kübler-Ross who first introduced her five stage grief model in her book On Death and Dying. Kübler-Ross’ model was based off her work with terminally ill patients and has received much criticism in the years since. Mainly, because people studying her model mistakenly believed this is the specific order in which people grieve and that all people go through all stages. Kübler-Ross now notes that these stages are not linear and some people may not experience any of them. Yet and still, others might only undergo two stages rather than all five, or one stage, or three stages and so forth. 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 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. IMAGE ATTRIBUTION - Photo by behnam jaafarianpoor on Unsplash

Denial

The first reaction to the overwhelming and often unimaginable news of a death is denial. 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 feel a sense of disbelief psychologically even though they know that the results are true.

Anger

Like denial, 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. It is much easier to be angry than to be sad, 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 (according to a person's own beliefs), or at the world in general. 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.

Photo by Diana Simumpande on Unsplash

Bargaining

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.

Depression

Depression in this stage might include withdrawal from life, feeling numb, living in a fog, and not wanting to get out of bed. The world might seem too much and too overwhelming to face. There is no desire to be around others, the person does not feel like talking, and experiences feelings of hopelessness, even potential suicidal thoughts – thinking “what’s the point of going on?” Sometimes hospice care may include the use of antidepressants to help manage depression during this stage.

Acceptance

The final stage in the Kübler-Ross model is acceptance. Acceptance involves learning how to carry on and to incorporate this aspect of the life span into daily life. 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.

According to Kübler-Ross (1969), behind these five stages focused on the identified emotions, there is a sense of hope. Kübler-Ross noted that in all the 200 plus patients she and her students interviewed, a little bit of hope that they might not die was often in the back of their minds.

Criticisms of the Kübler-Ross Five Stages of Grief Model

Some researchers have been skeptical of the validity of there being stages to grief among the dying (Friedman & James, 2008). 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?” (Kübler-Ross, 1969, p. 19). 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 (Kübler-Ross, 1969).

There have been challenges to the notion that denial and acceptance are beneficial to the grieving process (Telford, Kralik, & Koch, 2006). 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 (Taylor, Kemeny, Reed, Bower & Gruenewald, 2000).

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 (2008) and Telford et al. (2006) 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 the Five Stage of Grief Model (Maciejewski, Zhang, Block, & Prigerson, 2007). 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.

Although there is criticism of the Five Stages of Grief Model, Kübler-Ross made people more aware of the needs and concerns of the dying, especially those who were terminally ill. As she notes,…when a patient is severely ill, he is often treated like a person with no right to an opinion. It is often someone else who makes the decision if and when and where a patient should be hospitalized. It would take so little to remember that the sick person has feelings, has wishes and opinions, and has – most important of all – the right to be heard. (1969, p. 7-8).

Conclusion

Death and grief are topics that are being given greater consideration. 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.

OpenStax College, Psychology. OpenStax CNX. Oct 29, 2018 http://cnx.org/contents/4abf04bf-93a...fd46e68cc@9.25.

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Lifespan Development, A Psychological Perspective Open Education Resource (OER) textbook funded by a grant from the College of Lake County Foundation and supported by the Business and Social Sciences Division.http://creativecommons.org/licenses/by-nc-sa/3.0/ by Martha Lally and Suzanne Valentine-French remixed by Heather Valle