8.20: 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 et al., 2001).

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, and symptoms typically diminish within 6 to 10 weeks (Youdin, 2016).

Complicated Grief:

After the loss of a loved one, however, some individuals experience complicated grief, which includes atypical grief reactions (Newson et al., 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 a yearning for the deceased. Additionally, these symptoms may last six months or longer and mirror those seen in major depressive disorder (Youdin, 2016).

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According to the DSM-5-TR (American Psychiatric Association, 2022), 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, abortions, the death of a pet, lover, or ex-spouse, and psychological losses, such as a partner developing Alzheimer's disease. Due to the type of loss, there are 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.

Models 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.

Five Stages of Grief:

Kübler-Ross (1969, 1975) describes five stages of loss experienced by someone who faces the news of their impending death. 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.

• 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.
• 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, 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. 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.
• Bargaining involves trying to think of what could be done to turn the situation around. Living better, devoting oneself to a cause, or 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 or 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.
• 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.

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 always in the back of their minds.

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 (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). 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 (Kübler-Ross & Kessler, 2005). 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 (Friedman & James, 2008).

There have been challenges to the notion that denial and acceptance are beneficial to the grieving process (Telford et al., 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 Kübler-Ross's five stage theory of grief (Maciejewski et al., 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).

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.

Prolonged Grief Disorder:

Most people are able to move on from the loss of those close to them. Unfortunately, some individuals demonstrate an inability to overcome the death of a loved one after more than a year of grieving. Further, their grief interferes with their daily functioning and is disabling in a way that normal grieving is not. Consequently, the most recent edition of the DSM-5-TR (American Psychiatric Association, 2022) added prolonged grief disorder to the list of mental health disorders. Prolonged grief disorder is characterized by the following diagnostic criteria:

• Death, at least 12 months ago, of a person who was close to the bereaved individual
• Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly every day for at least the last month
  • Intense yearning/longing for the deceased person
  • Preoccupation with thoughts or memories of the deceased person
• Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month:
  • Identity disruption (e.g., feeling as though part of oneself has died) since the death
  • Marked sense of disbelief about the death
  • Avoidance of reminders that the person is dead
  • Intense emotional pain related to the death
  • Difficulty reintegrating into one's relationships and activities after the death
  • Emotional numbness as a result of the death
  • Feeling that life is meaningless as a result of the death
  • Intense loneliness as a result of the death

According to the DSM-5-TR (APA, 2022), risks for prolonged grief disorder symptoms include increased dependency on the deceased prior to the death, the death of a child, violent or unexpected deaths, and economic stressors. A higher prevalence is noted following the death of a spouse/partner or child compared with other family relationships. This diagnosis would not be for individuals who periodically feel grief after a year, but for those who have intense grief that affects their functioning. Additionally, the duration and severity of the person's bereavement exceeds expected social, cultural, or religious norms.

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 (Kübler-Ross & Kessler, 2005, p. 205). We often grieve privately, quickly, and medicate our suffering with substances or activities. Employers may grant 3 to 5 days for bereavement, if the loss is that of an immediate family member. 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 (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 religious organizations, hospitals, hospice, nursing homes, mental health facilities, and schools for children.

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