Grief is the universal, instinctual and adaptive reaction to loss, and particularly, the loss of a loved one (Dialogues in clinical neuroscience, 2012). It is a natural response, and can be anything from missing out on a scholarship to loss of limbs through accident to loss of a car or other possessions through theft. Surely the most painful loss is that of someone we love through death. Loss is an emotional wound, and like physical wounds, requires time to heal: not just a few days or weeks, but months rolling into years. The process of grieving, or mourning, allows people to come to terms with their loss. This does not mean that the person who died is forgotten, but that those left behind come to accept that the person is no longer around.

Grieving has as many forms as there are people grieving. It is guaranteed to be painful, hard work which sucks up a huge amount of emotional and physical energy. It is also highly individual. Like snowflakes, no two grieving paths are exactly the same, and the precise support needed varies accordingly. In this article, we look at some of the factors and circumstances which create very different experiences of grief, and also explore common characteristics of grief.

Past experience

This category holds a multitude of influences. We can ask, “How has the bereaved person’s childhood impacted on the ability to deal with loss now? That is, what other losses were there: in childhood, in adolescence, in adulthood? Was the person held well in working through the grief of these (for instance, being supported emotionally and encouraged to express grief in a safe environment)? Has the person had the chance to integrate and heal from the losses? What other losses or changes can we identify in the person’s life prior to this current loss: for example, have there been financial or relational issues? Did the person experience trauma from health or workplace challenges? How functional has their family life been in the past?

And what has been the mental health history of the bereaved person: have there ever been issues of depression, anxiety, or other mental health problems? Have they been treated with medications for these, or hospitalised? What ways of responding to life were characteristic in the bereaved person’s culture, and in his or her family (for example, did the parents express grief or did they feel the need to have a “stiff upper lip”)? What other conditioning influences from the past might be affecting the bereaved person’s experience now?

Relationship with the dead person

As individual as paths of grief are, so too are the special bonds that tie one person to another. How can any of us measure the unique connection that may exist between a bereaved person and the one for whom they grieve? Length of time of the relationship, type of role (such as parent/child, husband/wife, or friend/friend), degree of closeness, and strength of attachment (including balance of “love-hate” feelings) all enter into the equation of how long and how intensely the bereaved person will need to grieve for the departed one.

Beyond that, there are issues of the informal roles that the deceased may have played in the bereaved person’s life. For example, was the one who took his or her life the primary earner in the family? Or perhaps the emotional “pillar” on whom the bereaved person always leaned? Maybe the dead person was the only significant friend, or the only one in a partnership who could drive, or handle difficult teenagers, or…? The possibilities are endless. The reality is that when people leave our lives, we miss their particular personalities and “take” on life, but we may also greatly feel the loss of the roles that they took up within our relationship, the special tasks that they performed that we now must somehow replace. You can be particularly helpful by tuning into the nature of the relationship between deceased and bereaved, and helping the bereaved person come to terms with the roles that are now missing from his or her life.

Circumstances surrounding the death

How the deceased person’s death occurred and in general the circumstances surrounding the death are central to the bereaved person’s capacity to integrate the loss, coming to a place of acceptance of it. Was the person’s death in keeping with the natural order of things, such as when a leaf flutters to the ground in late autumn because it has finished its life cycle, or was the situation more like a leaf being ripped harshly off the branch in early spring? Death may be sad anytime, but a parent surviving a child feels tragic. We can have greater capacity to support a bereaved person if we also find out what sorts of warnings they may have had that the loss was imminent. Or did death come so suddenly that there was no advance notice, no chance to say goodbye, no opportunity to resolve “unfinished business” interpersonally? Does the bereaved person have a sense that the death could have been prevented or postponed? Importantly, how much responsibility is the bereaved person taking for the death? Is there a sense that the deceased accomplished their life’s mission and that their life was rewarding and full? If there is anything unresolved between the deceased and the bereaved, how much guilt is being generated in the bereaved person as a result?

Influences in the present

Finally, understanding the bereaved person’s path from grief to restored wholeness depends on knowing what the interplay of factors in their present life is. How stable is the bereaved person’s mental health? How resilient is their personality, how developed their coping skills? Is the person young and hardy enough to bounce back from this death? Is he or she wise and mature enough to accept the loss and grow with the experience? Can life be rebuilt? Is the rebuilding going to be made more challenging because of secondary losses incurred through the death, such as that of the home or income? Did the death break up the family? How is the bereaved person’s health? What opportunities does the person see for themselves now (even though they would never have chosen to have the opportunity if it meant losing the loved one)?

Role expectations make a big difference to a grief response, too. What role expectations has the bereaved person set for themselves (such as, say, trying to be the “strong one” for the rest of the family)? What role expectations may be imposed from family, friends, or the culture in general? Will the bereaved person try to meet these or, feeling unable to meet them, simply withdraw in isolated despair? What factors in the person’s cultural, ethnic, and religious background might offer comfort, holding, and strength? Are there any religious or philosophical beliefs which engender guilt or add burden to the grieving? And how good are the social support networks of the bereaved person? (Tesik, n.d.).

Being aware of the way in which the above factors combine to create the intensity, duration, and tone of the grieving can help you to be sensitive to clients’ needs, guiding them to get just the right help for their needs at each stage of mourning. Even so, the different characteristics and reactions to grief may mean that some journeys through grief are much smoother than others.

Grief characteristics

As we noted above, the grief response is instinctive in human beings, and possibly in many animal species as well. As challenging as it is to experience it, we recognise that, at least in the beginning, it is an adaptive reaction to the loss of a loved one. Grief can be divided into acute grief, which is the initial painful response, integrated grief, which is the ongoing adaptation to the death of a loved one, and finally complicated grief (CG), which is sometimes labelled as prolonged, unresolved, or traumatic grief. CG is the cold, hard place where the sense of loss remains persistent and intense and does not transition into integrated grief (Dialogues in clinical neuroscience, 2012).

Acute grief

When someone we care for dies, even from natural causes, we experience intense and distressing emotions. Numbness, shock, and denial, for example, come immediately after the death. The reason that these feelings are said to be adaptive, at least at first, is that they provide a respite from the pain, allowing the bereaved person the time and energy to not only take in the death, but also deal with the many practical tasks that must suddenly be tended to: planning the funeral, doing what is necessary for children or other dependents, and settling the estate of the deceased. The pain cannot be put off indefinitely, however, and eventually the anaesthetic of shock and numbness wears off. Whether that occurs days, weeks, or even months after the death, when the reality of it is fully comprehended (both cognitively and emotionally), intense feelings of sadness, longing, and emptiness may peak.

While the intense emotions of anguish and despair initially seem ever-present, they gradually begin to occur in waves: the pangs of grief that come about when the bereaved is exposed to concrete reminders of the deceased. People know that they are healing as, over time, the waves become less intense and less frequent. The bereaved individual accepts the loss and re-establishes emotional balance. While the person is still keenly aware of how much the deceased meant to him or her, attention begins to shift to the outer world (Dialogues in clinical neuroscience, 2012).

Integrated grief

Fortunately, most people tend to transition away from acute grief within several months to the more healed place of integrated grief. What are the signposts that you as a mental health practitioner can look to in order to identify this stage? The bereaved will have the ability to recognise that they have been grieving, yet they will be able to disidentify from the grief, thinking about the deceased with equanimity. The bereaved will be able to return to work, to again experience pleasure, and to seek the companionship and love of others. Many are the survivors who reflect that capacities such as greater depth of wisdom, formerly unrecognised strengths, and enhanced capacity for meaningful relationships now emerge within them (Zisook & Shuchter, 1993). A few survivors, however, do not achieve such resolution. These are the ones who go on to develop a complicated grief (CG) reaction (Zisook, Simon, & Reynolds, et al., 2010).

Complicated grief

If the bereaved client sitting in front of you experienced the loss some time ago – let’s say a year – but they complain of feeling still an acute distress which interferes with their functioning, if the person’s longing for the deceased has not abated, and if they say that they have not been able to re-establish any sort of meaningful life without the deceased, you may suspect that your client’s acute grief has gone into complicated grief. When the pain of the loss stays fresh and the bereaved remains in intense grief, the person may be stuck in complicated grief, the symptoms of which include recurrent and intense pangs of grief and a preoccupation with the person who died: mixed in with avoidance of reminders of the loss.

In CG there may be intrusive images of the death recurring, while positive memories may be blocked or re-interpreted as sad. The person might complain of inability to concentrate, which is interfering with daily activities. If the client feels an overwhelming emptiness, they may even hint at wanting to join the deceased in death, or alternatively, the continuing pain from their loss may feel so strong that it seems the only possible relief available is their own death. Associated with poor outcomes on both psychological and physical levels, individuals with CG often have impairments not only in daily life and social functioning, but also in terms of career and occupational issues. They suffer from higher rates of major depression occurring alongside the grief, and have greater posttraumatic stress disorder (PTSD). At higher risk for suicidal ideation and behaviour, clients with CG will experience poor health outcomes which persist indefinitely if they are not treated (Lichtenthal, Cruess, & Prigerson, 2004).

This article was adapted from the Mental Health Academy CPD course “Supporting the Suicide-Bereaved”. This course explores who the suicide-bereaved are and what they tend to go through: the early and ongoing reactions that define the often complicated grief of suicide bereavement.

References

• Dialogues in clinical neuroscience. (2012). Suicide bereavement and complicated grief. Dialogues in clinical neuroscience. Retrieved on 31 March, 2014, from: hyperlink.
• Lichtenthal W.G., Cruess D.G., Prigerson H.G. (2004). A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clin Psychology Rev. 2004; 24:637–662.
• Tesik, J. (undated). Beyond surviving. Survivors of suicide. Retrieved on 29 March, 2012 from: hyperlink.
• Zisook S. & Shuchter, S.R. (1993). Uncomplicated bereavement. Journal of Clinical Psychiatry. 1993; 54:365–372.
• Zisook S., Simon N.M., Reynolds C.F., et al. (2010). Bereavement, complicated grief, and DSM, part 2: complicated grief. Journal of Clinical Psychiatry. 2010; 71:1097–1098.