Grief is the normal psychological reaction to loss.
Bereavement is the reaction to loss of a loved
Mourning is the social expression of grief.
involves the gradual adjusting to a whole series of losses and
disappointments. Each loss causes grief. Very often the
earlier losses are harder to cope with than dying itself.”
(Colin Murray Parkes)
loss of a loved person is one of the most intensely painful
experiences any human being can suffer.” (John Bowlby)
the normal reaction to loss. Understanding the process of
grief is important because it affects both the dying person
and the bereaved. An understanding of the process, and how it
can be facilitated, helps us to draw alongside the dying.
Counseling & Grief Therapy, William Worden writes of the
“tasks of mourning”, and of grief as a healing process that
requires effort. He emphasizes that unresolved grief is a
common cause of psychiatric and psychosomatic illness. Where a
death is predictable there is time for anticipatory grief to
occur. This can be a healing process for both the dying person
and for the future of the family.
Problems, Family Therapy)
difficult to predict how a person will respond to loss. Every
loss is different. The grieving person must have time and
space to adjust in his own way. There is no “correct”
reaction. The intensity of grief depends on personality, the
nature of the relationship, concurrent life crises, and
availability of social supports.
Bereavement care starts before the death occurs. The
quality of medical and nursing care and support that the
patient receives creates powerful memories and affects the
bereavement of those who are left. In particular, the way bad
news is first communicated will be vividly remembered.
(see Breaking Bad News)
dying patient and the family can and do grieve before the
death, which explains why an anticipated death is usually
less traumatic than a sudden death. Helping families to
realize this can reduce the alienation that can occur at this
time. Sensitive encouragement from professionals can help the
family say things that need to be said, (often simply "I love
you and I will miss you"), which helps considerably after the
One good memory can replace years of bad memories.
events around the time of the death will affect the family in
their grief and in future life crises. Anticipatory
guidance reduces subsequent problems. Accurate information,
encouragement to express emotions and helping communication
between the family and the dying person all help the process
of grief. Encourage family members to be present at the time
of death and to say good-bye afterwards to the body. This
helps to make the loss a reality, which can enable the process
of grieving to begin.
tasks of grieving (with thanks to William Worden):
to the loss
make it real – Initial numbness is normal, but
within a few weeks the person has to accept that the
deceased has gone. Prolonged denial means the other tasks of
grieving cannot be worked through.
present at the death, seeing the dead body, saying good-bye,
attending the funeral service and talking repeatedly about the
event of the death and the feelings about it can help a person
to accept the reality of the death.
feel the pain – An initial anxiety state can
occur which is somewhat analogous to the restless searching
behavior seen in animals separated from an attachment object.
Bereaved persons may be distracted, unable to concentrate, and
preoccupied with the deceased. They may become overactive or
withdrawn from society. Over 50% of bereaved persons have
hallucinations of the deceased.
manifestations (breathlessness, tiredness, tightness in
the chest, insomnia) are common. An anxiolytic such as
diazepam or lorazepam is helpful only as a short term
measure for severe anxiety symptoms or insomnia.
Grief itself cannot be suppressed or resolved with drugs.
feelings are still not generally recognized as part of normal
grief, especially guilt, anger and fatigue.
is universal in grief. ("If only . . .") It may be
irrational, or occasionally justified. It needs to be reality
tested. ("How would you have felt if it happened to you?" "If
she were here now what would she say?")
is common. (“Look at the mess he’s left me in.”) Most people
feel guilty about feeling angry at the deceased, and displace
it on others (threatening to sue the doctor or nurse, for
example) or on themselves (causing depression).
relationships involve both positive and negative feelings, and
it is important that these be brought into balance in grief.
Ask “What do you miss about him?” Emphasize positive memories,
but give permission to express the negative. Later in grief it
can become possible to ask “What don’t you miss about him?”
and mental fatigue can be compelling. Simple tiredness
occurs from weeks or months of caring for an increasingly ill
person, and from making funeral and numerous other necessary
arrangements around the time of death. Numbness, restlessness
and crying make it difficult to function normally.
adjust to the loss – Bereaved persons may need extra
support and gentle help in making even simple decisions. A
problem-solving approach to everyday decisions must be
encouraged as they are helped to develop new skills.
bereaved persons can eventually form new attachments
without feeling they are somehow dishonoring the memory of the
deceased. They can think of the deceased without pain, and can
start to enjoy their memories. This signals a healthy end of
grieving. This stage is sometimes reached within a year but
usually takes two or three years, and is sometimes never
bereaved person forms a new relationship too soon after losing
a spouse, it usually ends in frustration that the replacement
person is not a perfect match for the lost partner.
Principles of bereavement support:
takes time. The person may need extra support in critical
periods for at least a year. Critical periods include three
months and twelve months after the death, anniversaries and
holidays, and religious festivals. Offer continuing support.
visiting, set a specific time to return. It can be hard
for bereaved persons to take the initiative in asking for
normal symptoms of grief (restlessness, forgetfulness, poor
appetite, insomnia, visions of the deceased) can be
frightening. A bereaved person may fear he is going mad.
Just understanding the common symptoms of acute grief, and
acknowledging the pain of grief, can help a bereaved person to
platitudes. (“I know how you feel.”) Avoid describing your
own losses in detail. This is not helpful. Encourage the
bereaved person to talk about the events surrounding the
death, and ask about his feelings. This helps him to accept
the reality of the loss and to experience the pain of grief.
pamphlet can be very helpful, briefly explaining the
normal intense feelings of grief and including information
about support groups.
Be aware of those persons who may be particularly at risk of
an abnormal grief reaction. They include those who:
over-dependent on the deceased
negative feelings about the deceased
unable to express feelings
concurrent life crises
history of depression
difficult reactions to previous losses
social or family support
About 1 of
every 3 persons who suffer a major loss (the death of a child
or a spouse, for example) may require special help. Persons
who are isolated or severely affected can benefit greatly from
regular support given by a competent counselor, from a support
group or by trained volunteers.
Pathological grief – If a person fails to work through the
tasks of grief, it can become prolonged (“stuck”) or
exaggerated or may simply present as depression. Pathological
grief may require skilled psychotherapy rather than straight
forward support and counseling.
Clues to a pathological grief reaction may be:
grief over two years after the death
event which triggers intense grief
Preserving the environment of the deceased
the same symptoms as the deceased suffered
off social contacts
about illness or dying
Exaggerated anger or guilt
Pathological grief can cause years of misery. If it is
suspected as a cause of depression a useful first question is
“What is the worst thing that has ever happened to you?”
Talking about the deceased encourages expression of feelings.
Pathological grief can be due to unfinished business with the
deceased person, with whom there was often an ambivalent
relationship. The expression of repressed feelings of anger or
guilt may need several specialist sessions of psychotherapy
or psycho-drama, in which these feelings are
re-experienced and reality-tested.
avoidance of grief can sometimes be overcome by techniques of
forced mourning, using “linking objects” (personal possessions
or photographs of the dead person) to provoke renewed grief
grief may call for work to improve personal self-esteem.
Permission to stop grieving may be needed. The person’s
purpose in prolonging grief should be explored. (What will
this person lose in giving up his grief?)
psychotherapist often substitutes in part for the deceased, to
give comfort and additional support. The psychotherapist must
skillfully prepare the grieving person to say good-bye at the
end of the therapy.
and the family – Bereavement usually affects a whole
family. Therapy for the family unit can be a very effective
way of facilitating grief work. Any loss resonates with
previous losses, which are often reawakened. Responses to loss
are more easily understood in the light of previous losses.
Families vary in their ability to express and tolerate
feelings and to support each other emotionally. Where grief is
not acknowledged it can damage family relations in a number of
ways. The role of the deceased in the family may be given
inappropriately to a child (“replacement child”). The anger of
grief may be displaced onto a family member (“scapegoat”) who
becomes the target of all wrath. Allowing a family to witness
emotional distress in one member can release them to talk
about their own feelings.
(see Family Therapy)
children can develop psychological disorders. Children
most at risk are those bereaved at 3 to 5 years, and in early
adolescence. Instinctive protectiveness often leads families
to exclude children from bad news. Yet children need to find
their own answers to loss and death.
of death depends on the strength of the attachment, which may
be as strong to a grandparent as to a parent.
often see bereavement in terms of desertion. (“Daddy left
me.”) They also commonly see death as somehow being their fault.
These fantasies need to be brought into the open and
clarified. Ask the child what he thinks. Children often fear
that one death may herald another, particularly if someone
else in the family becomes ill. They need reassurance and
cope best when they are included and allowed to witness the
sadness of other family members. Children should be gently
encouraged to attend the funeral. If they do not, they benefit
from an alternative ritual of some kind. One study showed that
children who attended funerals had less deviant behavior and
increased crying, and that children who cried more (and talked
about the lost person) had fewer behavioral and emotional
fears and feelings lie near the surface. Grief is incorporated
into play. Playing at “funerals” may seem macabre to adults,
but children express their feelings through play. Children
also express their concern in practical ways. One child
shocked her family by asking “Will the funeral be expensive?”
only minutes after her father had died. It sounded callous,
yet her immediate concern was the future support of her
be acted out at school and be mistaken for naughtiness. The
parents should be encouraged to stay in close touch with the
usually need to ask a lot of questions and need a lot of
explanation. Explanation must use the words and concepts of
the family’s own belief system, which must first be explored.
Explanations need to be clear and simple. (“Death means a
person stops moving and breathing and is still and peaceful.”)
Children can cope well with bereavement provided they are
supported and encouraged to grieve. Children do not cope well
with the mystification of death. Secrecy is not protective -
it causes confusion and isolation.
Mrs. C.M., a 42-year old woman with a glioma, died in an
in-patient hospice. She denied her illness, but at a family
meeting two weeks before her death one son, Darren (age 6),
shocked his parents by suddenly announcing “Mommy is dying,
she will be dead before Christmas.” Two months later
Darren’s father phoned the hospice asking for help because
Darren’s behavior was disturbing. A meeting was arranged
with the doctor and social worker. (The room was equipped
with ice cream, and paper and pencils for drawing.) As they
came into the room, Tommy (age 4), suddenly asked “Can we
see the bed where Mommy died?” The boys were taken there,
but their father refused to go. When they returned, Tommy
announced he “wanted to pee” so his father took him to the
toilet. On the way back, Tommy led his father to the room
where his mother had died, and showed him the bed.
The boys had their ice cream, chatted and drew
pictures. Darren brought the conversation round to his
mother by telling a joke he had made up, about a snowman who
wanted a wife. (It emerged that his mother had given him a
large poster of a snowman before she died, which hung above
his bed.) The father, a quiet man, suddenly said he had
recently taken Tommy, the younger boy, to see his mother’s
grave. The doctor asked why Darren had not gone. The father
explained that the grave was in the village churchyard
across a busy road, and he was worried Darren might try to
go there by himself. The social worker asked Darren if he
would like to visit his mother’s grave and Darren said he
children need to mourn. Parents often say "The child is too
young to understand" because they need to protect themselves
from the idea of their child’s sadness and grief.
The author and publisher have taken
precautions to ensure that the information in this book is
error-free. However, readers must be guided by their own
personal and professional standards of good practice in
evaluating and applying recommendations made herein. The
contents of this book represent the views and experience of
the author, and not necessarily those of the publisher.