Grief is the normal psychological reaction to loss.

Bereavement is the reaction to loss of a loved person.

Mourning is the social expression of grief.

«  “Dying 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)

«  “The loss of a loved person is one of the most intensely painful experiences any human being can suffer.” (John Bowlby)

Grief is 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.

In Grief 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. (see Communication Problems, Family Therapy)

It is 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)

Both the 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 death.

«  One good memory can replace years of bad memories.

The 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.

The tasks of grieving (with thanks to William Worden):

  1. To make it real

  2. To feel the pain

  3. To adjust to the loss

1. To 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.

Being 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.

2. To 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.

Physical 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.

Some common feelings are still not generally recognized as part of normal grief, especially guilt, anger and fatigue.

Guilt 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?")

Anger 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).

All human 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?”

Physical 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.

3. To 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. (see Support)

Most 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 reached.

If a 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:

  • Grieving 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.

  • After visiting, set a specific time to return. It can be hard for bereaved persons to take the initiative in asking for help.

  • The 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 cope.

  • Avoid 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.

  • A simple 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:

  • Were over-dependent on the deceased

  • Had negative feelings about the deceased

  • Are unable to express feelings

  • Have concurrent life crises

  • Have a history of depression

  • Have had difficult reactions to previous losses

  • Lack 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:

  • Intense grief over two years after the death

  • A minor event which triggers intense grief

  • Preserving the environment of the deceased

  • Showing the same symptoms as the deceased suffered

  • Breaking off social contacts

  • Phobias about illness or dying

  • Prolonged helplessness

  • Loss of self-esteem

  • Exaggerated anger or guilt

  • Changed behavior

  • Threats of suicide

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.

Prolonged 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 work.

Chronic 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?)

The 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.

Grief 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)

Grieving 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.

The impact of death depends on the strength of the attachment, which may be as strong to a grandparent as to a parent.

Children 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 explanation. 

Children 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 problems.

Children’s 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 mother.

Anger may be acted out at school and be mistaken for naughtiness. The parents should be encouraged to stay in close touch with the child’s teachers.

Children 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 would.

Young 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. (see Children, Talking with Children)

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.

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