Chapter-14
Grief and Bereavement
Bereavement is a darkness impenetrable to the imagination of the unbereaved.
– Irish Murdoch, writer, 1974
Grief is a multifaceted response to loss, particularly to the loss of someone or something to which a bond was formed. While the terms are often used interchangeably, bereavement is the period of sadness after losing loved one through death. Mourning is the expression of sorrow for a person who has died. Death, grief and mourning are normal life events. They occur in all placed and all cultures. Different cultures, however, have different myths and mysteries about death that affect the attitudes, believes, and practices of the bereaved. The ways in which people of all cultures feel grief personally are similar. This has been found to be true even though different cultures have different mourning ceremonies and traditions to express grief. All cultures have practices that best meet their needs for dealing with it.
Grief is a natural response to loss. It is the emotional suffering one feels when something or someone the individual loves is taken away. Grief is also a reaction to any loss. Individuals grieve in connection with a variety of losses throughout their lives, such as – ill health, the end of a relationship or loss of a job or loss of a pet. The loss can be categorized as physical or abstract. The physical relates to something the individual can touch or measure. The abstract loss relates to a person’s social interaction which is hard to measure.
Common grief reactions include the following:
- Feeling emotionally numb.
- Feeling unable to believe the loss occurred.
- Feeling of anxiety from the distress of being separated from the loved one.
- Mourning along with depression.
- A feeling of acceptance.
Grief is a physiological response
“No one ever told me that grief felt like fear,” C.S. Lewi wrote in “A Grief Observed,” months after the death of his wife. Scientists have found that grief, like fear, is a stress reaction, attended by a deep physiological changes in the body. Levels of stress hormones like cortisol increase. Sleep patterns are disturbed. The immune system is weakened. Studies of MRI (brain blood flow scan) scans of women with grief, showed local inflammatory response in the brain. Similar brain response was also activated by thinking about grief and grief related words. This suggests that grief can cause stress and this reaction is linked to the emotional processing parts of the frontal lobe of the brain. Previously it was believed that grief was only a human emotion, but studies have shown that other animals-also grieve.
Types of Grief Reactions
There are three types of grief reactions: anticipatory grief, normal grief, and complicated grief.
Anticipatory Grief
Anticipatory grief occurs when a death is expected, but before it happens. It may be felt by the families of people who are dying and by the person dying. It can be a time to take care of unfinished business with the dying person, such as saying “I love you” or “I forgive you.” Like grief that occurs after the death of a loved one, anticipatory grief involves mental, emotional, cultural, and social responses.
Symptom of anticipatory grief includes the following:
- Depression.
- Feeling a greater than usual concern for the dying person.
- Imagining what the loved one’s death will be like.
- Getting ready emotionally for what will happen after the death.
Anticipatory grief helps family members cope with what is to come. For the dying person it may be too much to handle and may cause him to withdraw from others. Some researchers report that anticipatory grief is rare.
Normal Grief
Normal or common grief begins soon after a loss and most symptom go away overtime. During normal grief, the bereaved person moves toward accepting the loss and is able to continue normal day-to-day life even though it is hard to do. Common grief reactions include:
- Emotional numbness, shock, disbelief, or denial. These often occur right after the death, especially if the death was not expected.
- Anxiety over being separated from the loved one. The bereaved may wish to bring the person back and become lost in the thoughts of the deceased. Images of death may occur often in the person’s everyday thoughts.
- Distress that leads to crying; sighing, having dreams, illusions, and hallucinations of the deceased; and looking for places or things that were shared with the deceased.
- Anger.
- Periods of sadness, loss of sleep, loss of appetite, extreme tiredness, quiet, and loss of interest in life. Day-to-day living may be affected.
In normal grief, symptoms will occur less often and will feel less severe as time passes. Recovery does not happen in a set period of time as was thought before.
For most bereaved people having normal grief symptoms lesson between 6 months and 2 years after the loss.
Many bereaved people will have grief bursts or pangs. Grief bursts or pangs are short period (20-30 minutes) of very intense distress. Sometimes these bursts are caused by reminders of the deceased person. At other times they seem to happen for no reason.
Grief is sometimes described as a process that has stages. Dr. Elisabeth Kubler – Ross’s book “On Death and Dying” came out in 1969 and became a best seller. Dr. Kubler-Ross, a psychiatrist, interviewed 200 terminally ill patients at Billings Hospital in Chicago. Based on her interviews she proposed a five-stage theory of grieving: (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. It was a empirical study and not a scientifically controlled study. Her theory was also based on interviews of people who were dying and not the people who experience the death of a loved one. In spite of these flaws, Dr. Kubler-Ross stage-theory became quite popular and caught on quickly with lay people and grief-counsellors.
Dr. George Bonanno, a professor of clinical psychology, at Columbia University, New York, has conducted more than two decades of international studies on grief and trauma. He studied several thousands people who have suffered losses through war, terrorism, deaths of children, premature deaths of spouses, and childhood diagnosis of AIDS. He concluded that people do not necessarily go though the stages as described by Dr. Kubler-Ross, but natural resilience is the main component of grief and trauma reaction. In other hands, most people cope well with loss of a loved one.
There are several theories about how the normal grief process works. Experts have described different types and numbers of stages that people go through as they cope with loss. At this time, there is not enough information to prove that one of these theories is more correct than the others.
Although many bereaved people have similar responses as they cope with their losses, there is no typical grief response. The grief process is personal – unique to each individual.
Complicated Grief
There is no right or wrong way to grieve, but studies have shown that there are patterns of grief that are different from the most common. This has been called the complicated grief. Complicated grief reactions that have been seen in studies include:
- Minimal grief reaction: A grief pattern in which the person has no, or only a few signs of distress or problems that occur with other type of grief.
- Chronic grief: A grief pattern in which the symptoms of common grief last for a much longer time than usual. These symptoms are lot like ones that occur with major depression, anxiety, or post traumatic stress.
In general, younger bereaved people have more problems after a loss than older bereaved people, but they may recover more quickly than older people. Lack of social support increases the chance of having problems coping with a loss. Social support includes the person’s family, friends, neighbors, and community members who can give psychological, physical, and financial help. After the death of close family members, many people have a number of related losses. The death of a spouse, for example, may cause a loss of income and change in lifestyle and day-to-day living. These are all related to social support.
Treatment of Grief
Most bereaved people work through grief and recover within the first 6 months to 2 years. They do not need treatment. Researchers are studying whether bereaved people experiencing normal grief would be helped by formal treatment. They are also studying whether treatment might prevent complicated grief in people who are likely to have it.
Complicated grief may be treated with different types of psychotherapy (talk therapy). Cognitive behavior therapy (CBT) for complicated grief has been found to be helpful in clinical trials. Depression related to grief can sometimes be treated with anti-depressant medications. However many healthcare professionals think depression is a normal part of grief and does not need to be treated.
Children and Grief
A child’s grief process is different from an adult’s. These are some of the ways children’s grief is different:
- Children may seem to show grief only once in a while and for short times. A grieving child may be sad one minute and playful the next. Often families think the child doesn’t really understand the loss or has gotten over it quickly. Usually neither is true.
- Grieving children may not show their feelings as openly as adults. Grieving children may throw themselves into activities instead of with drawing or showing grief.
- Children may have trouble putting their feelings into words. Strong feelings of anger and fears of death or being left alone may show up in the behavior (acting out) of grieving children.
- Children may ask confusing questions. For example, a child may ask, “I know grandpa died, but when will he come home?”
Although grief is different for each child, several factors can affect the grief process of a child:
- The child’s age and stage of development.
- The child’s previous experience with death.
- The child’s relationship with the deceased.
- The cause and the process of dying.
- Whether the child is given the chance to share and express feeling and memories.
- How the parents cope with the death.
- How stable the family life is after the loss.
Children at different stages of development have different understandings of death and the events near death.
Age 2- 3- years
Children at this age confuse death with sleep and may feel anxiety as early as age 3. They may stop talking and appear to feel overall distress.
Age 3 – 6 years
At this age a child cannot fully separate death from life and may see death as a kind of sleep. Children may think that the person is still living, even though he or she might have been buried. The child may think that he might have caused the death.
Grieving children under 6 may have trouble eating, sleeping, and controlling the bladder and bowel.
Age 6 – 9 years
Children at this age are often very curious about death, and may ask questions about what happens to the body when it dies. They may see death as final and scary but as something that happens mostly to old people and not to themselves. Grieving children can be afraid of school, have learning problems, show antisocial or aggressive behavior. They may also either withdraw from adults or become too clingy. They may also feel abandoned, especially if a parent has died.
Age 9 and Older
Children aged 9 and older usually know that death cannot be avoided, and do not see it as a punishment. By the time the child is 12 years old, death is seen as a final and something that happens to everyone.
Grieving children at this age range may have strong-emotions, guilt, anger and shame. They feel guilty about being alive, especially if there is a death of a brother, sister or a friend. They may have increased anxiety over their own death.
They may have eating and sleeping problem and lose interest in outside activities. Most children who have had a loss have three common worries about death. They have three important questions- (1) Did I make the death happen? (2) Is it going to happen to me? (3) Who is going to take care of me?
Talking honestly and openly about the death and including the child in rituals (funeral, burial services etc.) may help the grieving child. When talking about death with children, describe it simply and tell the truth. Answer questions in language the child can understand. Use correct words, such as “cancer”, “died” and “death”. Avoid words and phrases like “he passed away”, “he is sleeping”, “we lost him”, “gone to be with god” and “gone to heaven”. Children should be included in the planning and attending memorial or funeral services. Before a child attends a funeral, wake, or memorial services, give the child a full explanation of what to expect. Children often worry that they will also die, or their surving parent will go away. They need to be told that they will be safe and taken care of.
Death of a Child
Death of a child can take the form of a loss in infancy such as miscarriage or still birth, or neonatal death (death under 28 days of life), or the death of an older child. In most cases, parents find the grief unbearably devastating. This loss also bears a lifelong process: one does not get “over” the death but instead must live with it.
Feeling of quiet, whether legitimate or not, are pervasive. Parents who suffer miscarriage or coerced abortion may experience resentment towards other who experience successful pregnancies. Some studies have shown that the chances of divorce are high following the death of a child.
Suicide is a worldwide problem among the teenagers. When a parent lose their child through suicide it is traumatic, sudden and affects all loved ones impacted by this child. Suicide leaves many unanswered questions and leaves most parents feeling hurt, angry and deeply saddened by such a loss. Parents feel they can’t openly discuss their grief and feel their emotions because how their child died and how people around them perceive the situation. There is a wall of silence that goes up around them and how people interact towards them. One of the best ways to grieve and move on from this type of loss is to find ways to keep that child as an active part of their lives. It might be privately at first but as parents move away from the silence they can move into a more proactive healing time.
Death of a spouse
The death of a spouse is usually a particularly powerful loss. A spouse often becomes part of the other in a unique way: many widows and widowers describe losing ‘half’ of themselves. The days, months and years after the death of a spouse will never be the same and learning to live without them may be harder than one would expect. After a long marriage, at older ages, the elderly may find it a very difficult to begin a new relationship.
The survivor of a spouse who died of illness has a different experience of such loss than survivor of a spouse who died of an accident. The grief, in all events, however, can always be of most profound to the widow or widower. Emotional unsteadiness, bouts of crying, helplessness and hopelessness are some of the common symptoms. Depression and loneliness are very common. Feeling bitter and resentful are normal feelings for spouse who is “left behind.” Social isolation may also become imminent. Widows of many cultures, for instance wear black or white (Hindus) for the rest of their lives to signify the loss of their husband and their continued grief.
Death of a Parent
For a child, the death of a parent, may result in long-term psychological harm. This is more likely if the surving parent is struggling with his or her own grief and is psychologically unaviable for the child. The role of the surving parent or other close caregiver in helping children adapt to a parent’s death is critical. Studies have shown that losing a parent at a young age did not just lead to negative outcomes; there are some positive effects. Some children had an increased maturity, better coping skills and improved communication.
When an adult child loses a parent in later adulthood, it is considered to be “timely” and to be a normative life course event. This allows the adult children to feel a permitted level of grief. For adult surving children, it is a major lifeevent, bringing about the fear of one’s own mortality.
Death of a sibling
The loss of a sibling is a devastating life event. The sibling relationship is a unique one, as they share a special bond and a common history from birth. The sibling relationship tends to be the longest significant relationship of one’s life. With the death of one sibling comes the loss of that part of the survivor’s identity. Adult siblings expect the loss of aging parents first and don’t expect to lose their siblings early. Hence when a sibling dies, the surviving sibling may experience a longer period of grief. If siblings were not on good terms or close with each other, then intense feeling of guilt may ensure on the part of the surving sibling. The guilt may be not being able to prevent the death, having argued with the sibling or not being there for him or her.
Living with grief
Coping with death of a loved one is vital to our mental health. It is only natural to experience grief when a loved one dies. There is nothing abnormal about it. Followings are some ways one can cope with grief:
- Seek out caring people
Find relative and friends who can understand your feelings of loss. Join support groups with others who are or have experienced similar losses.
- Postpone major life changes
Try to hold off on making any major changes such moving, selling the house, remarrying, having another child, or changing your job. You should give yourself time to adjust to your loss.
- Take care of your health
Eat, exercise and socialize, maintain regular contact with your physician. Don’t drown your sorrow in alcohol and drug, because of danger of addiction.
- Accept that life is for living
It takes effort to begin to live again in the present and not dwell in the past.
Don’t isolate yourself.
- Be patient
There is no right way to grieve or no time limit on grieving. Every situation is unique. It takes months or even years to absorb a major loss and accept your changed life.
- Seek professional help
Grief can result in depression, alcohol and drug abuse. It can also be severe enough to impact daily living. If your grief seems like too much to bear, and paralyzes you and you are unable to function, please seek professional help. Professional can use multiple modalities to help someone cope with grief. Remember, with support, and patience, you will survive grief. Someday the pain will lessen, leaving with the cherished memories of your loved one.
Sources:
- National Cancer Institute (USA): www.cancer.gov/cancertopics/pdq/supportiave care/Bereavement 2/12/2014
- Wikipedia.org/grief-2/4/2014
- Mental Health America: www.nmha.org/grief-and-bereavement. 2/8/2014
- Ross, Elisabeth Kubler M.D., “On Death and Dying.” New York: Scribner, 1969
- Konigberg Ruth Davis, “Relief from Grief. Time, January 24, 2011, P-42