Grief is a multi-faceted response to loss,
particularly to the loss of someone or something to which we have
formed a bond. Although conventionally focused on the emotional
response to loss, it also has physical, cognitive, behavioral,
social, and philosophical dimensions. Common to human experience is
the
death of a loved one, whether it be a
friend, family, or other companion. While the terms are often used
interchangeably, bereavement often refers to the state of loss, and
grief to the reaction to loss.
Losses can range from loss of employment,
pets,
status, a sense of safety, order, or possessions, to the loss of
loved ones. Our response to loss is varied and researchers have
moved away from conventional views of grief (that is, that people
move through an orderly and predictable series of responses to
loss) to one that considers the wide variety of responses that are
influenced by
personality,
family,
culture, and
spiritual and
religious beliefs and practices.
Bereavement, while a normal part of life, carries a degree of risk
when limited support is available. Severe reactions to loss may
carry over into familial relations and cause trauma for children,
spouses and any other family members: there is an increased risk of
marital breakup following the death of a child, for example. Issues
of faith and beliefs may also face challenge, as bereaved persons
reassess personal definitions in the face of great pain.
While many who grieve are able to work through their loss
independently, accessing additional support from professional
psychiatrists or therapy may promote
the process of healing.
Grief
counseling, professional support groups or educational classes,
and peer-led support groups are primary resources available to the
bereaved. In the United States, local hospice agencies may be an
important first contact for those seeking bereavement
support.
Stage theories and processes
Dr.
Elisabeth Kübler-Ross
posited sequential stages of grief including denial,
anger, bargaining,
depression, and
acceptance, which are commonly referred to as the
"
grief cycle."
The stages model, which came about in the 1960s, is theoretical,
based on observation of people who are dying, not on scientific
research into the experiences of people who have survived the death
of a loved one. This model has largely been debunked because of the
rigorous work of bereavement research pioneer,
George Bonanno.
In 1991, Bonanno began studying grief for the first time using
rigorous, peer-reviewed scientific techniques. Until then, the
field of grief was largely based on theoretical models, such as the
stages model, or that of
John Bowlby and
Parkes, or
Sigmund
Freud. Bonanno's many studies followed people over time who
have suffered a loss: such as death of a child, a spouse, or a
loved one. In none of his many studies did he find evidence that
the stages model exists. In large part due to his work, the stages
model is now considered invalid scientifically but it remains a
popular idea among the public.
In 2008,
Skeptic Magazine published the findings of the
Grief Recovery Institute, which further contest the stages of grief
as they are related to people's dealing with the deaths of those
important to them.
John Bowlby, a noted
psychiatrist, outlined the ebb and flow of processes such as shock
and numbness, yearning and searching, disorganization and despair,
and reorganization.
Physiological and neurological processes
fMRI scans of women from whom grief was
elicited about the death of a mother or a sister in the past 5
years found it produced a local inflammation response as measured
by salivary concentrations of
pro-inflammatory cytokines. These
were correlated with activation in the
anterior cingulate cortex and
orbitofrontal cortex. These
activation also correlated with free recall of grief-related word
stimuli. This suggests that grief can cause stress, and that this
is linked to the emotional processing parts of the
frontal lobe.
Among those bereaved within the last three months, those who report
many intrusive thoughts about the deceased show ventral
amygdala and rostral
anterior cingulate cortex
hyperactivity to reminders of their loss. In the case of the
amygdala, this links to their sadness intensity. In those who avoid
such thoughts, there is a related opposite type of pattern in which
there is a decrease in the activation of the dorsal amgydala and
the
dorsolateral
prefrontal cortex.
In those not so emotionally affected by reminders of their loss,
fMRI finds the existence of a high functional
connectivity between the dorsolateral prefrontal cortex and
amygdala activity, suggesting the former regulates activity in the
latter. In those who had greater intensity of sadness, there was a
low functional connection between the rostal anterior cingulate
cortex and amygdala activity, suggesting a lack of regulation of
the former part of the brain upon the latter.
Risks
Many studies have looked at the bereaved in terms of increased
risks for stress-related illnesses.
Colin
Murray Parkes in the 1960s and 1970s in England
noted
increased doctor visits, with symptoms such as abdominal pain,
breathing difficulties, and so forth in the first six months
following a death.
Others have noted increased mortality rates (Ward, A.W. 1976) and
Bunch et al.found a five times greater risk of
suicide in teens following the death of a parent.
Grief puts a great stress on the physical body as well as on the
psyche, resulting in wear and tear beyond what is normal.
Types and duration
"Complicated grief", now also commonly referred to as "prolonged
grief", can be differentiated from normal grief. Normal grief
typically involves a range of transient behavioral and emotional
responses to loss. While the experience of grief is a very
individual process depending on many factors, certain commonalities
are often reported.
Nightmares,
appetite problems, dryness of mouth, shortness of
breath,
sleep disorders, and
repetitive motions to avoid pain are often reported by people
experiencing normal grief. Even
hallucinatory experiences may be normal early
in grief.
Examples of complicated grief can often be found in those who have
survived a suicide attempt (Hsu, 2002). Complicated grief responses
almost always are a function of intensity and timing: a grief that
after a year or two begins to worsen, accompanied by unusual
behaviors, is a warning sign. Deaths such as suicides, murders,
accidents, and other sudden and unexpected deaths can result in
complicated grief due to the sudden shock.
The surprise makes it difficult to integrate the "story" of the
loss, so the person struggles with an initial task of simply
believing that the loss has occurred. Variables surrounding the
death such as expectedness, naturalness, presence of violence,
ambivalence, degree of attachment, and others play into the
presence of complicated grief. All too often complicated grief can
last for years. Most people (friends of the mourner) will recoil
when hearing that this sort of grief may still be present after
several years.
There is a clinical problem of becoming "identified" with the
grief. In this situation, mourners are reluctant to release the
grief because grieving has been integrated as part of their
identity. Reporting in the journal
NeuroImage (
May 10 2008, online), scientists
suggest that complicated grief activates neurons in the reward
centers of the brain, possibly giving these memories addiction-like
properties. The authors found activity in the nucleus accumbens, a
region of the brain most commonly associated with reward. It is one
that has also been shown to play a role in social attachment, such
as sibling and maternal affiliation.
Types of bereavement
Differing bereavements along the life cycle may have different
manifestations and problems which are age related, mostly because
of cognitive and emotional skills along the way. Children will
exhibit their mourning very differently in reaction to the loss of
a parent than a widow would to the loss of a spouse.
Reactions in one type of bereavement may be perfectly normal, but
in another the same reaction could be problematic. The kind of loss
must be taken under consideration when determining how to
help.
Childhood bereavement
When a parent or caregiver dies or leaves, children may have
symptoms of psychopathology, but they are less severe than in
children with major depression (Cerel, 2006). The loss of a parent,
grandparent or sibling can be very troubling in childhood, but even
in childhood there are age differences in relation to the loss. A
very young child, under one or two, may be felt to have no reaction
if a carer dies, but this is far from the truth.
At a time when trust and dependency are formed, a break even of no
more than separation can cause problems in wellbeing; this is
especially true if the loss is around critical periods such as 8–12
months, when attachment and separation are at their height in
formation, and even a brief separation from a parent or other
person who cares for the child can cause distress (Ainsworth
1963).
Even as a child grows older, death is still difficult to assimilate
and this affects the way a child responds. For example, younger
children will find the 'fact' of death a changeable thing: one
child believed her deceased mother could be restored with '
band-aids', and children often see death as
curable or temporary, more as a separation.
Reactions here may manifest themselves in 'acting out' behaviors: a
return to earlier behaviors such as sucking thumbs, clinging to a
toy or angry behavior: they do not have the maturity to mourn as an
adult, but the intensity is there. As children enter pre-teen and
teen years, there is a more mature understanding.
Adolescents may respond by
delinquency,
or oppositely become 'over-achievers': repetitive actions are not
uncommon such as washing a car repeatedly or taking up repetitive
tasks such as sewing, computer games, etc. It is an effort to stay
'above' the grief. Childhood loss as mentioned before can
predispose a child not only to physical illness but to emotional
problems and an increased risk for suicide, especially in the
adolescent period.
Death of a child
Death of a child can take the form of a loss in infancy such as
miscarriage,
stillbirth or neonatal
death,
SIDS, or the
death of an older child. In all cases, parents find the grief
almost unbearably devastating, and while persons may rate the death
of a spouse as first in traumatic life events, the death of a child
is still perhaps one of the most intense forms of grief, holding
greater risk factors.
This loss also bears a lifelong process: one does not get 'over'
the loss but instead must assimilate and live with the death.
Intervention and comforting support can make all the difference to
the survival of a parent in this type of grief but the risk factors
are great and may include family breakup or suicide.
Because of the intensity of grief emotions, irrational decisions
are often made. In the event of a miscarriage or abortion, it is
important for friends and family members to acknowledge the loss of
the pregnancy, and not to attempt to minimize the significance of a
pregnancy that did not come to term.
Feelings of guilt, whether legitimate or not, are pervasive, and
the dependent nature of the relationship disposes parents to a
variety of problems as they seek to cope with this great loss.
Parents who suffer miscarriage or abortion may experience
resentment towards others who experience successful
pregnancies.
Death of a parent
As a child, the death of a parent, without support to manage the
effect of the grief, may result in long term psychological harm.
Therefore, it is important that the emotions the child feels are
worked through completely and discussed openly.
An adult may be expected to cope with the death of a parent in a
less emotional way; however, it can still invoke extremely powerful
emotions. This is especially true when the death occurs at an
important or difficult period of life, such as when becoming a
parent, graduation or other times of emotional stress. It is
important to recognize the effects that the loss of a parent can
cause and address these. As an adult, the willingness to be open to
grief is often diminished. A failure to accept and deal with loss
will only result in further pain and suffering.
Death of a sibling
The loss of a sibling is a devastating event. Sibling grief is
often a disenfranchised type of grief (especially with regard to
adult siblings). It is overlooked by society as a whole and people
in general, thus negating the depth of love that exists between
siblings. Siblings who have been part of each other's lives since
birth help form and sustain each other's identities; with the death
of one sibling comes the loss of that part of the survivor's
identity.
The sibling relationship is a unique one, as they share a special
bond and a common history from birth, have a certain role and place
in the family, often complement each other, and share genetic
traits. Siblings who enjoy a close relationship participate in each
other's daily lives and special events, confide in each other,
share joys, spend leisure time together (whether they are children
or adults), and have a relationship that not only exists in the
present but often looks toward a future together (even into
retirement).
Siblings who play a major part in each other lives are essential to
each other. The sibling relationship can be the longest significant
relationship of the lifespan, and this loss intensifes their grief.
Adult siblings eventually expect the loss of aging parents, the
only other people who have been an integral part of their lives
since birth, but they don't expect to lose their siblings early; as
a result, when a sibling dies, the surviving sibling may experience
a longer period of shock and disbelief.
Overall, with the loss of a sibling, a substantial part of the
surviving sibling's past, present, and future is also lost. It
should be noted that if siblings were not on good terms or close
with each other, then intense feelings of guilt may ensue on the
part of the surviving sibling (guilt may also ensue for: having
survived, not being able to prevent the death, having argued with
their sibling, etc.). (For further elaboration and information on
the preceding information, see "Understanding Sibling Loss" CIGNA;
Sibling Grief, " P. Gill White, Ph.D.; and
Surviving
the Death of a Sibling, T.J. Wray).
Death of a spouse
Although the death of a spouse may be an expected change, it is a
particularly powerful loss of a loved-one. A spouse often becomes
part of the other in a unique way: many widows and widowers
describe losing 'half' of themselves. After a long marriage, at
older ages, the elderly may find it a very difficult assimilation
to begin anew.
Furthermore, most couples have a division of 'tasks' or 'labor',
e.g., the husband mows the yard, the wife pays the bills, etc.
which, in addition to dealing with great grief and life changes,
means added responsibilities for the bereaved. Social isolation may
also become imminent, as many groups composed of couples find it
difficult to adjust to the new identity of the bereaved.
Other losses
Parents may grieve due to permanent loss of children through means
other than death. This loss differs from the death of a child in
that the grief process is prolonged or denied because of hope that
the relationship will be restored. In this sense, children may be
lost due to many different causes, including loss of
custody in
divorce
proceedings; legal termination of
parental rights by the government, such as in
cases of
child abuse; through
kidnapping; because the child voluntarily left home (either as a
runaway or, for children over 18, by leaving home legally); or
because an adult refuses or is unable to have contact with a
parent.
Many other losses predispose persons to these same experiences,
although often not as severely. Loss reactions may occur after the
loss of a romantic relationship (i.e.
divorce or break up), a vocation, a pet (
animal loss), a home, children leaving home
(
empty nest syndrome), a friend,
a favored appointment or desire, a faith in one's religion,
etc.
A person who strongly identifies with their occupation may feel a
sense of grief if they have to stop their job due to retirement,
being laid off, injury, or loss of certification. While the
reaction may not be as intense, experiences of loss may still show
in these forms of bereavement. Those who have experienced a loss of
trust, will also experience some form of grief. For example, people
that have been either physically or sexually abused as children may
have issues around trust as an adult.
Cultural diversity in healthy grieving
Each society specifies manners such as rituals, styles of dress, or
other habits, as well as attitudes, in which the bereaved are
encouraged or expected to take part.
An analysis of non-Western cultures suggests that beliefs about
continuing ties with the deceased varies. In Japan, maintenance of
ties with the deceased is accepted and carried out through
religious rituals. In the Hopi of Arizona, the deceased are quickly
forgotten and life continues on.
Different cultures grieve in different ways, but all have ways that
are vital in healthy coping with the death of a loved one.
See also
Notes
- http://www.tc.columbia.edu/faculty/index.htm?facid=gab38 George
A. Bonanno's Columbia University Faculty Website
-
http://www.perseusbooksgroup.com/basic/book_detail.jsp?isbn=0465013600
"The Other Side of Sadness: What the New Science of Bereavement
Tells us About Life After the Loss"
- http://www.grief.net/Articles/Myth%20of%20Stages.pdf
- O'Connor MF, Irwin MR, Wellisch DK. (2009). "When grief heats
up: Pro-inflammatory cytokines predict regional brain activation",
Neuroimage, 47: 891–896PMID 19481155
- Freed PJ, Yanagihara TK, Hirsch J, Mann JJ. (2009). Neural
mechanisms of grief regulation. Biol Psychiatry. 66(1):33-40. PMID
19249748
- Chronic Grief Activates Pleasure Areas of the Brain
Newswise, Retrieved on June 23, 2008.
- For a true account of one couples' experience with the
stillbirth of their baby, see Brad Stetson, Tender
Fingerprints: A True Story of Loss and Resolution, (Grand
Rapids, MI: Zondervan, 1999).
- For discussion of this process, see Brad Stetson, Living
Victims, Stolen Lives: Parents of Murdered Children Speak to
America, (Amityville, N. Y.: Baywood Press, 2003).
- Santrock, J. W.(2007). A Topical Approach to Life-Span
Development-4th ed. New York : McGraw-Hill Higher
Education.
References
- Wierzbicka Anna, 2004. "Emotion and culture: arguing with Marta
Nussbaum". Ethos, 31 (4), pp. 577–601.
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