Bereavement is the state of loss when a loved loved one such as a parent, child, spouse, or close friend has died. Grief refers to the psychological reaction to the bereavement. Grief can occur due to various losses:
- Spousal death: Under the age of 55 about 1% of adults are widows, but by age 85 the majority of people are widowed. Spousal death after decades of marriage can be an enormous shock and adjustment.
- Anticipatory grief: When a spouse is experiencing a debilitating illness like Alzheimer’s or is admitted to a personal care home, grief may occur prior to the physical death. This is sometimes referred to as “anticipatory grief” but is in many ways is a full grief. At the same time that one is experiencing “caregiver stress” for taking care of a debilitated spouse, one is also grieving the loss of the marital companionship and affection.
- Death of a child: Death of a young child can be an emotionally painful parental experience. We all find the death of a child disturbing. Health care workers such as physicians and nurses working in pediatrics can experience significant grief distress when witnessing the deaths of their young patients. About one in ten of older people over the age of 65 will experience the death of one of their adult-aged children, a loss that can significantly deplete the family support network as they age.
- Cumulative bereavement: This refers to the reality that older adults will experience a number of losses of family and friends, often very close together. As we age, our social network can grow smaller and smaller as friends die, and we need to be able to re-build it, sometimes over and over again. Maintaining and rebuilding social networks is one of the essential tasks required for successful aging.
- Pets: Research shows that the death of a family pet can result in significant grief.
Many life changes can possibly also trigger an adjustment reaction similar to a grief response, including loss of health (amputations), retirement and loss of career identity, divorce.
While many aspects of this discussion of grief can apply to younger adults and children, much of our understanding of grief comes from the psychological study of middle aged and elderly bereavement, especially death of a spouse.
What is grief?
Grief is normal. Grief, especially for the death of a child, has been observed in many intelligent social animals such as dolphins and elephants. Creating social bonds and attachments is necessary for the survival and well-being of many species. When that bond is severed, grief is a normal reaction.
When death occurs for a person who has been a constant companion and with whom we have had a close emotional attachment, many changes in our life must be assimilated. Over many years of a close relationship, our self-concept can become defined by the relationship and this identity now must be reshaped. C S Lewis, the author of the well-known Narnia books, wrote of his own experience: “grief comes from the frustration of so many impulses that had become habitual.” Lewis observed in himself that many daily thoughts, feelings, and actions focused on the loved one as their object, “but now there’s an impassable frontierpost across it.”
Patterns of grief reactions
What is the normal intensity and length of grief? Are there stages or phases to this experience? There are many different reactions to grief and no one single pattern that fits most people.
About 30% or more, one in three people, experience a relatively mild distress in response to the death of a spouse, are able to quickly accept the loss of a loved one and resume normal activities. These people do not typically experience a delayed grief, and have good health outcomes. On the other hand about 30% experience waves of high distress. And another 30% or so falls in between these extremes and experience a moderate distress. Another 10% of people appear to experience a slightly delayed grief about 6 months after the bereavement. These estimates are approximate as different studies have found slightly different results.
The idea that grief occurs in stages is a common one, and was implied by Charles Darwin in 1872: “after the mind has suffered from an acute paroxysm of grief, and the cause still continues, we fall into a state of low spirits; or we may be utterly cast down and dejected.” Some people experience an initial stage of shock or numbness, followed by a period about 3 months after the death of an increased depressed mood and yearning for the loved one. Generally, as acceptance of the death increases towards the end of the first year, the yearning, sadness, and anger gradually diminishes.
The experience of grief
The normal grief response can be very intense. For the 30% who experience an intense grief, symptoms may include waves of sadness, sleeplessness, fatigue, poor concentration, and loss of appetite. There will be a strong yearning for the lost loved one. Death of a close life partner may lead to sensing the presence of the dead spouse, such as briefly hearing their voice; this is very common and can last for over a year. Many people find hearing the voice of a spouse or dreaming of the spouse reassuring if they are aware that it is normal.
An intense grief experience may closely resemble the symptoms of a depression. Indeed, grief can be more intense than a depression. DSM-5, the diagnostic manual of the American Psychiatric Association, indicates that a careful clinical judgement by a professional is sometimes required to differentiate a normal intense grief from a depression. DSM-5 suggests that grief can be differentiated from depression in that grief comes in waves of emotion, whereas in a clinical depression the mood is more constantly negative. In grief, the individual usually maintains a positive self-esteem and the focus of the grief experience is specific to the loss of a loved one, whereas depression includes a much broader negative view of the self.
How long does grief last?
How long is grief expected to last? There is no straightforward answer to this question. The answer varies by person, circumstance and culture. We are not meant to forget the deceased loved one, and memories of that person may be painful for years to come. Increasingly, grief experts suggest that a sense of a “continuing bond” and relationship with the deceased is quite normal and healthy. The resolution of grief does not mean forgetting the deceased person, or lessening our affection for them. But one is expected to resume normal activities.
Many events during the first year can be difficult such as the first family dinner, first birthday, first wedding anniversary, first major religious holiday, or first anniversary of the death. After the first anniversary of the death, the intensity of grief reactions has typically subsided with the individual having returned to everyday activities and normal daily mood. However, even after many years, brief waves of grief may still occur, especially at anniversaries.
When is prolonged grief considered a problem?
At the time of the bereavement, most grief reactions of varying intensities, even intense reactions, are generally considered normal. Grief is typically only considered a mental health issue if it becomes excessively prolonged. About 7% of people experience a prolonged high level of grief.
In a prolonged or “complicated” grief, the individual stops making progress in recovering from the bereavement stress and remains overly focused on past memories for many months and years. In a prolonged complicated grief, the individual continues to yearn for the deceased and remains withdrawn from resuming normal social activities. Everyday thoughts and memories of the deceased continue to be accompanied by severe emotional spells. There may be pervasive feelings of numbness towards others, loneliness, emptiness, meaninglessness, regret, and difficulty acknowledging the death. There may be a continuing avoidance of places that are reminders of the deceased person including family gatherings, social groups, the church where both attended, medical facilities, and other funerals. Some degree of these symptoms may occur from time to time in most grieving people; it is only when these prolonged symptoms are excessive and interfere with normal everyday functioning that the grief is seen as problematic.
A prolonged grief may depend on many factors. Grief may be complicated by the circumstances of the death, such as being unexpected, accidental, by suicide, or after a difficult and painful illness. Death of one’s child at any age is difficult to accept. Life factors may contribute to the development of a complicated grief, such as a lack of support from family and friends. The personality style of the grieving person can also lead to complicated grief. For example, if the individual has been overly dependent on the now-deceased spouse or parent, the grief process may be more difficult or prolonged.
How long is too long? There is much debate and controversy as to the length of grief that should be required as the minimum to consider a prolonged grief as warranting a mental health diagnosis. The World Health Organization (ICD-11) uses a diagnostic category of Prolonged Grief Disorder which can be considered at a minimum of 6 months following the bereavement. Prolonged Grief Disorder is conceptualized within ICD-11 as a stress disorder, similar to an Adjustment Disorder. The American Psychiatric Association’s DSM-5 proposes a similar diagnostic category of Persistent Complex Bereavement Disorder, which is considered only after 12 months post bereavement. These different recommended minimums for a prolonged grief disorder need to be viewed as arbitrary. Expecting an adjustment to a severe grief reaction of at least 12 months post bereavement more closely matches the normal course of grief. There are many varying circumstances, and a great variety of grief reactions.
When and how is pronged complicated grief treated?
Grief is a normal response. Grief is not an illness and usually does not require medication or psychological treatment unless safety issues emerge. Treatment of grief should be approached with caution. It is not necessarily desirable to eliminate grief, which is part of a normal emotional adjustment to the death of a lifelong partner or loved one.
Preventative approaches immediately following the death have not received evidence of a lasting effectiveness. Early grief interventions such as bereavement groups can provide useful social support and reassurance if conducted carefully, but appear to have only a temporary positive effect and little evidence of long-lasting benefit. Bereavement groups may potentially be harmful if they convey to the individual that their grief is unhealthy, or undermine the person’s normal coping by forcing onto them an intense emotional grief focusing.
Psychological interventions are best reserved for a prolonged complicated grief. When psychological intervention is provided to a prolonged grief, at least 6 months following the bereavement, there is evidence of moderate but lasting benefit. For prolonged grief there is also some evidence of greater benefit using an individual format rather than group interventions.
Cognitive-behavioural therapy (CBT), cognitive processing therapy, interpersonal psychotherapy, brief psychodynamic or other effective psychotherapies can be used to help the person engage in activities and think about and understand the impact of the loss. Some individuals may need to work through some of the complicating aspects of their relationship to the deceased. Regret resolution can be important. For example, it may be useful to revisit past relationship hurts and forgive past faults, regrets, anger, and guilt.
Cognitive behavioral interventions are used to help people gradually return to their daily routines. An important component of a psychological treatment for traumatic aspects of grief is to help the individual to return to situations they are avoiding because of the fear of the distressing memories. Continued avoidance of these situations increases the sensitization to grief emotions, whereas only by entering these situations does the excessive distress gradually dissipate. Cognitive behavioural strategies to overcome avoidance have been shown to be more effective than supportive counseling.
You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/PTassociations/.
This fact sheet has been prepared for the Canadian Psychological Association by Dr. Lorne Sexton, Psychology Program Site Manager at St. Boniface General Hospital, Winnipeg Regional Health Authority, and Associate Professor, Department of Clinical Health Psychology, University of Manitoba.
Revised: September 2019
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