Grief

Grief is a multi-faceted response to loss, particularly to the loss of someone or something to which a bond was formed. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social, and philosophical dimensions. 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 one's home, employment, status, a sense of safety, order, or possessions, to the loss of loved ones (including pets). 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.

While many adults who grieve are able to work through their loss independently, accessing additional support from licensed psychologists or psychiatrists may promote the process of healing. Because they are less developed psychologically, grief in children is usually more complex. 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.

Theories and processes


The Kübler-Ross model, commonly known as the five stages of grief, was first introduced by Elisabeth Kübler-Ross in her 1969 book, On Death and Dying.

It describes, in 5 discrete stages, a process by which people deal with grief and tragedy, especially when diagnosed with a terminal illness or catastrophic loss. The five stages, denial, anger, bargaining, depression and acceptance are a part of the framework that makes up our learning to live without the one we lost. They are tools to help frame and identify what we may be feeling. They are not stops on some linear timeline in grief. Not everyone goes through all of them or in a prescribed order. In addition to this, her book brought mainstream awareness to the sensitivity required for better treatment of individuals who are dealing with a fatal disease.

The stages model, which came about in the 1960s, is a theory based on observation of people who are dying. This model found empirical support in a landmark study by Maciejewski et al. George Bonanno reviewed two decades of scientific studies that follow people who have suffered losses in different cultures, but he did not explicitly test the Kübler-Ross theory. His conclusion is that the theory is under dispute.

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. This 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
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.

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
Elizabeth Kubler Ross herself in the opening paragraph of On Grief and Grieving says, "The stages have evolved since their introduction, and they have been very misunderstood over the past three decades. They were never meant to tuck messy emotions into neat packages.  They are responses to loss that many people have, but there is not a typical response to loss.  There is no typical loss.  Our grief is as individual as our lives." If our grief is as individual as our lives the following categories must be allowed to be questioned. "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.

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. Queen Victoria was known for her prolonged grieving for her husband Prince Albert. After his death in 1861, she wore nothing but black clothing for the rest of her life.

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. 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 found 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 well-being; this is especially true if the loss is around critical periods such as 8–12 months, when attachment and separation are at their height information, and even a brief separation from a parent or other person who cares for the child can cause distress.

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 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 or stillbirth or neonatal death, SIDS, or the death of an older child. In most 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.

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 a regretful or coerced abortion may experience resentment towards others who experience successful pregnancies. Because of the intensity of grief emotions, irrational decisions are often made.

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.

Death of a parent
For a child, the death of a parent, without support to manage the effects 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 intensifies 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. 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.)

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), sibling(s) leaving home, 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.

The American family's approach to grieving was depicted in "The Grief Committee," by T. Glen Coughlin. The short story gives an inside look at how the American culture has learned to cope with the tribulations and difficulties of grief. (The story is taught in the course, The Politics of Mourning: Grief Management in a Cross-Cultural Fiction. Columbia University)