Grief and the grieving process
Grief is a normal yet complex phenomenon, which has been broadly explained through the Descriptive and Process theories. The former depict the phenomenology of the grief process in a basic and descriptive way, but lack an explanation as to why or how grief responses occur. The latter, provides a model for the psychological mechanisms underlying grief and investigates the purposes behind these mechanisms (Barbato & Irwin, 1992). This paper refers mostly to Bowlby’s Attachment Theory a specific Process theory, which considers the reasoning behind grief in response to death and major losses and the various factors that impact on the intensity of the response that is experienced.
Bowlby's Attachment Theory
The meaning of attachment furthers our ability to comprehend grief. Throughout human development, continual attachments to others are formed. According to Bowlby’s Attachment Theory, attachments develop from needs for security and safety which are acquired through life, and are usually directed towards a few specific individuals (Worden, 1991). The goal of attachment behaviour is to form and maintain affectionate bonds, throughout childhood and adulthood.
Bowlby proposed that grief responses are biologically general responses to separation and loss. Throughout the course of evolution instinct develops around the premise that attachment losses are retrievable. Similarly, behavioural responses making up the grieving process are pro-survival mechanisms geared towards restoring the lost bonds (Worden, 1991).
Dimensions of Grief
The process of grief is multifaceted, with bereaved individuals experiencing major physical, emotional, and cognitive changes. Barbato and Irwin (1992) suggested that grief is a state in which the bereaved person has lost someone or something of personal value. When faced with this loss, the most powerful forms of attachment behaviour are activated in an attempt to reinstate the relationship. Worden (1991) described the vast repertoire of behaviours under four general categories; emotional response, physical sensations, altered cognitions, and behaviours.
Grief is fundamentally an emotional response to loss, the expression of which can include sadness, sorrow, fatigue, depression, relief, shock, anger, guilt, and anxiety (Barbato & Irwin, 1992).
Grief behaviours frequently have a similar profile to those found in people suffering from depression. Although grief and depression do share a number of similar aspects including sleep and appetite disturbances, and intense sadness, these behaviours are only evident for a short time in a grief reaction. In addition, those experiencing a grief reaction do not always experience the loss of self esteem that is commonly found in most people who are clinically depressed (Worden, 1991). However, intense feelings of loneliness and isolation, following the death of a loved one, may become so overwhelming that the bereaved may withdraw from social contact, thereby isolating themselves from support. Such reactive depression following a significant loss is not abnormal and usually dissipates over the first year of bereavement.
Anger is a frequently experienced emotion following a loss and is often confusing for the bereaved. The anger may be directed at the deceased for leaving the bereaved or may result from a sense of frustration that the bereaved couldn't prevent the death (Worden, 1991). If the anger is not addressed complications in the grieving process may arise. There is a risk that the anger will be directed towards others through attributing blame, or turned inwards.
Grief not only elicits emotional disturbances, but also physical symptoms such as: tight feelings in the throat and chest, oversensitivity to noise, breathlessness, muscular weakness and lack of energy (Barbato & Irwin, 1992). These sensations are considered to be a normal component of grief (Worden, 1991). Usually these are transitory, but on occasions may become of concern to the bereaved and warrant clinical intervention. Occasionally physical health may be seriously impaired, and growing evidence indicates that recently bereaved people are relatively vulnerable to illness (Barbato and Irwin, 1992).
Often new thought patterns occur in the early stages of mourning but usually disappear after a short period. However, persistent maladaptive thoughts may trigger feelings that can lead to depression or anxiety (Worden, 1991). Disbelief is often the initial cognitive reaction to the news of a death, especially if the death was sudden. Although this response is usually transitory, it can persist and become denial, where the bereaved does not accept the death. Other cognitive responses include feelings of confusion, difficulty organising thoughts and preoccupation with the deceased, which may evoke intrusive thoughts of how the deceased died. The bereaved person may report a sense of presence of the deceased and may think that the deceased is still around. A further cognitive phenomenon is that of auditory and/or visual hallucinations. Many find these experiences comforting, and assign spiritual or metaphysical explanation to the phenomena, which can help the bereaved to cope with the loss (Worden, 1991).
Although there are a number of behaviours associated with grief which may be of concern to the bereaved, they generally subside over time. Complications in the grieving process or a depressive disorder may be indicated if the behaviours impede a person’s ability to function. The most commonly reported behaviours include disturbances in sleep, altered appetite (either over-eating or under-eating), absent mindedness, social withdrawal, dreams of the deceased, and avoidance behaviour in which the bereaved may go to great lengths to avoid any situations or objects that remind them of the deceased (Worden, 1991). Additionally, the bereaved may feel restless, breathless or find themselves searching or calling out for the deceased. Another behaviour often associated with grief is crying, a response which is believed to relieve emotional stress, although the exact mechanism by which this occurs is not known (Worden, 1991).
Determinants of Grief
The intensity and emotional response to loss vary according to many factors, including the importance attributed to the loss, the circumstances of the death and the availability and utilisation of support networks. The length and intensity of grief experienced by the bereaved varies depending on the nature of the relationship and the degree of attachment. The strength and existence of ambivalence of the relationship has an impact on the intensity of grief felt. Relationships that include a high degree of ambivalence may lead to extensive feelings of guilt often accompanied by anger.
The mode of death impacts on the degree of grief experienced. Worden (1991) categorises death into four groups: natural, accidental, suicidal, and homicidal. Sudden and accidental deaths are likely to have the greatest impact on grief.
Impact of Grief on Morbidity and Mortality.
Grief exacerbates not only physical morbidity but psychiatric morbidity as well, particularly in cases associated with the loss of a spouse. Studies have found that bereaved individuals suffer from more depressive symptoms during the first year after the loss than non-bereaved controls. The young are more susceptible to physical distress and drug taking for symptom relief. Further, following the death of a spouse there is an increase in symptoms such as headaches, trembling, dizziness, heart palpitations and gastrointestinal symptoms .
Nineteenth-century physicians working with cancer patients frequently reported that severe emotional losses and grief occurred in some cases before cancer. Research in psychoneuroimmunology has reactivated interest in the connection, and provides a convincing background. Studies strongly suggest that stress, through neuroimmune modulatory mechanisms, can significantly affect the appearance and progression of mammary cancer. Although the difficulty of measuring stress makes it difficult to demonstrate a tangible relationship between stress and breast cancer, studies reveal that stress is related to breast cancer in various ways.
For example, a study by Biondi and his colleagues investigated the case of a 45-year-old woman who had a moderate genetic-familial risk of mammary cancer, but was clear at time of initial examination. The woman’s affection for her only child compensated for inadequacies in her marriage, which had become increasingly unstable. The child died in a traumatic accident at home while she was near him but unable to help. The patient developed long-lasting intense grief, despair and hopelessness, and developed symptoms of breast cancer 3 years after the loss of her child. Although aware that stress does not necessarily create cancer, Biondi suggested that in this case the stress of unresolved grief could have contributed to the cancer by activation of a latent neoplasia and/or by impairing immunocompetence during a critical life phase.
Further support was provided by Kemeny and colleagues who conducted a study to investigate whether immune changes relevant to HIV progression occurred in 39 HIV-seropositive men after the death of their intimate partner. They compared the Immunological parameters, from blood samples drawn before and within 1 year after the death of the partner (bereaved group) or over an equivalent time period (non-bereaved group). They found evidence to suggest that the death of an intimate partner in HIV-positive men is associated with immune changes that are relevant to HIV progression. This study confirms that the death of an intimate partner can adversely affect immune function and promote the progress of illness.
If unresolved grief can exacerbate health problems, the question that begs to be asked is whether grief counselling can reduce the incidence of health problems following intense grief. A general model of psychosomatics assumes that inhibiting or holding back one's thoughts, feelings, and behaviours is associated with long-term stress and disease. It seems that actively confronting upsetting experiences, through writing or talking, can increase measures of cellular immune-system function and reduce health centre visits. Hence, externalising traumatic experiences is physically beneficial, and may serve as a preventative treatment for health problems. The implications are that grief counselling which encourages disclosure of pain may prevent future health problems.
Mourning - The Adaptation to Loss
Mourning is a process, not a state of mind, and as in any process, work is done so that the process can proceed to successful finalisation. According to Worden (1991), there are four tasks to mourning, which may take place in any order.
Task 1 - Accepting the reality of the loss.
This task involves coming face to face with the reality that the person is dead and will not return. Often the bereaved refuse to face the reality of the loss, and may go through a process of not believing, and pretending that the person is not really dead. This denial can take several forms:
Denying the facts of the loss. The bereaved may manifest symptoms that range from slight reality distortions to full blown delusions. There may be attempts to keep the body in the house, retaining possessions ready for use when the deceased returns or keeping the room of the deceased untouched for years.
Denying the meaning of the loss. In an attempt to make the loss less significant than actuality, the meaning of the relationship can be denied. The bereaved may express thoughts such as "We weren't close", "he wasn't a good person", or may remove all reminders of the deceased so as not to be reminded of his or her existence.
Denying that death is irreversible. In an attempt to maintain the attachment contact, the bereaved may seek recourse to spiritualists. There may be incidents of selective forgetting, or blocking out memories of the deceased. Traditional rituals such as burials and cremations may help the bereaved accept the loss as the rituals force them to face the reality of death.
Task 2: To work through the pain of grief.
The process of allowing oneself to feel the pain rather than suppressing the experience is thought to be beneficial in the normal resolution of mourning. In some social contexts the expression of grief may be encouraged, while in others a subtle message may be given that the mourner should stop grieving and get on with life. Hence, the expression of grief may be considered unhealthy and demoralising, with the proper action of a friend being to distract the mourner from grief. People can hinder the mourning process by avoiding painful thoughts, using thought stopping strategies, or by entertaining only pleasant thoughts of the deceased, idealising the dead, avoiding reminders of the dead, and using alcohol or drugs to desensitise.
Task 3: To adjust to an environment in which the deceased is missing.
Following the death, the bereaved must take on new roles and adjust to the changed dynamics in his or her environment. Frequently the full extent of what this involves, and what has been lost, is not realised for some time after the loss occurs. Many resent having to develop new skills and cope with the changed situation. In addition, survivors have to cope with their own sense of self, particularly if they have denied their own identity so as to care for others following the death. If attempts to fulfil the roles previously carried out by the deceased fail, a reduction in self-esteem can result. Alternatively, the bereaved may promote their own helplessness by not using or developing the skills they need to cope. In response, the bereaved person may withdraw from the world and not face the requirements of the situation.
Task 4: To emotionally relocate the deceased and move on with life.
Emotional relocation requires that the bereaved form an ongoing relationship with the memories associated with the deceased, in such a way that they are able to continue with their own lives after the loss. Holding on to the past attachment rather than allowing the evolution of a new relationship with the memories of the deceased can hinder this task.
Although most people are able to independently work through the broad range of reactions that follow a death some experience difficulty in resolving their feelings and emotions and may seek counselling to help them resolve their normal grief.
Worden (1991) proposed a model in which objectives for counselling include; (a) helping the person to accept the reality that their loved one has died; (b) assisting the person to work through the emotions of anger, guilt, anxiety and helplessness that he or she is feeling; and (c) reassuring the person that what he or she is experiencing is normal. According to the model a person may also need assistance to face a future in which he or she must perform roles previously assumed by the deceased and in which a need to establish new relationships exists. The counsellor should provide support over an extended time period, and prepare the person for times, such as anniversaries and Christmas that are likely to evoke emotional reactions. Counselling may commence as soon as 24 hours after the death or may be delayed until some years later, when the person feels distressed as a result of complications (Worden, 1991).
In some cases the normal process of mourning becomes distorted. In DSM-IV (American Psychological Association (APA), 1994) abnormal grief reactions are referred to as "complicated bereavement". By definition complicated bereavement is the intensification of grief to a level such that the person feels overwhelmed, resorts to maladaptive behaviour, or remains interminably in a state of grief without progression of the mourning process towards completion (Worden, 1991). Normal and complicated mourning are on a continuum, with extremes of effect, intensity and time scale determining pathology, rather than the presence of any one particular symptom. An awareness of the different stages of grief, and the characteristics of each, allows a counsellor to determine if a behaviour is abnormal in duration (Worden, 1991).
The normal process of mourning can turn to complicated mourning for a number of reasons. These may include; (a) difficult circumstances surrounding the death, such as multiple losses within a short time period, (b) a person’s history of grieving experiences, (c) the personality of the bereaved person, and (d) social factors surrounding the death such as how the person died and the availability of social support (Worden, 1991).
Worden (1991) has proposed four headings under which complicated grief reactions can be categorised; (a) chronic grief reactions, in which the normal grief reactions continues for an excessive period of time without coming to a satisfactory conclusion, (b) delayed reactions in which the reaction occurs some period of time after the death, (c) exaggerated grief reactions, in which person is so overwhelmed by the symptoms of grief that they develop major psychiatric disorders, and (d) masked grief reactions in which a person experiences physical symptoms that may not at first appear to be related to the loss.
The DSM-IV contains limited diagnostic information regarding atypical grief reactions. Marwit (1996) conducted a study in which four case studies, describing individuals experiencing complicated grief, were presented to each of 40 practitioners. The practitioners were asked to first assign a DSM-III-R diagnosis to each case, and then to rate each according to Worden’s operational criteria of chronic, delayed, exaggerated, and masked grief, as well as DSM-III-R’s definition of uncomplicated bereavement. Marwit found that inter-rater agreement was considerably higher when using Worden’s classifications and concluded that consideration should be given to the inclusion of updated diagnostic grief categories in future updates of the DSM.
Likewise, Speckhard and Rue (1993) argued that the psychological effects of abortion on women ranged from Post Abortion Distress, a type of adjustment disorder, to Post Abortion Syndrome a variant of post-traumatic stress syndrome that has been reported to occur in some women who perceive their abortions as traumatic, to Post Abortion Psychosis which may include major thought and affective disorders. However, the American Psychiatric Association does not support the existence of Post Abortion Syndrome. Speckhard and Rue presented the convincing argument that the effects on a woman of an abortion, that is perceived to be traumatic, closely match the diagnostic criteria of the DSM for post traumatic stress disorder, and that this creates grounds for inclusion of such a diagnostic category in future updates.
Therapy for Complicated Grief
The goal of grief therapy is to identify and facilitate the resolution of difficulties that are preventing the individual from completing the tasks of mourning (Worden, 1991). Worden suggested that certain procedures should be considered for therapy, after ensuring the presenting symptoms are not due to some physical disorder. For example, identifying which of the grief tasks have not been resolved and working through these with the person. If the therapist believes that a previous death may be at the root of the current problems, helping the bereaved to explore the past relationship may resolve the current problems.
Suicide, Parental and Adolescent Grief
The circumstances surrounding the death have a marked impact on how people grieve. Survivors of suicide, for example, have been found to experience a severe form of bereavement that differs both quantitatively and qualitatively from other forms of bereavement (Silverman, Range, & Overholser, 1994-95). Likewise the sudden death of a child leads to unique grief responses by the parents (Lang & Gottlieb, 1993). Therapeutic interventions that have proven helpful in these groups include the provision of information regarding the death, opportunity to view the body, or photographs of the body, support groups, and advice regarding the likelihood of further such deaths in the family (Clark & Goldney, 1995).
Adolescent bereavement frequently differs from that experienced by adults. It is common that when an adolescent is confronted with these issues that they have no previous experience to draw on to help them cope with the feelings of rage, loneliness, disbelief, and guilt that accompany personal loss. Consequently the adolescent may not consider that things will get better (Kandt, 1994). Frequently adolescents express their feelings through behaviours rather than emotions. Kandt suggested that appropriate interventions for this group include careful questioning to encourage the individual to express emotions, providing support for the legitimacy of feelings expressed and encouraging involvement in a support group for bereaved adolescents.
The Resolution of Grief
Mourning is considered to be complete when the person is able to experience pleasures, take on new roles, look forward to new events, and when memories of the deceased no longer evoke physical responses of sorrow and pain, although occasional feelings of sadness may remain (Worden, 1991).
Bereavement is a complex issue with emotional and behavioural impacts. Individuals experience grief through a wide range of reactions, and research has indicated that grief can have an impact on morbidity and mortality. The model of the grief process presented by Worden (1991) provides a comprehensive framework around which counselling and therapy can be structured to help individuals to satisfactorily resolve their grief.