Grief
Characteristics/process | complicated grief | what to do about grief | the tasks of bereavement | telling the death story | sadness | "negative" feelings | reviewing the relationship | possibilities in life | understanding & acceptance
Grief is the pain that results from any significant loss, especially the death of a loved one. Grief and mourning (the act of grieving) are normal, not something to avoid (though, heaven knows, we wish we could), nor illnesses to cure. Grief then, is the inevitable cost paid for living and loving.
When a loved one dies, grief is nearly always influenced by factors in addition to the loss of the person who died. Previous losses and related grief may reemerge and add to the pain. There are usually changes in the survivor's role in life, financial status, and living arrangements. So grief is related to the death and to the consequences of the death.
Characteristics and Process of Grief
Grief is experienced globally; with emotional/psychological, spiritual, and physical pain. One would expect sadness and grief after a loved one dies, but often the depth and encompassing nature of the pain of grief is shocking: Grief impacts all areas of life and living. We usually view grief as the response to the death or loss of a person loved in the conventional sense of warm, loving, and reciprocated feelings. However, grief or related feelings are experienced when the relationship was characterized primarily by anger, rejection, or other negative emotion. Grief after death is felt not just for a person and love; but for love unexpressed, anger unresolved, or a relationship unfulfilled. This paragraph may be worth reading again.
The emotional/psychological manifestations of grief include sadness, guilt, and anger. The sadness is profound and often includes aspects of depression. There is intense yearning for the deceased and the life that was shared with him or her. Again and again there is the shock-like realization that the loss is permanent and all the tomorrows will be without the deceased. Sadness comes in waves of despair and crying. There are times when the bereaved person cries and groans uncontrollably.
Of course I knew it would be painful after she died, but I was surprised at how deeply it hurt. I remember telling a friend that I didn't think I would ever be okay again. My wise friend just nodded in acknowledgment of what I said. Eventually I was okay again, but it was a long sad time.
The sadness is expected, but guilt may come as a surprise. Suddenly, when it is too late to do anything about them, all the lost opportunities of the relationship come into sharp focus. Some survivors blame themselves for what happened, "Its all my fault. If only I had . . ." Even more surprising and distressing to some is the anger at the person who died. For many people, it feels "wrong" to be angry at someone who died. Nevertheless, anger is an almost universal (though often denied) response to a loved one dying. "How could he do this to me! Its not fair!" Regardless of how much guilt and/or anger is experienced, however, sadness is usually the most powerful and enduring feeling. There are countless other emotional/psychological responses to grief. Among them are:
Numbness or denial is common and pervasive. "This didn't happen. Its not happening. Maybe I can do something that can change it." In the many attempts by theoreticians to conceptualize grief, the first "stage" is usually numbness or denial. And, in fact, the first response to a terrible event is often denial. However, some form of denial (of what happened or what is felt about what happened) often continues intermittently well past the beginning of grief.
Ambivalence is not only common, but normal. Some people feel obligated to feel only love and sadness, but the fact is, it is common to feel love and anger at the same time toward the same person. We may even feel love and hate at the same time. Of course, many people have the idea that one shouldn't hate - but sometimes and in some ways, it is normal to have feelings that can only be accurately described as hate.
Severe anxiety or nervousness is also common and normal. Anxiety may be experienced as pervasive feelings of dread, nervousness, apprehension, or tension. Some people feel like they are losing control; and if control is ever lost, they feel they will never regain it. Tears come with little or no provocation. There may be increased desire for prescription or other mind-altering substances.
Changes in behavior and relationships may range from an inability to perform even the most basic activities of daily living; to dragging through daily life; to restless, disorganized behavior, including a kind of hopeless searching for what was lost. Relationships are dissatisfying and seem like more trouble than they are worth. Sometimes family conflict occurs or worsens. Developing new relationships seems out of the question. Who could ever understand this much sadness? Life loses its meaning and satisfaction without the lost person, and there does not seem to be any hope of a new life to which the bereaved individual can turn. This inability to relate to others, coupled with loss of meaning is a major factor in the development of despair or hopelessness. There are people who prey (usually sex or money) on people who are bereaved. Be wary of any relationship that involves sex or money.
Disturbing thoughts/experiences may include hallucinations or a strong sense of the presence of the deceased. These may cause great discomfort and the feeling that the bereaved person is losing his or her mind. In the vast majority of cases, these perceptions of presence decrease over time and, unless threatening or abusive, are not generally considered abnormal. Angry feeling about or toward the person who died are common - and distressing.
Grief often affects all aspects of the spiritual life of the bereaved. Without the deceased, life may lose much of its meaning. There may be little perceived meaning in the suffering of the person who died and the pain of survivors. Hope may have been destroyed in the course of the illness; and the future may seem without hope. Relatedness to God may seem impossible. The question arises, "What kind of God would cause this kind, gentle person . . . this child . . . anyone . . . to suffer like this?" Prayers seem empty. Church feels awkward. God seems far far away. Transcendence seems impossible.
Physical manifestations of grief commonly include fatigue, insomnia, anorexia, feelings of choking, shortness of breath, tightness in the chest, menstrual irregularities, and gastrointestinal disturbances. Bereaved persons tend to frequently seek medical attention for vague symptoms such as chest discomfort or abdominal pain. While some physical complaints may seem to have no physiologic basis, there is a clear link between grief and increased vulnerability to physical and mental illness, especially heart disease and depression.
There are certain times when the mourner is most vulnerable to despair. These commonly include (but are not limited to):
As with any other human behavior or experience, grief and mourning are sometimes carried to extremes in behavior or length - "complicated grief." What constitutes extremes in grief is subject to debate and influenced by culture, who died, the circumstances of the death and other factors. Some experts view mourning that lasts beyond a year as extreme, while others view mourning as normally lasting at least a year. In a sudden traumatic death such as by murder or suicide; or when a child dies, grief may last longer and be more incapacitating. What is normal, then, is not well-defined and varies according to many factors. Types of complicated grief includes grief which:
There are no absolute predictors of who will experience complicated grief. There are, however, factors that, when several are operational, indicate increased risk of complicated grief. These include:
If several of the above are present, the bereaved person and his or her support system should be alert to the possibility of complicated grief, and should consider seeking help as described in the section on what to do about grief. One possible rule of thumb is that help should be sought when grief results in depression or has a significant negative impact on life a year past the death, especially when there are persistent or serious thoughts of suicide.
Dealing with grief begins before the death in two important ways: (1) contributing to the care of the person who is terminally ill and (2) making significant effort to resolve any conflicts or "unfinished business" with the person who is dying. Contributing to the care gives people the sure and lasting knowledge that they helped in the final days. This knowledge does not make grief go away, but it is like a rock to which people can cling. They may question the relationship, themselves, others, God, and whatever and whoever else they usually turn to in troubled times; but doing the work is something solid that endures. Grief is complicated by conflict or regrets about not saying words of love or forgiveness. Thus the resolution or attempts at resolution of conflicts is very helpful in bringing the relationship to a close. It may be hard to accept, but some conflicts may not be resolved and some "business" (of love or forgiveness) may not be finished. But grief is harder with the realization that there was not an effort made at resolution.
Hopefully, family, place of worship, friends, and one's own internal resources provide most of the support needed to move through grief. When this is not the case, bereavement groups are helpful to many people. Such groups are usually offered through churches, synagogues, and other places of worship. Hospice programs, the American Cancer Society, hospitals, and other health providers may also offer or be able to help find bereavement groups (contact social services or chaplain committee or department).
| Why do many people benefit from bereavement groups as opposed to traditional sources of support? Bereavement groups began in the late 1960s and early 1970s in response to a lack of traditional sources of support. Most families are scattered across the country, or at least across suburbs, far more people work outside the home, many older people live in air-conditioned isolation in front of the TV behind locked doors, and few neighborhood churches remain. Traditional sources of support are able to offer phone calls and perhaps a weekly visit, but this is not enough. Bereavement groups seek to offer a sense of community and shared experience difficult to find elsewhere. |
The Bible is a time-tested source of help. Jews and Christians alike can turn to Psalms, Ecclesiates, and other books for understanding and solace. Most bookstores have a number of books on grief in the self-help section. Libraries tend to have less current books, but most have at least several books on grief. Many people find the brief or meditation-style books helpful.
In working with mourners, therapists, nurses, ministers, and others have identified some "tasks of bereavement." These tasks can be used as a kind of checklist to identify blocks in the mourning process. The tasks are not, however, a checklist that one can mark off one by one and then be done with grief! Grief is more than that. Some of the tasks are ongoing and all are usually addressed more than once. When one works on or addresses a particular task, one's understanding of self, the deceased, and the relationship usually deepens. The tasks of bereavement include telling the "death story;" expressing and accepting the sadness; expressing and accepting guilt, anger, and other negatively perceived feelings; reviewing the relationship with the deceased; exploring possibilities in life after the death, including, for some, finding new relationships; understanding common processes and problems in grief; and being understood or accepted by others. These are discussed one by one below.
Those who gave care and/or were there when the death occurred have a need to tell and retell in as much detail as possible what happened and how they reacted to what happened. In most cases, these stories are an attempt to make it real and understand what happened. Often there is a sense of disbelief that what happened actually happened. In addition to telling the story, some find that they reach a deeper understanding of what happened by writing (and usually rewriting) the story.
Expressing and Accepting the Sadness
It might seem obvious that expressing and accepting the sadness of grief is part of mourning. Not so. Many people, men in particular, feel that they should not express sad feelings beyond, perhaps, acknowledging that some sadness exists. Some people are reluctant to express their feelings because they fear if they ever start, they will be unable to stop. Some families have rules about not expressing feelings, such as "We don't wallow in misery." In other cases, a mourner may be consistently in the role of being strong and helping others to the extent of not helping self, "I have to be strong for her/him/them." Another very common way that feelings are inhibited is through the "comfort" that insists that everything is or will be fine. This alleged comfort comes from friends, family members, and even in funerals that "celebrate" religious beliefs or life rather than acknowledge the pain of life and death. To mourn, it is normal and necessary to express, and gradually, over time, to accept the deep sadness of grief. Note that the focus here is more on enduring than resolving or working through the sadness. TV newscasters send the consistent message that "the healing has begun." So now its time to move on. Not likely!
Expressing and Accepting Guilt or Anger or Other Feelings Perceived as Negative
People and their relationships are not perfect. That seems obvious, but often people and relationships are idealized after death. Moreover, many bereaved persons see themselves as at fault in some aspect of the relationship or the care. "If only I had . . . " then he or she wouldn't have died or would have lived better, etc. etc. Of course regrets are common in relationships. But in grief there often is excessive guilt. Acknowledging and expressing this guilt is sometimes complicated by the bereaved person feeling great shame over his or her perceived shortcomings that, to the guilt-ridden person, seem completely unique.
Of course whatever the perceived shortcomings might be, they are not unique. Talking about the guilt with others is probably the most helpful action one can take to relieve it. Just saying out loud what one feels guilty about can begin the process of putting the feelings in perspective and eventually letting go. Some people find that service to others is helpful in dealing with guilty feelings.
Guilt and anger are sometimes connected. The bereaved person is angry at (the idealized) deceased and feels guilty about the anger. Anger may also be denied or suppressed; or turned inwards to self and ultimately experienced as depression; or be chronically expressed toward others. In any case, anger felt toward the person who died is often directed to any other target. But the fact is, it is normal and usual to feel angry about a loved one dying. It is not wrong to have such feelings; it is just human.
To resolve anger it is first necessary to acknowledge and express it. A major block to expressing the anger is the unrealistic idealization of the deceased and the relationship. It may thus be necessary to take a realistic look at the person and the relationship. He or she was not perfect and neither was the relationship. Looking realistically at the relationship allows one to look realistically at the anger; and then at what lies beneath the anger. Beneath the anger we often find feelings of abandonment, of devastation, of helplessness and hopelessness. There is no magic thing one can do to deal with these. Recognize them, accept them, and gradually, in working through the grief, the "negative" feelings slip slowly away.
Reviewing the Relationship With the Deceased
Too often mourning focuses on the last or more difficult days of the relationship. But there was more than that. In looking at all the days of the relationship with the deceased, one realizes the fullness of the relationship, not just the painful last. This is a task that is both sad and enriching; and necessary to grieving.
Look as far back as the early days of the relationship. For spouses or life partners, for example, one might recall meeting, the courtship, early hopes, disappointments, successes, friends, children, and all else that makes up a shared life. For children (adult or child) of a parent who died, looking back to early as well as later remembrances is important. For anyone, it is important to explore what would have been or what was hoped for had the death not occurred.
Exploring Possibilities in Life After the Death
Looking to the future is a task that usually emerges later in the grief process. Early in the process of grief it may seem like the future holds only the sadness and pain of grief. But as the sadness is endured and worked through, there is a growing awareness that there may be hope for a life in the future. How long this takes varies; it is a gradual process and most people do not at first notice that it is happening. Sometimes the awareness that there may be life (and perhaps even happiness) seems like a betrayal of the deceased. That, too, is part of the process and gradually passes. Rushing into new possibilities is a relatively common mistake. Emotional, sexual, and/or financial commitments or decisions must be approached with extreme caution.
Exploring future possibilities is complicated by the loss of the past. Among adult couples, a death often changes friendships. Not only is the survivor impacted by the loss, and thus less socially able, but the dynamics of couples relationships are also radically changed. Simply put, some relationships no longer work. Bereavement groups are especially helpful in showing that life and relationships are possible.
Understanding Common Processes and Problems in Grief
In times past, grief was often a community experience and people knew how devastating it can be. Now, except for the few days surrounding the death and funeral, grief is often a private experience, and as families and communities, we know less about it than before. The power and duration of grief and its overwhelming emotions are a terrible surprise for many. Knowing what is common or expected in grief helps people understand that they are not abnormal or different. Knowing what is common or expected does not change or make grief easier. It only tells the mourner that he or she is grieving, not losing his or her mind.
Being Understood or Accepted by Others
The emotion and process of grief, along with the way we live, often results in isolation. Isolation, to some extent is a natural part of mourning. But the isolation should be that of the mourner, not of the misunderstood. Family and other sources of support are better able to help when they, too, understand what happens in grief. It is not that they can necessarily change what happens; only that they understand.
Finally
Grief is a terrible and universal experience that affects all aspects of life. It cannot be understood except by direct personal experience. There is no "answer" to grief that can remove the pain like an antibiotic removes an infection. The best we can do is live in it and work to understand it and our relationship with who was lost. Ultimately we look to where humans have always looked for help: family, community, self, and God. We do not always find what we were looking for at these sources. But we keep on because that too is what we, as humans, have always done. And we get better.
A voice says, "Cry!" and I asked, "What shall I cry?" "All flesh is grass, and all its beauty is like the flower of the field. The grass withers, the flower fades; but the word of our God will stand forever." Isaiah 40: 6,8
References
Burnell, G.M. and Burnell, A.L. (1989). Clinical Management of Bereavement: A Handbook for Healthcare Professionals. New York: Human Sciences Press.
Kemp, C.E. (1999). Terminal Illness: A Guide to Nursing Care. Philadelphia: Lippincott, Williams & Wilkins.
Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry. 101, 141-148.