Grief

Learn about the different ways people grieve, how people work through grief and when therapy or additional treatment is necessary.

While grief shares characteristics with depression, it is not a disorder. Grief is a natural process that everyone goes through after losing a loved one. The painful emotions of grief arise from the intense power of the human bond. The connections we make with the people we love do not dissipate after someone dies. Instead, these bonds persist even after death.

Grief is the process by which a person adjusts to the physical absence of someone with whom they continue to have a psychological or spiritual relationship. Regardless of their spiritual or religious beliefs, most people continue to experience the presence of loved ones after their deaths. People say that their loved ones live on in their hearts, referring not only to memories they share but to the deep emotions and the sense of presence they feel. By going through successive stages of grief, a person learns to accept the loss and find peace and even joy in good memories and persisting feelings of love.

What Is Grief?

In their clinical overview of grief, psychiatrists and grief specialists Katherine Shear, MD, and Sidney Zisook, MD, provide the following grief definition: grief is a series of “emotional, cognitive, functional and behavioral responses” to death or other kinds of loss such as “loss of youth, of opportunities, and functional abilities.” They emphasize that grief is “not a state, but rather a process.”

Many people tasked with understanding grief have developed stage or process models to explore the way people move through it. Many people have found these ideas helpful, though most clinicians—and most people who have grieved—agree that everyone grieves differently and that there is no single right or standard way to grieve. Still, most grief models acknowledge that there are broad stages of grief most people experience:

1. An initial period of shock or denial, especially when the loss was sudden
2. A period of acute grief in which someone experiences intense emotional pain
3. A period of integrated, abiding or prolonged grief in which someone either finds meaning and resolution or becomes “stuck” in the acute grief phase

The severity of the acute grief period and whether people experience prolonged grief depends on several factors. One of the most important factors affecting the course of grief is whether people can find meaning in the loss or reconstruct a sense of purpose afterward. For many people, religious belief is a primary source of meaning, especially in matters related to death. Others find meaning by reflecting on what a loved one accomplished in life or whether they found peace at the end of it.

Symptoms of Grief

Bereavement counselors evaluate grief symptoms to determine whether they are normal grief symptoms or unhealthy grief symptoms. In the early, or acute phase of grief, intense feelings and extreme reactions are not unusual. However, when these feelings persist without any change for long periods, they can indicate complicated grief.

People who experience acute depressive symptoms require additional intervention beyond grief counseling. A grieving person who frequently thinks about suicide is not having a normal reaction and is at risk of acting on those thoughts. People who develop severe symptoms may be diagnosed with prolonged grief disorder or a major depressive episode and need treatment for these conditions. Hospitalization is necessary when a person is at risk of self-harm.

Physical Symptoms

The physical symptoms of grief can include:

• Fatigue
• Headaches
• Sleep problems
• Physical weakness
• Digestive problems
• Changes in appetite
• Frequent bouts of illness
• Muscle tension or soreness

Many of these symptoms are caused by severe, prolonged emotional stress that comes with acute grief. Like depression, grief is emotionally exhausting and can hamper the body’s natural healing processes by disrupting the functioning of the immune system.

Emotional Symptoms

People grieve differently and can experience a wide range of emotional states as they grieve. For example, some people might feel angry at themselves or the person they lost for leaving them, while others might feel guilt and self-blame. Others feel simple, tender sadness. All of these reactions are considered to be normal.

The following list of emotional symptoms of grief includes many normal reactions to grief but is not exhaustive.

• Guilt
• Anger
• Anxiety
• Irritability
• Sadness
• Loneliness
• Numbness
• Detachment

Many people feel some degree of detachment or numbness in the early phases of grief when the loss still does not feel real to them. As they start to accept the loss, other emotions begin to arise. Some people may first feel anger, then move to sadness, while others might feel afraid to be alone or anxious about their future.

Types of Grief

One of the significant advancements in the understanding of grief has been the classification of different types of grief. In the past, people had strict definitions of normal and abnormal grief. Now, counselors can identify specific forms of grief and tailor their responses to them. Not only are many different types of grief now considered healthy, there is a much better understanding of unhealthy or complicated grief and evidence-based interventions that can help.

Anticipatory Mourning

Anticipatory mourning is grief that begins before a loss occurs. People dying of terminal illness go through it, as do their loved ones. When doctors tell people they only have a limited amount of time to live, they start to review their lives and reflect on whether they have any unfinished business to address, like a meaningful conversation or unmet life goal. During this time, talking openly about feelings is important as people come to terms with being at the end of their lives or having a loved one who is dying.

Normal Grief

Normal grief refers to a wide range of reactions to loss. Some people are more open and demonstrative, while others express grief indirectly. The important factor that separates healthy from unhealthy grief is whether the grieving person can cope with what they feel and ultimately accept the loss. Variations of normal grief can include:

• Inhibited Grief
• Masked Grief
• Delayed Grief

These forms of grief can reflect personality differences or practical needs. For example, some people may inhibit or delay their expression of grief until specific tasks are complete, such as planning a funeral, updating living arrangements or addressing the provisions of a will. Others may not be comfortable showing others how vulnerable they feel. These responses are healthy as long as a person can eventually find a way to express their authentic feelings and learn how to live with the loss.

Secondary Loss

Secondary loss refers to other losses that follow a death. In some cases, these can be harder to adjust to than the death itself. People who lose a partner may experience a loss of income and social support. They may have to leave a home of many years for emotional, practical or financial reasons. For example, if they relied on a partner or family member to address their care needs, they might need to move into an assisted living facility after losing their primary caregiver.

Other types of secondary loss are more internal or symbolic. Many people struggle with losing a role that was important to their sense of identity or personal meaning. Others lose hopes and dreams for future experiences that they can no longer share with the person they have lost. People are sometimes able to cope with role or identity loss by taking on new roles in the community and can accept lost hope by finding new sources of meaning or new activities to look forward to.

Complicated Grief

Complicated grief disorder, also called prolonged grief disorder, refers to persistent, severe emotional reactions that occur in response to certain kinds of loss. Symptoms of complicated grief include the following:

• Feeling angry or bitter
• Feeling dazed or emotionally numb
• Wanting to die to join the deceased
• Being in disbelief or unable to accept a loss
• Feeling prolonged, intense sadness and yearning
• Ruminating on the circumstances surrounding the death
• Feeling like life is meaningless, senseless or profoundly unfair

People who lose a loved one to suicide experience complicated grief twice as often as other bereaved people. The term ambiguous loss describes the complicated grief that arises from losing a loved one to dementia. The loved person is still there physically, but psychologically absent, making it hard to recognize the loss.

Related Topic: Complicated grief treatment

Chronic Grief

Chronic and prolonged grief are periods of grief that can last for years. They are more likely to arise from traumatic loss. These painful forms of grief can cause major depressive episodes and require specialized mental health treatment.

People whose loved ones die from acts of violence often require counseling to help them process this difficult loss and the chronic grief that can follow. Some people who lose a loved one to violence overcome complicated grief and find meaning by committing themselves to a related cause and working to ensure others don’t have to suffer what they did.

Absent Grief

Absent grief refers to a prolonged state of denial when a person cannot even acknowledge a loss. It can also describe an unusually long period in which a person reacts as if nothing has changed even if they can acknowledge a loss intellectually.

Cumulative Grief

Cumulative grief occurs when a person suffers numerous losses in a short period. Having to grieve multiple losses at the same time often prolongs grief. In some cases, people experience a delayed or absent grief reaction to one loss, only to suddenly feel grief for that loss after another loss or series of losses.

Disenfranchised Grief

Disenfranchised grief occurs when a person suffers a loss that is not acknowledged by society. For example, gay men who lost partners to AIDS during the 1980s suffered disenfranchised grief when neither their families nor the families of their partners acknowledged the death or came to the funeral. Women who suffer miscarriages or have abortions frequently grieve alone for losses others do not understand.

Causes of Grief

The causes of grief can include different kinds of loss. In general, the most painful grief follows the death of a loved one. However, many other losses that can spark grief. Many people suffer significant grief after the loss of a companion animal. Others grieve more abstract losses, like loss of physical health after being diagnosed with a chronic illness.

The causes of prolonged grief are less universal. These painful reactions often follow sudden or violent deaths that are hard to make sense of. Individual factors like mental illness can also affect how someone grieves. Risk factors for complicated grief include:

• Being exposed to trauma
• Having a psychiatric condition
• Suffering a loss due to an act of violence
• Having previous losses, especially recent losses

People who experience a loss during a period of acute stress or trauma have an elevated risk of complicated grief. Conflicted relationships with the deceased can also lead to complicated grief.

Grief Process Models

Elizabeth Kubler-Ross’s model of the stages of grief has helped many people understand their grief. This grief process model is no longer considered authoritative but is still used to help people talk about what they are feeling. As people have studied grief and found it to be more complex and less uniform than Kubler-Ross’s five-stage model, new theories about the phases of grief have been developed and used as the basis for grief recovery methods.

Five Stages of Grief

Many people are not aware that Elizabeth Kubler-Ross’s theory of the five stages of grief was initially developed to describe a terminally ill person’s reaction to their diagnosis, not another person’s response to the death of a loved one. These stages are:

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

Kubler-Ross never said that everyone progresses through the 5 stages of grief in exact order or that everyone always goes through all five stages. This interpretation of her model has led to some controversy over its validity. However, when used as a flexible reference for common reactions to grief, it can spark self-reflection and help people understand the progression from denial to acceptance that often occurs in normal grief.

Dual Process Model

The dual process model of grief is rooted in the concept of primary and secondary losses. According to this model, bereavement causes two types of stressors: loss-oriented stressors and restoration-oriented stressors. Loss-oriented stressors are the direct effects of loss, like feelings of yearning and sadness. Restoration-oriented stressors follow from secondary losses like the loss of roles or living circumstances. As people cope with grief, they must address tasks related to both stressors by processing emotions while adapting to new ways of living.  

Four Tasks of Mourning

Harvard psychology professor J. William Worden developed an influential model of grief that lists 4 tasks for mourning. His theory is based on the idea that people need to preserve their connection with loved ones who have died while moving forward in their lives. Worden’s 4 tasks of mourning are as follows:

1. Accept the reality of the loss.
2. Work through the pain of grief.
3. Adjust to a world without the person who has died.
4. Maintain a connection with the deceased while moving forward in life.

These tasks reflect similar ideas as the five stages of grief and the dual process model but with a unique emphasis on establishing a different kind of relationship with a person who has died. As they accept and adapt to a loss, many people find peace in rituals or acts of remembrance that preserve their connection to the person they continue to love.

Effects of Grief on Mental Health

Some of the earliest ideas about depression were based on observations of the effects of grief. However, while people who grieve often feel depressed, they only rarely meet criteria for a diagnosis of major depressive disorder. Similarly, grief can cause anxiety but rarely to the extent a person is diagnosed with an anxiety disorder.

The relationship between grief and mental health is more complicated for people who have pre-existing mental health conditions. Symptoms of a mood or anxiety disorder can worsen in response to grief and require more intensive treatment, a temporary increase in the dosage of mental health medications or even brief hospitalization.

Scientists have studied the effects of grief on the brain and found that grief activates the same circuits in the brain as physical pain. Counterintuitively, brain scans of people with complicated grief show activity in the nucleus accumbens, which is part of the brain’s reward center. This is likely because these people still feel deeply attached to the person they have lost.

Grief Statistics

Grief statistics show that 10 to 20 percent of people who suffer a loss experience prolonged or complicated grief. About 43 percent of people who lose someone to suicide have complicated grief reactions.

While standard models of grief define the initial mourning period as lasting from six months to one year, research by psychologist Edward Diener shows that people who lose a spouse take 5-8 years to adjust to the loss entirely.

Grief and Addiction

Statistics on grief and addiction show that grief, primarily complicated grief, increases the risk of developing a substance use disorder. One study found that men who had been bereaved for two years were twice as likely to have an alcohol use disorder than men who were not grieving. Bereaved women did not have significantly different rates of alcohol misuse. However, another study found that both women and men with major depressive disorder and complicated grief had higher lifetimes rates of alcohol dependence than other people.

Grief Treatment

Many counselors and therapists base a grief treatment plan on one of the stage or process models of grief. For example, in the early phase of bereavement counseling, a person might work to overcome denial, then in the next phase, they might focus on processing emotions related to the loss. Therapists often focus on reducing feelings of blame and guilt and helping people adapt to new roles or life circumstances. Adhering to a treatment plan improves a person’s ability to cope with symptoms of grief.

The primary treatment for grief is therapy. People with clinical depression or complicated grief may be prescribed antidepressants to help them cope but still require a counselor or a support group to help them work through their grief. People struggling with grief and substance abuse may require additional interventions including inpatient or outpatient substance use disorder treatment.

Integrated treatment programs can help people address substance use disorders and process grief at the same time. Addiction professionals at The Recovery Village offer evidence-based integrated treatment and cater treatment plans to meet individuals’ specific needs. To learn more about how treatment can improve your life, contact The Recovery Village today.

Medically Reviewed By – Stephanie Hairston, MSW

Stephanie Hairston received her Bachelor of Arts degree in Psychology and English from Pomona College and her Master of Social Work degree from New York University. Read more