Grief

Grief is a multi-faceted response to loss. Although conventionally focused on the emotional response to loss, it also has a physical, cognitive, behavioural, social and philosophical dimensions. Common to human experience is the death of a loved one, be they friend, family, or other. 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 employment, pets, status, a sense of safety, order, possessions, to the loss of the people nearest to us. 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.

Stage Theories vs Processes
Some researchers such as Dr. Elisabeth Kübler-Ross and others have posited sequential stages including denial, anger, bargaining, depression and acceptance. As research progressed over the past 40 years, many who worked with the bereaved found stage models too simplistic and instead began to look at processes, dynamics, and experiences common to all. Bowlby, a noted psychologist, outlined the ebb and flow of processes such as Shock and Numbness, Yearning and Searching, Disorganization and Despair, and Reorganization. Bowlby and Parkes both note psychophysiologic components of grief as well. Included in these processes are:

I. Shock and Numbness
Feelings of unreality, depersonalization, withdrawal, and an anesthetizing of affect. These feelings often occur early in grief, and may be a self-protective way of getting through the facts of the death. Persons often remark on how someone appears stoic or strong when they are actually in shock.

II. Yearning and Searching
The grieving person tries to locate the lost person. Normally this is a functional endeavor, as the 'lost' person is found, but in bereavement the searching is fruitless. This process has also been referred to as 'pining'. Common reactions include feelings and even cognitions of 'seeing' the deceased for fleeting moments, hearing the door at the time they used to come home, or even incorrectly 'finding' the person, for example in a crowd, although intellectually realizing this is not so. Actually feeling that one 'sees' or 'hears' the deceased ranges in report from 90% in oriental cultures to 10-15% in western cultures, although this may be more a factor of reporting bias than of actual experience. This process appears to be an attempt of the person to cognitively and emotionally begin to let go, by coming to terms with the reality of the loss.

III. Disorganization and Despair
These are the processes we normally associate with bereavement, the mourning and severe pain of being away from the loved person. There are no easy answers to assuage this difficult experience: it must simply be endured, although it may take years of all of the above experiences overlapping, waxing and waning before the last process takes place.

IV. Reorganization
Reorganization is the assimilation of the loss and redefining of life and meaning without the deceased. Many times, in widowhood, one is so much a part of their spouse, that new definitions of identity must take place for healing. For the elderly after a lifetime of defining themselves in terms of their marriage relationships, this may take the rest of their lives.

Risks of Grief
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, and real illnesses such as colitis, 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. Further, grief is often accompanied by crying, lack of sleep, loss of appetite, and ceasing to care for one's physical and emotional wellbeing. All these can contribute to a predisposition for illness in bereavement, a finding which has been replicated often since the Lindemann studies of the Coconut Grove fire survivors in 1944. Other problems in social relations may arise: there is for example an increase of divorce following the death of a child, and children may exhibit signs of delinquency, rage, introversion or other problems. Further, grief can insidiously work in family relationships as individual members sort or act through their feelings about the death. The risks following a death in the family are as great or greater than for any other traumatic life event.

Normal vs Complicated Grief
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, and are perfectly normal. Even hallucinatory experiences may be normal early in grief, and our usual definitions will not suffice, necessitating a lot of grace for the bereaved. 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, but even here, caution must be used; it takes time to say goodbye.

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
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 felt to have no reaction if a caretaker 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 wellbeing; this is especially true if the loss is around critical periods such as 8-12 months when attachment and separation are at their height in formation and even a brief separation from a parent can cause distress. (Ainsworth 1963) A change in caretakers can have lifelong consequences, which may become so blurred as to be untraceable. As a child grows older, death is still difficult to assimilate and that fact 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 reversible, more as a separation. Reactions here 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 stillbirth or neonatal death, SIDS, or the death of an older child. In all cases, parents find the grief devastating and while persons may rate the death of a spouse as first in traumatic life events, the death of a child holds greater risk factors. This loss also bears a lifelong process: one does not get 'over' the loss but instead learns to 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, almost always unfounded, 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. This, coupled with normal experiences of grief, can be overwhelming.

Death of a Spouse
The most common loss in our society of a loved one is that of the death of a spouse: it is an expected change, particularly as we age. A spouse, though, often becomes part of the other in a unique way: many widows and widowers describe losing 'half' of themselves, and after a long marriage, at older ages, the elderly may find it a very difficult assimilation to begin anew. Further, 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 eminent as many groups composed of couples find it difficult adjust to the new identity of the bereaved. When queried about what in life is most troubling, most rate death of a spouse first, although the death of a child presents more risk factors.

Other Losses
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, a home, children leaving home (empty nest), a friend, a favored appointment or desire, etc. While the reaction may not be as intense, experiences of loss may still show in these forms of bereavement.

Summary
Bereavement, while a normal part of life for us all, carries high risk factors when no support is available. Severe reactions to loss may carry over into familial relations and cause trauma for children and spouses: there is an increased risk of marital breakup following the death of a child, for example. Many forms of what we term 'mental illness' have loss as their root and aetiology, but covered by many years and circumstances this often goes unnoticed. Issues of personal faith and beliefs also come under severe attack as persons reassess personal definitions in the face of great pain. Probably the best resource to avoid problems are early intervention and caring support, and understanding of the experience. Often non-professionals are just as or more effective in this role than professionals.