Grief

Grief is multidimensional. It has an impact on behaviour, emotions, cognitive processes, physical health, social functioning, and spiritual beliefs. A major loss forces people to adapt their assumptions about the world and about themselves, and grief is a transitional process by which people assimilate the reality of their loss and find a way of living without the external presence of the person who died. Traditionally, this process has been described as consisting of overlapping phases. While it is more useful to think of grief as characterised by simultaneous change and adjustment, such models provide useful descriptions of the major themes of grief.

The initial reaction is shock and disbelief accompanied by a sense of unreality. This occurs even when death is expected but may last longer and be more intense after an unexpected loss.

Numbness is replaced with waves of intense pining and distress. The desire to recover a loved one is strong and preoccupation with memories, restless searching, dreams, and auditory and sensory awareness of the deceased are common. Bereavement affects the immune system, and physical symptoms may also be caused by anxiety and changes in behaviour such as loss of sleep or altered nutrition, or may mimic the symptoms of the deceased. A crucial factor is the meaning of the loss, and bereaved people search for an understanding of why and how the death occurred. The events surrounding the death may be obsessively reviewed. For some, there may be questioning of previously deeply held beliefs, while others find great support from their faith, the rituals associated with it, and the social contact with others that religious affiliation often brings. Symptoms of depression such as despair, poor concentration, apathy, social withdrawal, lack of purpose, and sadness are common for more than a year after an important bereavement. This reflects the multidimensional impact of loss.

To carry on without what they have lost, bereaved people may need to rebuild their identities, find new purpose, acquire new skills, and take on new roles. Gradually people manage these adjustments more effectively and more positive feelings emerge accompanied by renewed energy and hope for the future. Eventually most bereaved people can remember the deceased without feeling overwhelmed. The deceased continue to be part of their lives, however, and family events and anniversaries may reawaken painful memories and feelings. In this sense there is no definite end point that marks “recovery” from grief.

A central notion of traditional models of grief is that it must be confronted and expressed, otherwise it may manifest in some other way, such as depression or anxiety. Throughout the period of mourning, however, most people cope by oscillating between confronting grief (for example, thinking about the deceased, pining, holding on to memories, expressing feelings) and seeking distraction to manage everyday life (for example, suppressing memories and taking “time off” from grief by keeping busy, regulating emotions). Neither pattern of coping is problematic and difficulties are likely only if the balance of behaviour is oriented exclusively on loss (chronic grief) or avoidance (absent grief). Although grief is universal, social norms vary and what is viewed as “normal” differs both within and across cultures. Personality factors, sex, and cultural background will influence the degree of individual oscillation—for example, women may be more emotional and loss focused while men may be more inclined to cope by seeking information, thinking through problems, taking action, and seeking diversion.

Courtesy of photos.com

Factors associated with poor adjustment

Research has identified several factors that influence the course of grief and are associated with ongoing poor health. There are three groups of factors: situational, individual, and environmental.

Situational is the circumstances surrounding the death and the impact of concurrent life events. Deaths that are untimely, unexpected, stigmatised, or unduly disturbing cause more severe and more prolonged grief. The death of someone with terminal illness can still be unexpected and distressing, and the strain of caring for a terminally ill person for more than six months also increases risk. People from minority cultural or ethnic groups may experience problems if they are not able to follow the rituals and customs they think are appropriate. Concurrent crises such as multiple losses and financial difficulties also strain coping resources.

Individual factors concern the meaning of the lost relationship and personal factors. The subjective meaning of the loss is more important than kinship, and the closer the relationship, the greater the risk. The more necessary the deceased was for the bereaved person’s sense of wellbeing and self esteem, the more all pervading the sense of loss. The loss of a child is particularly difficult. Highly ambivalent relationships are associated with continuing high levels of distress, particularly guilt. Studies that compare the health of widows and widowers with married people show that widowers are at greater risk, particularly younger men. Pre-existing health problems may be exacerbated by bereavement, and the risk of suicide is greater among those who have had a previous psychiatric illness.

Environmental is the social and cultural context of risk. A perceived lack of support is the common factor. Bereavement may deprive people of their main source of support and shared suffering, and differential grieving patterns within social networks may compound this. Family discord is a source of additional stress. Among elderly people, poor health, reduced mobility, and sensory losses may make it more difficult to cope and reduce the capacity to develop new interests or relationships.

Assessing complicated grief

As grief and its expression are influenced by the society in which a bereaved individual lives, and by attitudes and expectations in the immediate family, assessing grief is complex. The focus should be on understanding the individual and on recognising their strengths and resources as well as potential difficulties. The following should be taken into account:

Intensity and duration of feelings and behaviour—A woman who cries every day in the first few weeks after the loss of her husband or partner is within the normal range; if she is doing so 12 months later there is cause for concern. Prolonged intense pining, self reproach, and anger are danger signals, as is prolonged withdrawal from social contact. Failure to show any grief may also be problematic, but people cope in different ways and some recover quickly, especially if they were well prepared for the death.

“The death of Madame Bovary” by Albert-Auguste Fourie (b 1854). Reproduced with permission from Musée des Beaux-Arts, Rouen, France/ Lauros/Giraudon/The Bridgeman Art Library

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