Causes and Symptoms During life, people unavoidably experience a variety of losses. These may include the loss of loved ones, important possessions or status, health and vitality, and ultimately the loss of self through death. Grief is the word commonly used to refer to an individual’s or group’s shared experience following a loss. The experience of grief is not a momentary or singular phenomenon. Instead, it is a variable, and somewhat predictable, process of life. Also, as with many phenomena within the range of human experience, it is a multidimensional process including biological, psychological, spiritual, and social components.
The biological level of the grief experience includes the neurological and physiological processes that take place in the various organ systems of the body in response to the recognition of loss. These processes, in turn, form the basis for emotional and psychological reactions. Various organs and organ systems interact with one another in response to the cognitive stimulation resulting from this recognition. Human beings are self-reflective creatures with the capacity for experiencing, reflecting upon, and giving meaning to sensations, both physical and emotional. Consequently, the physiological reactions of grief that take place in the body are given meaning by those experiencing them.
The cognitive and emotional meanings attributed to the experience of grief are shaped by and influence interactions within the social dimensions of life. In other words, how someone feels or thinks about grief influences and is influenced by interactions with family, friends, and helping professionals. In addition, the individual’s religious or spiritual frame of reference may have a significant influence on the subjective experience and cognitive-emotional meaning attributed to grief.
The grief reactions associated with a loss such as death vary widely. While it is very difficult and perhaps unfair to generalize about such an intensely personal experience, several predictors of the intensity of grief have become evident. The amount of grief experienced seems to depend on the significance of the loss, or the degree to which the individual subjectively experiences a sense of loss. This subjective experience is partially dependent on the meaning attributed to the loss by the survivors and others in the surrounding social context. This meaning is in turn shaped by underlying belief systems, such as religious faith. Clear cognitive, emotional, and/or spiritual frameworks are helpful in guiding people constructively through the grief process.
People in every culture around the world and throughout history have developed expectations about life, and these beliefs influence the grief process. Some questions are common to many cultures. Why do people die? Is death a part of life, or a sign of weakness or failure? Is death always a tragedy, or is it sometimes a welcome relief from suffering? Is there life after death, and if so, what is necessary to attain this afterlife? The answers to these and other questions help shape people’s experience of the grief process. As Elisabeth Kübler-Ross states in Death: The Final Stage of Growth (1975), the way in which a society or subculture explains death will have a significant impact on the way in which its members view and experience life.
Another factor that influences the experience of grief is whether a loss was anticipated. Sudden and/or unanticipated losses are more traumatic and more difficult to explain because they tend to violate the meaning systems mentioned above. The cognitive and emotional shock of this violation exacerbates the grief process. For example, it is usually assumed that youngsters will not die before the older members of the family. Therefore, the shock of a child dying in an automobile crash may be more traumatic than the impact of the death of an older person following a long illness.
Death and grief are often distasteful to human beings, at least in Western Judeo-Christian cultures. These negative, fearful reactions are, in part, the result of an individual’s difficulty accepting the inevitability of his or her own death. Nevertheless, in cultures that have less difficulty accepting death and loss as normal, people generally experience more complicated grief experiences. The Micronesian society of Truk is a death-affirming society. The members of the Truk society believe that a person is not really grown up until the age of forty. At that point, the individual begins to prepare for death. Similarly, some native Alaskan groups teach their members to approach death intentionally. The person about to die plans for death and makes provisions for the grief process of those left behind.
In every culture, however, the grief-stricken strive to make sense out of their experience of loss. Some attribute death to a malicious intervention from the outside by someone or something else; death becomes frightening. For others, death is in response to divine intervention or is simply the completion of “the circle of life” for that person. Yet for most people in Western societies, even those who come to believe that death is a part of life, grief may be an emotional mixture of loss, shock, shame, sadness, rage, numbness, relief, anger, and/or guilt.
Kübler-Ross points out in her timeless discourse “On the Fear of Dying” (On Death and Dying
, 1969) that guilt is perhaps the most painful companion of death and grief. The grief process is often complicated by the individual’s perception that he or she should have prevented the loss. This feeling of being responsible for the death or other loss is common among those connected to the deceased. For example, parents or health care providers may believe that they should have done something differently in order to detect the eventual cause of death sooner or to prevent it once the disease process was detected.
Guilt associated with grief is often partly or completely irrational. For example, there may be no way that a physician could have detected an aneurysm in her patient’s brain prior to a sudden and fatal stroke. Similarly, a parent cannot monitor the minute-by-minute activities of his or her adolescent children to prevent lethal accidents. Kübler-Ross explains a related phenomenon among children who have lost a parent by pointing out the difficulty in separating wishes from deeds. A child whose wishes are not gratified by a parent may become angry. If the parent subsequently dies, the child may feel guilty, even if the death is some distance in time away from the event in question.
The guilt may also involve remorse over surviving someone else’s loss. People who survive an ordeal in which others die often experience survivor’s guilt. Survivors may wonder why they survived and how the deceased person’s family members feel about their survival, whether they blame the survivors or wish that they had died instead. As a result, survivors have difficulty integrating the experience with the rest of their lives in order to move on. The feelings of grief and guilt may be exacerbated further if survivors believe that they somehow benefited from someone else’s death. A widow who is suddenly the beneficiary of a large sum of money attached to her husband’s life insurance policy may feel guilty about doing some of the things that they had always planned but were unable to do precisely because of a lack of money.
Last, guilt may result when people believe that they did not pay enough attention to, care well enough for, or deserve the love of the person who died. These feelings and thoughts are prompted by loss of an ongoing relationship with the one who died, as well the empathetic response to what it might be like to die oneself.
Feelings of guilt are not always present, even if the reaction is extreme. If individuals experience guilt, however, they may bargain with themselves or a higher power, review their actions to find what they did wrong, take a moral inventory to see where they could have been more loving or understanding, or even begin to act self-destructively. Attempting to resolve guilt while grieving loss is doubly complicated and may contribute to the development of what is considered an abnormal grief reaction.
The distinctions between normal and abnormal grief processes are not clear-cut and are largely context-dependent; that is, what is normal depends on standards that vary among different social groups and historical periods. In addition, at any particular time the variety of manifestations of grief depend on the individual’s personality and temperament; family, social, and cultural contexts; resources for coping with and resolving problems; and experiences with the successful resolution of grief.
Despite this diversity, the symptoms that are manifested by individuals experiencing grief are generally grouped into two different but related diagnostic categories: depression and anxiety. It is normal for the grieving individual to manifest symptoms related to anxiety and/or depression to some degree. For example, a surviving relative or close friend may temporarily have difficulty sleeping, or feel sad or that life has lost its meaning. Relative extremes of these symptoms, however, in either duration or intensity, signal the possibility of an abnormal grief reaction.
In Families and Health (1988), family therapist William Doherty and family physician Thomas Campbell identify the signs of abnormal grief reactions as including periods of compulsive overactivity without a sense of loss; identification with the deceased; acquisition of symptoms belonging to the last illness of the deceased; deterioration of health in the survivors; social isolation, withdrawal, or alienation; and severe depression. These signs may also include severe anxiety, abuse of substances, work or school problems, extreme or persistent anger, or an inability to feel loss.
Treatment and Therapy There is no set time schedule for the grief process. While various ethnic, cultural, religious, and political groups define the limits of the period of mourning, they cannot prescribe the experience of grief. Yet established norms do influence the grief experience, inasmuch as the grieving individuals have internalized these expectations and standards. For example, the typical benefit package of a professional working in the United States offers up to one week of paid funeral leave in the event of the death of a significant family member. On the surface, this policy begins to prescribe or define the limits of the grief process.
Such a policy suggests, for example, that a mother or father stricken with grief at the untimely death of a child ought to be able to return to work and function reasonably well once a week has passed. Most individuals will attempt to do so, even if they are harboring unresolved feelings about the child’s death. Coworkers, uncomfortable with responding to such a situation and conditioned to believe that people need to “get on with life,” may support the lack of expression of grief.
Helpful responses to grief are as multifaceted as grief itself. Ultimately, several factors ease the grief process. These include validating responses from significant others, socially sanctioned expression of the experience, self-care, social or religious rituals, and possibly professional assistance. Each person responds to grief differently and requires or is able to use different forms of assistance.
Most reactions to loss run a natural, although varied, course. Since grief involves coming to grips with the reality of death, acceptance must eventually be both intellectual and emotional. Therefore, it is important to allow for the complete expression of both thoughts and feelings. Those attempting to assist grief-stricken individuals are more effective if they have come to terms with their own feelings, beliefs, and conflicts about death, and any losses they personally have experienced.
Much of what is helpful in working through grief involves accepting grief as a normal phenomenon. Grief-related feelings should not be judged or overly scrutinized. Supportive conversations include time for ventilation, empathic responses, and sharing of sympathetic experiences. Helpful responses may take the form of “To feel pain and sadness at this time is a normal, healthy response” or “I don’t know what it is like to have a child die, but it looks like it really hurts” or “It is understandable if you find yourself thinking that life has lost its purpose.” In short, people must be given permission to grieve. When it becomes clear that the person is struggling with an inordinate amount of feelings based on irrational beliefs, these underlying beliefs—not the feelings—may need to be challenged.
People tend to have difficulty concentrating and focusing in the aftermath of a significant loss. The symptoms of anxiety and depression associated with grief may be experienced, and many of the basic functions of life may be interrupted. Consequently, paying attention to healthy eating and sleeping schedules, establishing small goals, and being realistic about how long it may take before “life returns to normal” are important.
While the prescription of medication for the grief-stricken is fairly common, its use is recommended only in extreme situations. Antianxiety agents or antidepressants can interfere with the normal experiences of grief that involve feeling and coming to terms with loss. Sedatives can help bereaved family members and other loved ones feel better over the short term, with less overt distress and crying. Many experts believe, however, that they inhibit the normal grieving process and lead to unresolved grief reactions. In addition, studies suggest that those who start on psychotropic medication during periods of grief stay on them for at least two years.
The grief process is also eased by ritual practices that serve as milestones to mark progress along the way. Some cultures have very clearly defined and well-established rituals associated with grief. In the United States, the rituals practiced continue to be somewhat influenced by family, ethnic, and regional cultures. Very often, however, the rituals are confined to the procedures surrounding the preparation and burial of the body (for example, viewing the body at the mortuary, a memorial service, and interment). As limited as these experiences might be, they are designed to ease people’s grief. Yet the grief process is often just beginning with the death and burial of the loved one. Consequently, survivors are often left without useful guidelines to help them on their way.
Another common, although unhelpful, phenomenon associated with the process is for the grief-stricken person initially to receive a considerable amount of empathy and support from family, friends, and possibly professionals (such as a minister or physician) only to have this attention drop off sharply after about a month. The resources available through family and other social support systems diminish with the increasing expectation that the bereaved should stop grieving and “get on with living.” If this is the case, or if an individual never did experience a significantly supportive response from members of his or her social system, the role of psychotherapy and/or support groups should be explored. Many public and private agencies offer individual and family therapy. In addition, in many communities there are a variety of self-help support groups devoted to growth and healing in the aftermath of loss.
Perspective and Prospects The grief process, however it is shaped by particular religious, ethnic, or cultural contexts, is reflective of the human need to form attachments. Grief thus reflects the importance of relationships in one’s life, and therefore it is likely that people will always experience grief (including occasional feelings of guilt). Processes such as the grief experience, with its cognitive, emotional, social, and spiritual dimensions, may affect an individual’s psychological and physical well-being. Consequently, medical and other health care and human service professionals will probably always be called upon to investigate, interpret, diagnose, counsel, and otherwise respond to grief-stricken individuals and families.
In the effort to be helpful, however, medical science has frequently intervened too often and too invasively into death, dying, and the grief process—to the point of attempting to disallow them. For example, hospitals and other institutions such as nursing homes have become the primary places that people die. It is important to remember that it has not always been this way. Even now in some cultures around the world, people die more often in their own homes than in an institutional setting.
In the early phases of the development of the field of medicine, hospitals as institutions were primarily devoted to the care of the dying and the indigent. Managing the dying process was a primary focus. More recently, however, technological advances and specialty development have shifted the mission of the hospital to being an institution devoted to healing and curing. The focus on the recovery process has left dying in the shadows. Death has become equated with failure and associated with professional guilt.
It is more difficult for health care professionals to involve themselves or at least constructively support the grief process of individuals and families if it is happening as a result of the health care team’s “failure.” In a parallel fashion, society has become unduly fixated on avoiding death, or at least prolonging its inevitability to the greatest possible extent. The focus of the larger culture is on being young, staying young, and recoiling from the effects of age. As a result, healthy grief over the loss of youthful looks, stamina, health, and eventually life is not supported.
Medical science can make an important contribution in this area by continuing to define the appropriate limits of technology and intervention. The struggle to balance quantity of life with quality of life (and death) must continue. In addition, medical science professionals need to redouble their efforts toward embracing the patient, not simply the disease; the person, not simply the patient; and the complexities of grief in death and dying, not simply the joy in healing and living.
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