Bereavement

Bereavement is the process of grieving and letting go of a loved one who has died.

Definition

Bereavement means to be deprived of someone by death. The death of someone you love is one of the greatest losses that can occur. However, feelings of bereavement can also accompany other losses, such as the loss of your health or the health of someone you care about—or the end of an important relationship, through divorce, for example. Grief is a normal, healthy response to loss.

Everyone feels grief in their own way, but there are certain stages to the process of mourning. It starts with recognizing a loss and continues until a person eventually accepts that loss. People's responses to grief will vary depending upon the circumstances of the death.

For example, if the person who died had a chronic illness, the death may have been expected. The end of the person's suffering might even have come as a relief. If the death was accidental or violent, coming to a stage of acceptance could take longer.

Symptoms

A wide and confusing range of emotions may be experienced after a loss. There can be five stages of grief. These reactions might not occur in a specific order, and can (at times) occur together. Not everyone experiences all of these emotions:

  • Denial, disbelief, numbness
  • Anger, blame
  • Bargaining (for instance, "If I am cured of this cancer, I will never smoke again")
  • Depressed mood, sadness, and crying
  • Acceptance, coming to terms

People who are grieving will often report crying spells, some trouble sleeping, and lack of productivity at work. At this time, you may find it hard to accept that the loss has actually occurred.

Once the initial shock has worn off, denial of the loss can often be replaced by feelings of anger. The anger may be directed toward doctors and nurses, God, other loved ones, yourself, or even the person who has died. You may experience feelings of guilt with sentiments such as "I should have… ", "I could have… ", or "I wish I had… " Such thoughts are common. Your emotions may be very intense and you may have mood swings. These are all normal reactions to loss.

Each type of loss means the person has had something taken away. Grief may be experienced as a mental, physical, social, or emotional reaction. Mental reactions can include anger, guilt, anxiety, sadness, and despair. Physical reactions can include sleeping problems, changes in appetite, physical problems, or illness. Social reactions can include feelings about seeing family or friends or returning to work. As with bereavement, grief processes depend on the relationship with the person who died, the situation surrounding the death, and the person's attachment to the person who died. Grief may be described as the presence of physical problems, constant thoughts of the person who died, guilt, hostility, and a change in the way one normally acts.

Mourning is the process by which people adapt to a loss; mourning is also influenced by cultural customs, rituals, and society's rules for coping.

Bereavement is the period after a loss during which grief is experienced and mourning occurs. The time spent in a period of bereavement depends on how attached the person was to the person who died, and how much time was spent anticipating the loss.

If you feel that you are not coping with bereavement, it is important to seek help. Although it may seem easier to bury your pain than to face it, unresolved grief can cause long-term physical or emotional illness.

Causes

Your reaction to loss will, in part, be influenced by the circumstances surrounding it. The death of a loved one is always difficult, particularly when it is sudden or accidental. Your relationship to the person who has died will greatly influence your reaction to the loss.

A Spouse's Death

The loss of a husband or wife is particularly hard. The surviving spouse will usually have to deal with a multitude of decisions regarding funeral arrangements, finances, and other legalities at a time when they may feel least able to deal with such matters. The bereaved spouse may also have to explain the death to children and help them through their grief. In addition to the severe emotional trauma, the death may lead to financial problems if the deceased spouse was the family's main source of income. Returning to the job market (or entering it for the first time) can be one of the most challenging tasks for the recently bereaved spouse. When searching for a job, look for ways to capitalize on the skills you have developed over the years.

A Child's Death

Regardless of the cause of death, or the age of the child, this is an emotionally devastating event that overwhelms a parent. A child's death arouses an overwhelming sense of injustice—for lost potential, unfulfilled dreams, and senseless suffering. Parents may feel responsible for the child's death, no matter how irrational that may seem. Parents may also feel that they have lost a vital part of their own identity.

A Parent's Death

No matter what age you are—young or old, single or with a family of your own—you will still be deeply affected by the death of your mother or father. When your mom or dad dies, it may be one of the most emotional losses you'll experience in life. It is only natural to feel consumed by a combination of pain, fear, and deep sadness at the loss of such a significant influence in your life.

The specifics of how you grieve will depend on a number of personal factors, including your relationship with your parent, age, gender, religious beliefs, previous experience with death, and whether or not you believe it was time for your parent to die.

When you lose a parent, you may also lose a lifelong friend, counselor, and adviser. Therefore, you may suddenly feel very much alone, even if you have the support of other family and friends. Even the loss of your parent's home as a natural place for family gatherings can add to the grief you experience.

After the initial shock fades, you will experience what is called secondary loss. This is when you may begin to think of all the upcoming experiences that your parent will not be there to share in. Things like career accomplishments, watching your own children grow, and other milestones. If you are older, the death of a parent may even bring up issues of your own mortality.

Allowing yourself to grieve for the loss of your parent will help you to say goodbye and loosen the emotional bonds to a loved one who has been a special part of your life.

A Loss Due To Suicide

For every suicide it is claimed that on average six people suffer intense grief. Those affected include parents, partners, children, siblings, relatives, friends, coworkers, and clinicians. Coping with bereavement through suicide can be more difficult than dealing with other losses because of the feelings of stigmatization, shame, guilt, and rejection that are often experienced. The stigma that still attaches to deaths by suicide in many cultures can increase the bereaved person's sense of isolation and vulnerability.

A Pet's Death

The death of a pet will often mean the loss of a cherished family member and can trigger great sorrow. People love their pets and consider them members of their family. Caregivers celebrate their pets' birthdays, confide in their animals, and carry pictures of them in their wallets. So when your beloved pet dies, it's not unusual to feel overwhelmed by the intensity of your sorrow. Animals provide companionship, acceptance, emotional support, and unconditional love during the time they share with you. Other people may find it hard to understand such a reaction to what they may see as the loss of "just an animal," and they may, therefore, be less understanding of your grief. However, your loss is significant and you should give yourself permission to mourn the passing of your beloved pet.

Anticipatory Grief

Anticipatory grief is the normal mourning that occurs when a patient or family is expecting a death. Anticipatory grief has many of the same symptoms as those experienced after a death has occurred.

Anticipatory grief includes depression, extreme concern for the dying person, preparing for the death, and adjusting to changes caused by the death. It can give the family time to get used to the reality of the impending loss. People are able to complete "unfinished business" with the dying person (for example, saying "good-bye," "I love you," or "I forgive you").

Anticipatory grief may not always occur. A person does not necessarily feel the same kind of grief before a death occurs as the grief felt after a death. There is no set amount of grief that a person will feel. Grief experienced before a death does not make the grief after that death easier or shorter in duration.

Some people believe that anticipatory grief is rare. To accept a loved one's death while he or she is still alive may leave the mourner feeling as if the dying patient has been abandoned. Furthermore, expecting the loss can make the attachment to the dying person stronger. Although anticipatory grief may help the family, witnessing the grief of family and friends can be very hard for the dying person who can become withdrawn as a result.

Some grief reactions are not considered "normal." For example, persistent and intrusive feelings of guilt in the survivor (or thoughts that he or she should have died along with the deceased) are more characteristic of depression than normal bereavement. Depression in bereavement can be successfully treated.

Other losses occurring in later life may precipitate grief or depression. Retirement, loss of income, deteriorating physical health, and having to give up driving are just some of the more common occurrences that might cause grief reactions in older people.

Treatments

Grief is a powerful emotion. It is painful and exhausting. Therefore, it sometimes seems easier to avoid confronting these feelings. However, this approach is not a viable long-term solution. Buried grief can manifest itself later as physical or emotional illness. Working through your sorrow and allowing yourself to express your feelings will help you to heal.

"Grief work" includes the stages a mourner needs to complete before resuming daily life. These processes include separating from the person who died, readjusting to a world without him or her, and forming new relationships. To separate from the person who died, a person must find another way to redirect the emotional energy that was given to the loved one. This does not mean the deceased was not loved or should be forgotten, but that the mourner needs to turn to others for emotional satisfaction. The mourner's roles, identity, and skills may need to change to readjust to living in a world without the person who died. The bereaved needs to redirect the emotional energy that was once given to the deceased to other people or activities.

It is important not to neglect yourself while grieving. Try to eat regular, healthy meals. If meal preparation is too difficult, try eating several smaller snacks throughout the day.

Grieving is extremely tiring, both physically and emotionally. The grief one is feeling is not just for the person who died, but also for the unfulfilled wishes and plans with the person. Death often reminds people of past losses or separations. Mourning may be described as having the following three phases:

  • The urge to bring back the person who died
  • Disorganization and sadness
  • Reorganization

Depression shares common features with grief, but can completely take over the way you think and feel.

Symptoms of depression include:

  • A sad or "empty" mood that will not go away or lighten
  • Persistent feelings of hopelessness or worthlessness
  • A negative preoccupation with self

Depression in older people has been linked to death from suicide, heart attack, and other causes. Much can be done to ameliorate severe symptoms through formal treatment or through support-group participation. If you feel that you or someone you know is having difficulty in coping with their loss, seek professional help. A family physician can often help, or grief counseling or therapy may be appropriate.

Grief counseling helps mourners with normal grief reactions work through the tasks of grieving. Grief counseling can be provided by professionally trained people or in self-help groups where bereaved people help each other. All of these services may be available in individual or group settings.

The goals of grief counseling include:

  • Describing normal grieving and encouraging the bereaved to accept the loss by talking about it
  • Helping the bereaved to identify and express feelings related to the loss (for example, anger, guilt, anxiety, helplessness, and sadness)
  • Helping the bereaved to separate emotionally from the deceased, as well as to make decisions and live alone
  • Helping the bereaved to understand his or her methods of coping
  • Describing normal grieving and the differences in grieving among individuals
  • Providing continuous support
  • Providing support at important times, such as birthdays and anniversaries
  • Identifying coping problems the bereaved may have, and making recommendations for professional grief therapy, if necessary

Grief therapy is used with people who have more serious grief reactions. The goal of grief therapy is to identify and solve problems the mourner may have in separating from the person who died. When separation difficulties occur, they may appear as physical or behavioral problems, delayed or extreme mourning, conflicted or extended grief, or unexpected mourning.

In grief therapy, the mourner talks about the deceased and tries to recognize whether he or she is experiencing an expected amount of emotion about the death. Grief therapy may allow the mourner to see that anger, guilt, or other negative or uncomfortable feelings can exist at the same time as more positive feelings about the person who died.

Humans tend to make strong bonds of affection or attachment with others. When these bonds are broken, as in death, a strong emotional reaction occurs. After a loss, a person must accomplish certain tasks to complete the process of grief. These basic tasks of mourning include accepting that the loss happened, living with and feeling the physical and emotional pain of grief, adjusting to life without the loved one, and emotionally separating from the loved one and going on without him. It is important that these tasks are completed before mourning can end.

In grief therapy six tasks can be used to help a mourner work through her grief:

  1. Develop the ability to experience, express, and adjust to painful grief-related changes
  2. Find effective ways to cope
  3. Establish a continuing relationship with the person who died
  4. Stay healthy and keep functioning
  5. Reestablish relationships, and understand that others may have difficulty empathizing with the grief he is experiencing
  6. Develop a healthy image of herself and the world

Complications in grief may come about due to unresolved grief from earlier losses. The grief for these earlier losses must be managed to handle the current grief. Grief therapy includes dealing with blockages to the mourning process, identifying any unfinished business with the deceased and identifying other losses that result from the death. The bereaved must see that the loss is final and to picture life after the mourning period.

Grief therapy may be available as individual or group therapy. A contract is set up with the individual that establishes the time limit of the therapy, the fees, the goals, and the focus of the therapy.

Complicated Grief

Complicated grief reactions require more complex therapies than uncomplicated grief reactions. Adjustment disorders (especially depressed and anxious mood or disturbed emotions and behavior), major depression, substance abuse, and even post-traumatic stress disorder are some of the common problems of complicated bereavement. Complicated grief is identified by the extended duration of the symptoms, the disruption to daily life caused by the symptoms or by the intensity of the symptoms (for example, intense suicidal thoughts or acts).

Complicated or unresolved grief may appear as a complete absence of grief and mourning, an ongoing inability to experience normal grief reactions, delayed grief, conflicted grief, or chronic grief. Factors that contribute to the chance that one may experience complicated grief include the suddenness of the death, the gender of the person in mourning, and the relationship to the deceased (for example, an intense, extremely close or very contradictory relationship).

Grief reactions that turn into major depression require treatment. Someone who avoids any reminders of the person who died, who constantly thinks or dreams about the person who died, or who gets scared and panics easily at any reminders of the deceased may be suffering from post-traumatic stress disorder. Substance abuse may occur, frequently in an attempt to avoid painful feelings about the loss and consequent symptoms (such as sleeplessness), and this should also be treated.

Children and Grief

In the past, children were thought to be miniature adults and were expected to behave as adults. It is now understood that there are differences in the ways in which children and adults mourn.

Unlike adults, bereaved children do not experience continual and intense emotional and behavioral grief reactions. Children may seem to show grief only occasionally and briefly, but in reality a child's grief usually lasts longer than that of an adult. This may be explained by the fact that a child's ability to experience intense emotions is limited. Mourning in children may need to be addressed again and again as the child gets older. Since bereavement is a process that continues over time, children will think about the loss repeatedly, especially during important times in their life, such as going to camp, graduating from school, getting married, or giving birth to their own children.

A child's grief may be influenced by her age, personality, developmental stage, earlier experiences with death, and her relationship with the deceased. The surroundings, cause of death, family members' ability to communicate with one another and to continue as a family after the death can also affect grief. Factors that may influence grief include the child's ongoing need for care, the child's opportunity to share his feelings and memories, the parent's ability to cope with stress, and the child's steady relationships with other adults.

Children do not react to loss in the same ways as adults. Grieving children may not show their feelings as openly as adults. Grieving children may not withdraw and dwell on the person who died, but instead may throw themselves into activities (for example, they may be sad one minute and playful the next). Often families think the child doesn't really understand or has gotten over the death. Neither is true; children's minds protect them from what is too powerful for them to handle. Children's grieving periods are shortened because they cannot think through their thoughts and feelings like adults. Also, children have trouble putting their feelings about grief into words. Instead, his behavior speaks for the child. Strong feelings of anger and fears of abandonment or death may show up in the behavior of grieving children. Children often play death games as a way of working out their feelings and anxieties. These games are familiar to the children and provide safe opportunities to express their feelings.

Children's Grief and Developmental Stages

Children at different stages of development have different understandings of death and the events near death.

Infants

Infants do not recognize death, but feelings of loss and separation are part of developing an awareness of death. Children who have been separated from their mother may be sluggish, quiet, unresponsive to smiling or cooing, undergo physical changes (for example, weight loss), be less active, and sleep less.

Age 2-3 years

Children at this age often confuse death with sleep and may experience anxiety as early as age 3. They may stop talking and appear to feel overall distress.

Age 3-6 years

At this age children see death as a kind of sleep; the person is alive, but only in a limited way. The child cannot fully separate death from life. Children may think that the person is still living, even though she might have been buried, and ask questions about the deceased (for example, how does the deceased eat, go to the toilet, breathe, or play?). Young children know that death occurs physically, but think it is temporary, reversible, and not final. The child's concept of death may involve magical thinking. For example, the child may think that his or her thoughts can cause another person to become sick or die. Grieving children under 5 may have trouble eating, sleeping, and controlling bladder and bowel functions.

Age 6-9 years

Children at this age are commonly curious about death, and may ask questions about what happens to one's body when it dies. Death is thought of as a person or spirit separate from the person who was alive, such as a skeleton, ghost, angel of death, or bogeyman. They may see death as final and frightening but as something that happens mostly to old people (and not to themselves). Grieving children can become afraid of school, have learning problems, develop antisocial or aggressive behaviors, become overly concerned about their own health (for example, developing symptoms of imaginary illness), or withdraw from others. Or, children this age can become too attached and clinging. Boys usually become more aggressive and destructive (for example, acting out in school), instead of openly showing their sadness. When a parent dies, children may feel abandoned by both their deceased parent and their surviving parent because the surviving parent is grieving and is unable to emotionally support the child.

Ages 9 and older

By the time a child is 9 years old, death is known to be unavoidable and is not seen as a punishment. By the time a child is 12 years old, death is seen as final and something that happens to everyone.

Treatment—Child Specific

A child's grieving process may be made easier by being open and honest with the child about death. Not talking about death indicates that the subject is taboo and does not help a child to cope with loss. Use clear, direct language. Explanations should be simple and straightforward. Euphemisms such as "She passed away" or "We lost him" are best avoided, as they can confuse and alarm children. Each child should be told the truth, using as much detail as he or she is able to understand. Listen to any questions the child may have and try to answer them as fully as possible. Children often need to be reassured about their own security (they often worry that they, or a surviving parent, will also die).

If you are planning a memorial ceremony, try to include the child in the arrangements and in the ceremony itself. These events help children (and adults) remember loved ones. Children should not be forced to be involved in funerals or memorials, but they should be encouraged to take part in those portions of the events with which they feel most comfortable. If the child wants to attend the funeral, wake or memorial service, she should be given a full explanation of what to expect in advance. Try to encourage them to express their feelings. The surviving parent may be too incapacitated by his own grief to give the child full attention. Therefore, support from a familiar adult or family member can be extremely helpful.

Sources

  • AARP
  • National Cancer Institute
  • National Institutes of Health-Bethesda
  • National Institutes of Health-National Library of Medicine
  • Canadian Mental Health Association
  • Mental Health Association
  • Worden JW: Grief Counseling and Grief Therapy.
  • Shuchter SR and Zisook S. Treatment of spousal bereavement: a multidimensional approach. Psychiatric Annals
  • Corr CA, Nabe CM, Corr DM: Death and Dying, Life and Living.
  • Humane Society of the United States
  • National Funeral Directors Association
Last reviewed 02/17/2015