Grief

"Bereavement" redirects here. For the film, see Bereavement (film).

For other uses, see Grief (disambiguation).

A funeral during the Siege of Sarajevo in 1992

Grief is a multi-faceted response to loss, particularly to the loss of someone or something to which a bond was formed. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social, and philosophical dimensions. While the terms are often used interchangeably, bereavement refers to the state of loss, and grief is the reaction to loss.

Reactions

Crying is a normal and natural part of grieving. It has also been found, however, that crying and talking about the loss is not the only healthy response and, if forced or excessive, can be harmful.^[1][2] Responses or actions in the affected person, called "coping ugly" by researcher George Bonanno, may seem counterintuitive or even look dysfunctional, such as celebratory responses, laughter, self-serving bias in interpreting events.^[3] Lack of crying is also a natural, healthy reaction, potentially protective of the individual, and may also be seen as a sign of resilience.^[1][2][4] Science has found that some healthy people who are grieving do not spontaneously talk about the loss and pressing people to cry or retell the experience of a loss can be harmful.^[2] Genuine laughter is healthy.^[1][4]

Bereavement science

Grief can be caused by the loss of one's home and possessions, as occurs with refugees.

Main article: George Bonanno

Bonanno's Four Trajectories of Grief

George Bonanno, a professor of clinical psychology at Columbia University, conducted more than two decades of scientific studies on grief and trauma, which have been published in several papers in the most respected APA peer-reviewed journals in the field of psychology, such as Psychological Science and The Journal of Abnormal Psychology. Subjects of his studies number in the several thousand and include people who have suffered losses in the U.S. and cross-cultural studies in various countries around the world, such as Israel, Bosnia-Herzegovina, and China. His subjects suffered losses through war, terrorism, deaths of children, premature deaths of spouses, sexual abuse, childhood diagnoses of AIDS, and other potentially devastating loss events or potential trauma events.

In Bonanno's book, "The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss,"^[5] he summarizes his research. His findings include that a natural resilience is the main component of grief and trauma reactions.^[1] The first researcher to use pre-loss data, he outlined four trajectories of grief.^[1] Bonanno's work has also demonstrated that absence of grief or trauma symptoms is a healthy outcome, rather than something to be feared as has been the thought and practice until his research.^[3] Because grief responses can take many forms, including laughter, celebration, and bawdiness, in addition to sadness,^[4][6] Bonanno coined the phrase "coping ugly" to describe the idea that some forms of coping may seem counter intuitive.^[3] Bonanno has found that resilience is natural to humans, suggesting that it cannot be "taught" through specialized programs^[3] and that there is virtually no existing research with which to design resilience training, nor is there existing research to support major investment in such things as military resilience training programs.^[3]

The four trajectories are as follows:

• Resilience: "The ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event, such as the death of a close relation or a violent or life-threatening situation, to maintain relatively stable, healthy levels of psychological and physical functioning" as well as "the capacity for generative experiences and positive emotions."
• Recovery: When "normal functioning temporarily gives way to threshold or sub-threshold psychopathology (e.g., symptoms of depression or Posttraumatic Stress Disorder (PTSD)), usually for a period of at least several months, and then gradually returns to pre-event levels."
• Chronic dysfunction: Prolonged suffering and inability to function, usually lasting several years or longer.
• Delayed grief or trauma: When adjustment seems normal but then distress and symptoms increase months later. Researchers have not found evidence of delayed grief, but delayed trauma appears to be a genuine phenomenon.

Five stages theory

Main article: Kübler-Ross model

The Kübler-Ross model, commonly known as the five stages of grief, is a theory first introduced by Elisabeth Kübler-Ross in her 1969 book, On Death and Dying.^[7] The theory describes in five discrete stages a largely untested, but popular process by which people deal with grief and tragedy. Such events might include being diagnosed with a terminal illness or enduring a catastrophic loss. The five stages are denial, anger, bargaining, depression, and acceptance.

Mourners at the funeral for Christodoulos in Greece.

The theory holds that the stages are a part of the framework that helps people learn to live without what they lost. Lay people and practitioners consider the stages as tools to help frame and identify what a person who's suffered a loss may be feeling. The theory holds that the stages are not stops on a linear time line of grief. The theory also states that not everyone goes through all of the stages, nor in a prescribed order. In addition to the five-stages theory, Kübler-Ross has been credited with bringing mainstream awareness to the sensitivity required for better treatment of people who are dealing with a fatal disease.^[8]

The stages model, which came about in the 1960s, is a theory based on observation of people who are dying, not people who experienced the death of a loved one. This model found empirical support in a study by Maciejewski et al.^[9] The research of George Bonanno, however, is acknowledged as inadvertently debunking the five stages of grief because his large body of peer-reviewed studies show that the vast majority of people who've experienced a loss do not grieve, but are resilient. The logic is that if there is no grief, there are no stages to pass through.^[10]

Physiological and neurological processes

"Pietà" by El Greco, 1571-1576. Philadelphia Museum of Art

fMRI scans of women from whom grief was elicited about the death of a mother or a sister in the past 5 years found it produced a local inflammation response as measured by salivary concentrations of pro-inflammatory cytokines. These were correlated with activation in the anterior cingulate cortex and orbitofrontal cortex. This activation also correlated with free recall of grief-related word stimuli. This suggests that grief can cause stress, and that this is linked to the emotional processing parts of the frontal lobe.^[11] Activation of the anterior cingulate cortex and vagus nerve is similarly implicated in the experience of heartbreak whether due to social rejection or bereavement.

Among those bereaved within the previous three months, those who report many intrusive thoughts about the deceased show ventral amygdala and rostral anterior cingulate cortex hyperactivity to reminders of their loss. In the case of the amygdala, this links to their sadness intensity. In those who avoid such thoughts, there is a related opposite type of pattern in which there is a decrease in the activation of the dorsal amgydala and the dorsolateral prefrontal cortex.

In those not so emotionally affected by reminders of their loss, fMRI finds the existence of a high functional connectivity between the dorsolateral prefrontal cortex and amygdala activity, suggesting the former regulates activity in the latter. In those who had greater intensity of sadness, there was a low functional connection between the rostal anterior cingulate cortex and amygdala activity, suggesting a lack of regulation of the former part of the brain upon the latter.^[12]

Risks

Bereavement, while a normal part of life, carries a degree of risk when severe. Severe reactions affect approximately 10% to 15% of people.^[1] Severe reactions mainly occur in people with depression present before the loss event.^[1] Severe grief reactions may carry over into family relations. Some researchers have found an increased risk of marital breakup following the death of a child, for example. Others have found no increase.

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, with symptoms such as abdominal pain, 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.^[13]

Complicated grief

The existence of "complicated grief" is a current debate in the field.^{[14][Need quotation to verify][15][16][verification needed]} An attempt is being made to create a diagnosis category for complicated grief in the DSM-V.^{[16][verification needed]} Critics of including the diagnosis of complicated grief in the DSM-V say that doing so will make a natural response a pathology and will result in wholesale medicating of people who are essentially normal.^{[16][verification needed]}

Shear and colleagues found an effective treatment for complicated grief, by treating the reactions in the same way as trauma reactions.^[14][17]

Examples of bereavement

Death of a child

Death of a child can take the form of a loss in infancy such as miscarriage or stillbirth^[18] or neonatal death, SIDS, or the death of an older child. In most cases, parents find the grief almost unbearably devastating, and it tends to hold greater risk factors than any other loss. This loss also bears a lifelong process: one does not get 'over' the death but instead must assimilate and live with it.^[19]

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.^{[citation needed]}
Feelings of guilt, whether legitimate or not, 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. Parents who suffer miscarriage or a regretful or coerced abortion may experience resentment towards others who experience successful pregnancies. Because of the intensity of grief emotions, irrational decisions are often made.^{[citation needed]}

Death of a spouse

Although the death of a spouse may be an expected change, it is a particularly powerful loss of a loved one. A spouse often becomes part of the other in a unique way: many widows and widowers describe losing 'half' of themselves. After a long marriage, at older ages, the elderly may find it a very difficult assimilation to begin anew.

Furthermore, 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 imminent, as many groups composed of couples find it difficult to adjust to the new identity of the bereaved. Widows of many cultures, for instance, wear black for the rest of their lives to signify the loss of their husband and their grief. Only in more recent decades has this tradition been reduced to a period of two years, while some religions such as Christian Orthodox many widows will still continue to wear black for the remainder of their lives.

Death of a parent

For a child, the death of a parent, without support to manage the effects of the grief, may result in long term psychological harm. Therefore, it is important that the emotions the child feels are worked through completely and discussed openly.

An adult may be expected to cope with the death of a parent in a less emotional way; however, it can still invoke extremely powerful emotions. This is especially true when the death occurs at an important or difficult period of life, such as when becoming a parent, graduation or other times of emotional stress. It is important to recognize the effects that the loss of a parent can cause and address these. As an adult, the willingness to be open to grief is often diminished. A failure to accept and deal with loss will only result in further pain and suffering.

Death of a sibling

The loss of a sibling is a devastating life event. Despite this, sibling grief is often the most disenfranchised or overlooked of the four main forms of grief, especially with regard to adult siblings. However, the sibling relationship tends to be the longest significant relationship of the lifespan and siblings who have been part of each other's lives since birth, such as twins, help form and sustain each other's identities; with the death of one sibling comes the loss of that part of the survivor's identity.

The sibling relationship is a unique one, as they share a special bond and a common history from birth, have a certain role and place in the family, often complement each other, and share genetic traits. Siblings who enjoy a close relationship participate in each other's daily lives and special events, confide in each other, share joys, spend leisure time together (whether they are children or adults), and have a relationship that not only exists in the present but often looks toward a future together (even into retirement).

Siblings who play a major part in each other's lives are essential to each other. Adult siblings eventually expect the loss of aging parents, the only other people who have been an integral part of their lives since birth, but they do not expect to lose their siblings early; as a result, when a sibling dies, the surviving sibling may experience a longer period of shock and disbelief.

Overall, with the loss of a sibling, a substantial part of the surviving sibling's past, present, and future is also lost. If siblings were not on good terms or close with each other, then intense feelings of guilt may ensue on the part of the surviving sibling (guilt may also ensue for having survived, not being able to prevent the death, having argued with their sibling, etc.)^[20]

Loss during childhood

Mourners surround a coffin at a Brazilian funeral.

When a parent or caregiver dies or leaves, children may have symptoms of psychopathology, but they are less severe than in children with major depression.^[21] 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 found to have no reaction if a carer dies, but other children may be affected by the loss.

At a time when trust and dependency are formed, a break even of no more than separation can cause problems in well-being; this is especially true if the loss is around critical periods such as 8–12 months, when attachment and separation are at their height information, and even a brief separation from a parent or other person who cares for the child can cause distress.^[22]

Even as a child grows older, death is still difficult to assimilate and this 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^{[citation needed]}, and children often see death as curable or temporary, more as a separation. Reactions 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.^{[citation needed][awkward]} 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.^{[citation needed]} 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.

Children can experience grief as a result of losses due to causes other than death. For example, children who have been physically, psychologically and/or sexually abused often grieve over the damage to, or loss of, their ability to trust. Since such children usually have no support or acknowledgement from any source outside the family unit, this is likely to be experienced as disenfranchised grief.

Relocations can cause children significant grief, particularly if they are combined with other difficult circumstances, such as neglectful and/or abusive parental behaviors, other significant losses, etc.^[23][24]

Other losses

People who become unemployed, such as these California workers, may face grief from the loss their job

Parents may grieve due to loss of children through means other than death, for example through loss of custody in divorce proceedings; legal termination of parental rights by the government, such as in cases of child abuse; through kidnapping; because the child voluntarily left home (either as a runaway or, for children over 18, by leaving home legally); or because an adult refuses or is unable to have contact with a parent. This loss differs from the death of a child in that the grief process is prolonged or denied because of hope that the relationship will be restored.

Grief may occur after the loss of a romantic relationship (i.e. divorce or break up), a vocation, a pet (animal loss), a home, children leaving home (empty nest syndrome), sibling(s) leaving home, a friend, a favored appointment or desire, a faith in one's religion, etc. A person who strongly identifies with their occupation may feel a sense of grief if they have to stop their job due to retirement, being laid off, injury, or loss of certification. Those who have experienced a loss of trust will often also experience some form of grief.

Professional support

For a lot of people, no professional support is needed^{[citation needed]}. Some people, however, may decide to seek additional support from licensed psychologists or psychiatrists. Grief counseling, professional support groups or educational classes, and peer-led support groups are support resources available to the bereaved. In the United States, local hospice agencies may be a first contact for those seeking bereavement support.

Cultural diversity in grieving

Main article: Mourning

Each society specifies manners such as rituals, styles of dress, or other habits, as well as attitudes, in which the bereaved are encouraged or expected to take part. An analysis of non-Western cultures suggests that beliefs about continuing ties with the deceased varies. In Japan, maintenance of ties with the deceased is accepted and carried out through religious rituals. In the Hopi of Arizona, the deceased are quickly forgotten and life continues on.

Different cultures grieve in different ways, but all have ways that are vital in healthy coping with the death of a loved one.^[25] The American family's approach to grieving was depicted in "The Grief Committee", by T. Glen Coughlin. The short story gives an inside look at how the American culture has learned to cope with the tribulations and difficulties of grief. (The story is taught in the course, The Politics of Mourning: Grief Management in a Cross-Cultural Fiction. Columbia University)^[26]

In animals

Previously it was believed that grief was only a human emotion, but studies have shown that other animals have shown grief or grief-like states during the death of another animal. This usually occurs in mammals, typically between a mother and in the event of its offspring's death. She will often stay close to her dead offspring for short periods of time and may investigate the reasons for the baby's non-response. For example, some deer will often sniff, poke, and look at its lifeless fawn before realising it is dead and leaving it to rejoin the herd shortly afterwards. Other animals, such as a lioness, will pick up its cub up in its mouth and place it somewhere else before abandoning it. But when a baby chimpanzee or gorilla dies, the mother will carry the body around for several days before it may finally be able to move on without it; this behavior has been observed in other primates, as well.

Jane Goodall has described chimpanzees as exhibiting mournful behavior toward the loss of a group member with silence and by showing more attention to it. And they will often continue grooming it and stay close to the carcass until the group must move on without it. Another notable example is Koko, a gorilla that uses sign language, who expressed sadness and even described sadness about the death of her pet cat, All Ball. Other animals, such as elephants, have shown unusual behavior upon encountering the remains of another deceased elephant. They will often investigate it by touching and grabbing it with their trunks and have the whole herd stand around it for long periods of time until they must leave it behind. It is unknown whether they are mourning over it and showing sympathy, or are just curious and investigating the dead body. Another form of grief in animals is when an individual loses its mate; this can be especially brutal when the species is monogamous. So when a pair bonding species, such as a black-backed jackal, loses its mate it can be very difficult for it to detach itself from its dead mate.

See also

Anticipatory grief Coping (psychology) Disenfranchised grief Grief counseling The Grief Recovery Institute Grief therapy

List of counseling topics Postponement of grief Posttraumatic stress disorder Psychological trauma Stress Support group Thanatosensitivity

Notes

1. ^ ^{a b c d e f g} http://faculty.tc.columbia.edu/upload/gab38/americanPsychologist.pdf
2. ^ ^{a b c} New Ways to Think About Grief. Ruth Davis Konigsberg, 29 January, 2011, Time Magazine.
3. ^ ^{a b c d e} The Neuroscience of True Grit. Gary Stix, 15 February 2011. Scientific American.
4. ^ ^{a b c} Dolnick, Sam (11 April 2011). "At Ghanaian Funerals, a Time to Dance and Celebrate". The New York Times. http://www.nytimes.com/2011/04/12/nyregion/12funerals.html?hp. 
5. ^ http://www.perseusbooksgroup.com/basic/book_detail.jsp?isbn=0465013600 The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss
6. ^ http://www.giftofireland.com/Irishwakes.htm
7. ^ Broom, Sarah M. "Milestones: Aug. 30, 2004", TIME website
8. ^ Santrock, J.W. (2007). A Topical Approach to Life-Span Development. New York: McGraw-Hill. ISBN 0-07-338264-7
9. ^ Maciejewski, P.K. JAMA, February 21, 2007. Retrieved April 14, 2009
10. ^ "New Ways to Think About Grief". Time. 29 January 2011. http://www.time.com/time/magazine/article/0,9171,2042372.html. 
11. ^ O'Connor MF, Irwin MR, Wellisch DK. (2009). "When grief heats up: Pro-inflammatory cytokines predict regional brain activation", Neuroimage, 47: 891–896PMID 19481155 doi:10.1016/j.neuroimage.2009.05.049
12. ^ Freed PJ, Yanagihara TK, Hirsch J, Mann JJ. (2009). Neural mechanisms of grief regulation. Biol Psychiatry. 66(1):33-40. PMID 19249748
13. ^ J. Bunch, B. Barraclough, B. Nelson and P. Sainsbury, "Suicide following bereavement of parents", Social Psychiatry and Psychiatric Epidemiology Volume 6, Number 4, 193-199
14. ^ ^{a b} George A. Bonanno (May 2006). "Is Complicated Grief a Valid Construct?". Clinical Psychology: Science and Practice 13 (2): 129–134. doi:10.1111/j.1468-2850.2006.00014.x. 
15. ^ Fran Schumer (September 28, 2009). "After a Death, the Pain That Doesn’t Go Away". The New York Times. http://www.nytimes.com/2009/09/29/health/29grief.html. 
16. ^ ^{a b c} Allen Frances (August 14, 2010). "Good Grief". The New York Times. http://www.nytimes.com/2010/08/15/opinion/15frances.html. 
17. ^ Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. III. (2005). Treatment of complicated grief: A randomized controlled trial. Journal of the American Medical Association, 293, 2658–2660.
18. ^ For a true account of one couples' experience with the stillbirth of their baby, see Brad Stetson, Tender Fingerprints: A True Story of Loss and Resolution, (Grand Rapids, Michigan: Zondervan, 1999).
19. ^ For discussion of this process, see Brad Stetson, Living Victims, Stolen Lives: Parents of Murdered Children Speak to America, (Amityville, N. Y.: Baywood Press, 2003).
20. ^ "Understanding Sibling Loss", CIGNA; Sibling Grief, P. Gill White, Ph.D.; and Surviving the Death of a Sibling, T.J. Wray.
21. ^ (Cerel, 2006)
22. ^ (Ainsworth 1963)
23. ^ Sheppard, Caroline H.; William Steele (2003). "Moving Can Become Traumatic". Trauma and Loss: Research and Interventions. Nat'l Inst for Trauma and Loss in Children. http://www.tlcinst.org/Moving.html. Retrieved 22 January 2010. 
24. ^ Oesterreich, Lesia (April 2004). "Understanding children: moving to a new home". Iowa State University. http://www.extension.iastate.edu/Publications/PM1529G.pdf. Retrieved 22 January 2010. 
25. ^ Santrock, J. W.(2007). A Topical Approach to Life-Span Development-4th ed. New York : McGraw-Hill Higher Education.
26. ^ The Politics of Mourning: Grief Management in a Cross-Cultural Fiction, by Rochelle Almeida, 2004 by Rosemont Publishing Company, Associated University Press.

References

• Wierzbicka Anna, 2004. "Emotion and culture: arguing with Marta Nussbaum". Ethos, 31 (4), pp. 577–601.
• Francis, Mary, 2010. "The Sisterhood of Widows". A collection of true stories told by 16 widows about life after the death of their husbands.

External links

• "Grieving: A study of bereavement" by Megan O'Rourke at Slate.com