Grief is a multi-faceted response to loss, particularly to the loss of someone or something to which we have formed a bond. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social, and philosophical dimensions. Common to human experience is the death of a loved one, whether it be a friend, family, or other companion. 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, or possessions, to the loss of loved ones. 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.
Bereavement, while a normal part of life, carries a degree of risk when limited support is available. Severe reactions to loss may carry over into familial relations and cause trauma for children, spouses and any other family members: there is an increased risk of marital breakup following the death of a child, for example. Issues of faith and beliefs may also face challenge, as bereaved persons reassess personal definitions in the face of great pain.
While many who grieve are able to work through their loss independently, accessing additional support from professional psychiatrists or therapy may promote the process of healing. Grief counseling, professional support groups or educational classes, and peer-led support groups are primary resources available to the bereaved. In the United States, local hospice agencies may be an important first contact for those seeking bereavement support.
Stage theories and processes
The stages model, which came about in the 1960s, is theoretical, based on observation of people who are dying, not on scientific research into the experiences of people who have survived the death of a loved one. This model has largely been debunked because of the rigorous work of bereavement research pioneer, George Bonanno.
In 1991, Bonanno began studying grief for the first time using rigorous, peer-reviewed scientific techniques. Until then, the field of grief was largely based on theoretical models, such as the stages model, or that of John Bowlby and Parkes, or Sigmund Freud. Bonanno's  many studies followed people over time who have suffered a loss: such as death of a child, a spouse, or a loved one. In none of his many studies did he find evidence that the stages exist. In large part due to his work, the stages model is now considered invalid scientifically but it remains a popular idea among the public.
In 2008, Skeptic Magazine  published the findings of the Grief Recovery Institute, which further contest the stages of grief as they are related to people's dealing with the deaths of those important to them. John Bowlby, a noted psychiatrist, outlined the ebb and flow of processes such as shock and numbness, yearning and searching, disorganization and despair, and reorganization.
Types and duration
"Complicated grief", now also commonly referred to as "prolonged grief", can be differentiated from normal grief. Normal grief typically involves a range of transient behavioral and emotional responses to loss. 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 by people experiencing normal grief. Even hallucinatory experiences may be normal early in grief.
Examples of complicated grief can often be found in those who have survived a suicide attempt (Hsu, 2002). 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. Deaths such as suicides, murders, accidents, and other sudden and unexpected deaths can result in complicated grief due to the sudden shock.
The surprise makes it difficult to integrate the "story" of the loss, so the person struggles with an initial task of simply believing that the loss has occurred. Variables surrounding the death such as expectedness, naturalness, presence of violence, ambivalence, degree of attachment, and others play into the presence of complicated grief. All too often complicated grief can last for years. Most people (friends of the mourner) will recoil when hearing that this sort of grief may still be present after several years.
There is a clinical problem of becoming "identified" with the grief. In this situation, mourners are reluctant to release the grief because grieving has been integrated as part of their identity. Reporting in the journal NeuroImage, scientists suggest that complicated grief activates neurons in the reward centers of the brain, possibly giving these memories addiction-like properties. The authors found activity in the nucleus accumbens, a region of the brain most commonly associated with reward. It is one that has also been shown to play a role in social attachment, such as sibling and maternal affiliation.
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.
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 (Cerel, 2006). 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 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 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 in formation, and even a brief separation from a parent or other person who cares for the child can cause distress (Ainsworth 1963).
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', and children often see death as curable or temporary, 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 miscarriage, stillbirth or neonatal death, SIDS, or the death of an older child. In all cases, parents find the grief almost unbearably devastating, and while persons may rate the death of a spouse as first in traumatic life events, the death of a child is still perhaps one of the most intense forms of grief, holding greater risk factors.
This loss also bears a lifelong process: one does not get 'over' the loss but instead must 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.
Because of the intensity of grief emotions, irrational decisions are often made. In the event of a miscarriage or abortion, it is important for friends and family members to acknowledge the loss of the pregnancy, and not to attempt to minimize the significance of a pregnancy that did not come to term.
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 abortion may experience resentment towards others who experience successful pregnancies.
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.
Death of a parent
As a child, the death of a parent, without support to manage the effect 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 event. Sibling grief is often a disenfranchised type of grief (especially with regard to adult siblings). It is overlooked by society as a whole and people in general, thus negating the depth of love that exists between siblings. Siblings who have been part of each other's lives since birth 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 lives are essential to each other. The sibling relationship can be the longest significant relationship of the lifespan, and this loss intensifies their grief. 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 don't 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. It should be noted that 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.). (For further elaboration and information on the preceding information, see "Understanding Sibling Loss" CIGNA; Sibling Grief, " P. Gill White, Ph.D.; and Surviving the Death of a Sibling, T.J. Wray).
Parents may grieve due to permanent loss of children through means other than death. 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. In this sense, children may be lost due to many different causes, including 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.
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 (animal loss), a home, children leaving home (empty nest syndrome), 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. While the reaction may not be as intense, experiences of loss may still show in these forms of bereavement. Those who have experienced a loss of trust, will also experience some form of grief. For example, people that have been either physically or sexually abused as children may have issues around trust as an adult.
Cultural diversity in healthy grieving
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.
- http://www.tc.columbia.edu/faculty/index.htm?facid=gab38 George A. Bonanno's Columbia University Faculty Website
- 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 the Loss"
- 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
- Freed PJ, Yanagihara TK, Hirsch J, Mann JJ. (2009). Neural mechanisms of grief regulation. Biol Psychiatry. 66(1):33-40. PMID 19249748
- O'Connor MF, Wellisch DK, Stanton AL, Eisenberger NI, Irwin MR, Lieberman MD (May 10 2008). "Craving love? Enduring grief activates brain's reward center.". Neuroimage. 42: 969–972. doi:10.1016/j.neuroimage.2008.04.256. PMID 18559294.
- Chronic Grief Activates Pleasure Areas of the Brain Newswise, Retrieved on June 23, 2008.
- 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, MI: Zondervan, 1999).
- 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).
- Santrock, J. W.(2007). A Topical Approach to Life-Span Development-4th ed. New York : McGraw-Hill Higher Education.
- Wierzbicka Anna, 2004. "Emotion and culture: arguing with Marta Nussbaum". Ethos, 31 (4), pp. 577–601.