09/16/12: Back in the late 1960s, Elizabeth Kubler-Ross proposed 5 basic stages of grief (denial, anger, bargaining, depression, acceptance). Since that time, an immense amount of work has been done to better understand the grieving process, revealing an entirely different set of conclusions. The following post will give an overview of the latest scientific and therapeutic understanding of grief.
Grief vs. Bereavement
It is important to understand the differences between the terms “grief/grieving” and “bereavement”. Grief is the psychological-emotional experience following a loss of any kind (relationship, status, job, house, game, income, etc), whereas bereavement is a specific type of grief related to someone dying. This piece will be dedicated primarily to the larger grieving process, but is completely applicable to those experiencing bereavement.
Kubler-Ross to the Present
One of the key things most people don’t know about those original 5 stages, is that Kubler-Ross was writing about people confronting their own death, not the death of a loved one. Several groups of counselors later took the idea and used it to help people understand the loss of someone else. However, almost no scientific research has shown the existence of those stages, or that people go through stages at all.
Over the past 15 years or so, a much richer body of work has revealed a variety of different understandings and conclusions. The most important of these is that grief is a) a highly individualized process , b) has no specific timetable, and c) many people find that their lives are better after going through grief, due to something referred to as “post-stress growth”.
Components of Grief
One of the most influential researchers on grief and bereavement is Sidney Zisook (UC-San Diego). His work has shown that there are 4 major components of grief that show up in various forms depending on the person and the unique circumstances of the loss:
1. Separation Distress: this is a soup of feelings like sadness, anxiety, pain, helplessness, anger, shame, yearning, loneliness, etc
2. Traumatic Distress: this includes states of disbelief and shock, intrusions (like unwanted thoughts), and efforts to avoid intrusions and the spike of emotions they produce
3. Guilt, remorse, unanswered questions, and regrets
4. Social withdrawal
People may also experience some symptoms that are similar to depression such as loss of interest in pleasurable activities, disruptions in sleep and appetite, low energy, irritability, and depressed mood.
Acute vs Prolonged Grief
Research is starting to reveal that there is a natural and instinctive path that grief takes that leads to the healthier outcomes. This type is usually called “acute grief”. However, others who suffer for very long periods of time may be experiencing a block of that pathway, which has come to be known as “prolonged grief”, or “complex grief”.
Acute grief: this is a transient, yet powerfully painful state that includes the aforementioned components. As the grieving process continues over time, other things start becoming mixed in, including a) positive emotions like warmth and joy in remembering, or a sense of relief; b) acceptance, forgiveness, understanding, and compassion; and c) meaning-making about the loss and circumstances.
Many of us eventually move into something referred to as “integrated grief”, which is when we have a backdrop of bittersweet memories that can occasionally emerge for many years into the future, but do not overwhelm us when they do. Once reaching this place, many people say they have a better outlook on life, live more intentionally, and rearrange their priorities. A growing number of therapists (including me) see this as one of the desirable end-points of the grieving process.
Prolonged Grief: this is when a person becomes emotionally paralyzed by grief for a very long period of time. They experience the components of grief, but instead of the positive thoughts and feelings emerging, they often experience:
-Strong fear of painful emotions and the possibility of “losing control”
-In bereavement, fear of forgetting the person or betraying them by moving on
-Strong belief that they will “never be the same”
-Excessive guilt or anger
-Persistent sense of disbelief
-Rumination and a commitment to avoidance
Prolonged grief can often look a lot like depression, and usually requires some kind of treatment like counseling. Another common issue in prolonged grief is substance abuse. A lot of people get into problematic cycles of alcohol, marijuana, or other substance use as a way to escape some of the pain of grief, which can make move on even more complex.
What Helps in Grief
Since we have learned that grief is a highly individualized process, there is not a specific set of practices that will help everyone. In my counseling work, I have found that people who are grieving have developed very creative ways to work and cope with it, each of which could be it’s own book or research study. That being said, I generally think of the grieving process as a time of transition and adjustment, and things that are related to positively adjusting to the loss are favorable. These can include:
1. Staying physically healthy: depending on what kind of grieving we are doing, it can be a trying physical experience. It is essential to maintain the best diet, sleep schedule, and exercise as is possible each day.
2. Meaning making: this is a piece of ancient wisdom that is deeply embedded in all spiritual traditions and existential philosophies. Basically, when we can make sense out of what happened, derive meaning from it, and put it into a context, we feel better.
3. Honoring the loss: in bereavement, a lot of people feel better when they find ways to carry on the legacy of the person, and solidify a sense of remembering that will endure over time. Many people do this through some kind of art, activism, prayer, or community involvement. As a side note, it is also very common for people to maintain some kind of connection to the person they have lost, often by continued communication with them. This is only problematic when it becomes part of the excessive avoidance in prolonged grief.
4. Time for loss and time for life: when we are really consumed by grief, it can seem impossible to continue living as we normally do. My clients find it valuable to mark a difference between focusing on the loss, and focusing on their daily lives. Many of them make sure that they stay functional in their work and daily activities, and then also make time to focus on the loss. This is not always clean and easy, but becomes easier over time.
5. Don’t judge your feelings: There is a common mistake we make in judging our feelings, which only serves to make our lives more difficult. In grief, above anything else, it is very important to allow whatever feelings emerge, the space to breathe. They don’t necessarily need to be expressed or felt for long periods of time, but allowing them to be valid in your own mind will go a long way toward relieving tension and helping you stay on track toward healing.
6. Basic coping: there are all kinds of other strategies to use in dealing with the specific feelings as they emerge on a day to day basis. Check out my post on “Building a Coping System” for more.
Emotion Suppression: There are a number of classic psychological theories that view suppressing emotions a negative thing that will impact us in another way, or later in life. It is important to know that there is no research evidence that this is actually true, and for many people, suppressing emotions can be adaptive and help them move on and keep functioning.
I Should Feel…: Another common issue in grief is when we feel differently than we might have expected once a loss happens. When someone dies or we have another type of major loss, we would expect to feel devastated or emotionally moved, but many times we don’t. This is made worse when people in our lives suggest that we should be upset about something, or express that they are concerned because we are doing well. This can happen the other way as well, where we may not have expected to feel moved by something, but we do. An additional fear people have is that they must be “in denial” or that something is wrong with them for not feeling the way they thought they would, or the culture expected them to. However, since grief is such an individualized process, and each of us will have unique circumstances around losses, the key is just allowing your emotions to be what they are.
Unanswered Questions: When there are circumstances around a loss that we do not understand, we usually have an inclination to get the information and answer the questions. This can become painful when we ruminate or obsess about the questions. Sometimes I help clients do as much hypothesizing and information gathering as they can in an effort to get as close to the answers as possible, and move their understanding forward. Other times, either the information will never be known, or the person is not interested in that quest, and then the task becomes making peace with not knowing.
Helping Others in Grief
This is complicated because unless we know what the person who is grieving wants from us, we can become afraid of saying or doing the wrong thing. I have noticed that the type of help we default to is the type of help we would want if we were grieving, rather than what the other person actually wants. Given that, I encourage people who are grieving to share their wants and needs with the people in their lives, which can really reduce the chance of awkward moments and misunderstandings. Otherwise, I have a previous post that gives a lot of different ways we can help others (link). Additionally, research shows that most people grieving prefer that others:
1. Express condolences and sympathy
2. Ask them about the circumstances of the loss
3. Check in on them rather than waiting for them to reach out
4. Make plans to get together
5. Give hugs
6. Avoid saying the person should be “strong”
7. Avoid minimizing by suggesting it is “for the best”
It is very likely that 10 years from now we will have an even better sense of how grief works, and also what works to help people move through it in healthy ways. Counseling has been shown to be beneficial for people going through acute or prolonged grief.