Bereavement and Grief: Overview and Definitions

By Tom Smith, Ph.D.

 

“Love Never Dies”

Bereavement and grief begin before the death of the loved one. One cannot be bereaved or grief stricken unless one has loved. The only way to avoid grief is to avoid loving another person. Think of the alienated character Meursault in Albert Camus’ novel, L ‘Etranger (The Stranger). He attends his mother’s funeral and expresses no emotion. Why does he not grieve? Later in his life he is to be executed for murder and is remorseless. He does not know or cannot love. So, to love is to sign up for suffering and grief.

Grief is one the most, some say THE most, powerful and isolating human emotion shared by much, but not all of humankind. It is very, very difficult to share time and space with a grieving person or even to be with our own grief. It is the Great Pain of the highest order. The beloved is now free and we are bereft and left with a plethora of competing emotions. We find ourselves in a strange world that does not seem like it will ever be the same (It won’t). We can choose though, how we face the situation: With life affirming purpose or a belief that life has no meaning or point and then sink into a cowardly approach to living. On one hand, we can learn and grow from the experience and discover our heroic self and our loving, empathic community or submerge ourselves in anguish and surrender to guilt and self-loathing. We either can again embrace life or become a stranger to life.

Each person’s grief is unique to them. There is no method of dealing with it. We may try to deny it, ignore it, wish it away or pretend it is not there; but, sooner or later it emerges and we must feel it. There are no words to describe grief as there are for other emotions. Most of the time, we are unprepared for the strength and power of the feelings that can flood over us and catch us unawares. Grief is not a smooth transition from one stage of relationship to another.

In the immediate aftermath of the death, it can seem overwhelming. We go numb in order to get through the funeral rites, settle the estate and so on, but when everything is said and done and we are alone, this “Big Black Dog” appears that eats our appetite, consumes our sleep and makes us sick and tired. It seems to go in circles going around and then back again as if it will never end. We can find ourselves bursting out into tears at the most unexpected time. But, eventually, more often than not, the loss is accepted, we adjust to it and we reinvest ourselves back into life. This can take months and sometimes years. In the case of the death of a child or spouse, it may never really go away. The grief is always there, if you want to tap into it.

When our loved one enters hospice care, we and they begin the grief process. We start a psychosocial reorganization making practical and emotional plans for a world without this person and the dying person, if they are able, coming to grips with their mortality and leaving life and loved ones behind. We want to hold on to each other all the while knowing that we must let go. Living with the life-threatening or terminal illness of one’s self or loved one is an intense, powerful, traumatic experience filled with painful, negative emotions. Nevertheless, this time presents an opportunity to choose the attitude with which we want to frame the upcoming experience. Do we want to surrender to the fear of loss and the unknown or do we want to find some way to put joy into the process and embrace it with a sense of love?

Both the dying person and those around her or him have the chance to heal broken relationships, forgive anything said or done or what we have failed to do or say and resolve any unfinished business. It is an occasion in which we can review a life well lived or talk about what one hoped to do and now cannot, because the time together is almost over. Yes, it is a difficult time that is bittersweet. This is called anticipatory grief and can be complicated by the relationship we have with the dying person.

Is it our parent, spouse, brother, sister, aunt, uncle, nephew, cousin, lover, friend? Is the person facing death young or have they lived a long, full life? The nature of the grief process depends upon the relationship and how much we loved and depended upon the person. We may begin to detach ourselves from the experience or our loved ones, including each other to avoid the pain. Long-standing family dynamics play a great role in what occurs. In so many ways, we are grieving our own death. When we see another dying, especially a blood relative, we know that we are seeing ourselves die because we are of them or like them. We are mortal.

This aspect of grief is bypassed when death is not expected; for example, accident, murder or sudden death by heart attack or stroke. In these cases we are stunned and plunge headlong into acute grief.

Finally, the beloved dies. We may be there to witness the occasion. It is so very sad and yet, it also may be a time of relief. We may look at the body of the one we loved and see a great serenity and peace on their face that we may not have ever seen before. The world seems to come to a stop. We enter an altered state of consciousness. There are no words, just tears. We are bereaved; we are deprived of the loved one through a profound and interminable absence. They are gone.

Acute grief sets in. It is important to understand that whatever the circumstances of death, whether it is sudden or following a long drawn out illness, most people are never prepared to lose a loved one. Death almost always comes unexpectedly. Even at the death bed, when the last breath is drawn, we are surprised by the event and a wave of emotion washes over us. It is the end of a life, but not of the relationship.

Dramatic and disturbing reactions may occur that include denial, intense crying spells, anxiety, helplessness, irritability, impaired concentration, numbness, a sense that “it is not real” and sometimes visual and auditory hallucinations of the deceased. We may feel sick to our stomach, have headaches, cannot sleep or experience emotional outbursts that are out of character. This can be disconcerting and distressing to those around us; doctors, caregivers, relatives, friends and neighbors who are helpless to remedy the situation. We may feel angry or guilty that we could not have done more. Really, at this time, all we can do is be present to the situation and each other and acknowledge the loss. We must give ourselves permission and time to go through what we must go through.

If the death is sudden and unexpected, as noted above, acute grief sets in immediately and is a great shock that intensifies and confuses the above reactions. These feelings emerge when we are touched by the death of a revered person or persons: the President, the Pope, local police, firefighters or soldiers who die in the line of duty. It may also be a noted teacher, scientist, artist, musician, actor, philosopher, environmentalist or peacemaker. These deaths touch the collective and we as a society feel a shared grief. Who can forget their feelings when John Kennedy, John Paul II, the Challenger crew, Martin Luther King and John Lennon died and those who perished in the multiple disasters of September 11, 2001 or local heroes who gave their life in the service of the community or country in war?

When everything is finished, early bereavement sets in; ordinarily, this is considered to last about one month. During this time, it is important to continue palliative care of the survivors by asking about their feelings, if they have social support, if they are having any difficulties, how are they coping and reassuring them that grief is normal and takes time. It is also a good to ask about the customs, beliefs and cultural norms of the family that surround death, bereavement and mourning.

As bereavement continues into the next couple of months, it is prudent to assess the progress of mourning and to identify any depression, or need for counseling or psychopharmacological intervention. Normal grief can last up to a year with surges of emotion that lessen as time goes on. Even though, feelings of sorrow can last for years and years. Festive occasions like anniversaries or birthdays can be particularly difficult as the absence of the beloved is felt.

As the first year unfolds, it is advisable not to go it alone, but to ask for help or find someone to talk to. The bereaved might need household help like shopping, cooking or cleaning or assistance in servicing the car or keeping up the garden or yard.

Support groups can be of great succor. The group, however, has to be tailored to the needs of the bereaved. For example, if parents lose a child, if a relative or friend is murdered or the person dies of cancer or AIDS, etc., there are specific groups that address the unique concerns of each particular population.

In any case, avoiding “shoulds” and “oughts” (like, “I should be over this by now” or others saying, “You ought to go out more often”), periods of solitude, rest, sleep and walks in nature can be very healing. Expectations of self and others are best kept within reason and lowered if must needs be. It is wise to postpone major life changes; for example, if a spouse dies, do not quickly sell the house, spend large amounts of money or immediately throw one’s self into a new relationship.

During this taxing time, we can find solace in renewing our spiritual life, opening up to the big picture of what is really important and seeking a new vision and realization of self that brings growth and development. For example, if the loved one died of a drunk driving accident or community violence, we might join or even start a charitable group that addresses the characteristic needs of their survivors. In this way, we can experience an almost visceral sense of the difference between our individual, suffering ego and the self we share with others. It is possible to transform our grief into relief and liberation from ossified points of view that erect opaque partitions between our self and those around us.

Protracted grief, unattainable consolation, great fatigue, insomnia and nightmares, physical illness, substance abuse, loss of interest in activities of daily living and what had ordinarily given the bereaved pleasure may indicate complicated grief, the delayed or incomplete adjustment to the loss, or the onset of major depression. This must be taken seriously for it may lead to substantial sickness or worse, suicide. Complicated grief may be difficult to identify because the grief experience varies greatly among individuals and cultures. In some cultures, it may be totally appropriate to wear black or rarely speak for a year or more. Some individuals are particularly vulnerable to complicated mourning: Confused elderly, persons with learning or developmental disabilities and children and adolescents, especially when a parent dies.

If complicated grief is diagnosed as opposed to major depression, a poor outcome can be anticipated if certain factors are present; namely, if the person is an elderly widower, he may die within 6 months of his spouse’s death or the death of a child may lead to a breakdown of the family system and/or the dissolution of the marriage. Also, if the death is stigmatic in nature; e.g., suicide, murder or a death that results in mutilation or the inability to find or claim the body, there may be feelings of guilt, shame or interminable suspension and lack of closure. If the family cannot follow their cultural customs, a sense of things being unfinished or that the soul of the deceased cannot rest may set in.

Complicated grief can be ameliorated by following cultural norms or repeated visits to the grave or memorial, all the while patiently and gently helping the individual to recognize the loss and confront the fact of the immutable separation. One can also take time to recollect and re-experience the lost relationship and value it and finally, accommodate to the new situation and begin the process of reinvesting in the future. Support for the appropriate expression of feelings by listening, continued interaction with family, neighbors and community, the provision for the physical needs of survivors, kind and caring physical touch and simply being available can go a long way in helping everyone cope with the loss.

Finally, if nothing seems to work, it is imperative that professional help, be it physician, psychiatrist or counselor, be obtained to prevent serious physical and mental deterioration or to preclude anyone having extended difficulty dealing with the death.

It is through the process of mourning that we are healed. When our suffering becomes too much, we must remember that we share the experience of loss with everyone, for it is common to all humankind. We do not have to mourn alone. We can reach out to those who love us and those who we love. In the words of St. Bernard of Clairvaux:, “We find rest in those we love, and we provide a resting place for those who love us.”

References

Camus, Albert. (1989). The Stranger (Matthew Ward translation).

Lynn, J. and Harrold, J. (1999, 2006). Handbook for Mortals: Guidance for People Facing Serious Illness. Oxford University Press.

Casarett, D., Kutner, J., Abrahm, J. (2001). “Life after Death: A Practical Approach to Grief and Bereavement.” Annals of Internal Medicine, Vol. 134 (3).

Zilberfein, F. (1999). “Coping with Death: Anticipatory Grief and Bereavement.” Generations, Vol. XXIII, No. 1.