Grief is the response to losing a loved one; it contains thoughts, behaviors, emotions and physiological changes. When the loss is permanent, so too is grief, but its form evolves and changes as a person adapts to the loss. People have natural ways of adapting to loss, usually with the support of friends and relatives, and everyone does it in their own way. You can think of healing after loss as analogous to healing after a physical wound. The loss, like a physical injury, evokes pain which can be very strong. Physical injuries activate a healing process. Loss does too. Wound healing can be delayed and so, too can the process of adapting to loss. When this occurs, grief can be pervasive and prolonged, dominating a bereaved person’s life with an undo influence on their thoughts, feelings and behavior.
Grief and Adapting to Loss
Acute grief occurs in the early period after a loss and usually dominates the life of a bereaved person for some period of time; strong feelings of yearning, longing and sorrow are typical as are insistent thoughts and memories of the person who died. Other painful emotions, including anxiety, anger, remorse, guilt or shame are also common. Activities are often focused on doing or not doing certain things to try to deal with the loss.
Adapting to loss entails accepting the reality of the death and restoring the capacity for wellbeing. Accepting the reality includes its permanence and the permanence of grief, a changed relationship to the person who died, and the many other changes that accompany the loss. Restoring the capacity for wellbeing includes a sense of autonomy, competence and relatedness so that the future holds possibilities for a life with purpose and meaning, joy and satisfaction.
Integrated grief is a lasting form of grief that has a place in the person’s life without dominating it or being overly influential in thoughts, feelings or behavior. This form of grief is usually bittersweet and can be helpful in learning and growing in life. When grief is integrated it mostly resides in the background, but it’s often activated on certain calendar days, life events or with unexpected reminders of the loss. This does not mean that a bereaved person has not adapted to their loss.
Prolonged grief disorder (PGD) is a form of grief that is persistent and pervasive and interferes with functioning. It’s characterized by persistent intense yearning, longing and/or preoccupation with thoughts and memories of the person who died, along with other symptoms such as identity disruption, a marked sense of disbelief, avoidance of reminders of the loss, intense emotional pain related to the death, difficulty engaging in ongoing life, emotional numbness as a result of the death, feeling life is meaningless because of the death, or intense loneliness as a result of the death. Prolonged grief continues to dominate a bereaved person’s mind. The future seems bleak and empty, and the bereaved person feels lost and alone.
Note: Most mental health training does not include information about prolonged grief. However, trainees may be taught that grief is most likely to be especially difficult when there was an ambivalent relationship to the person who died. This is a misconception. Instead, while it is possible that there was a conflicted relationship with the person who died, we find that for most people with PGD, their relationship was especially strong and rewarding.
Examples of grief “stuck points” that derail adaptation
Acute grief is a complex, multi-faceted experience that is often powerful and disruptive. Our initial reaction is to try to protect ourselves from the much unwanted consequences of the loss of a loved one. We do this with some automatic defensive responses, such as protest, disbelief, imagining alternative scenarios and engaging in experiential avoidance. In the words of John Bowlby, “When a situation occurs which we evaluate as damaging to our interests or to those of persons we care for, our first impulse is to try to rectify the situation. “ Loss p. 229
This way of responding is natural and can provide some temporary respite, but is not optimally effective in the long run. We previously labeled these processes as “maladaptive” or “dysfunctional”. While this is one way to look at the stuck points in grief, we have come to believe it is more helpful to understand them as a part of the natural grief process and to validate the tendency to experience them. Here are typical kinds of thoughts, feelings and behaviors that can become stuck points that can derail the process of adapting to a loss.
Thoughts and Feelings
- Disbelief or protest
- Imagining alternative scenarios
- Caregiver self-blame or anger
- Judging grief
- Survivor guilt
- Avoiding grief triggers
- Inability to move forward
- Inability to connect with others
Thoughts are typically counterfactual; its natural to second guess a loved one’s death, especially if it was sudden, unexpected or untimely; most people worry about whether they are grieving in “the right way” and many dread the future in a world without their deceased loved one and/or feel uncomfortable moving forward in a positive way. People with prolonged grief ruminate over these kinds of thoughts. Inadequate emotion regulation is another common problem for people with prolonged grief. Acute grief is typically highly emotional. Most people have a range of ways to regulate these emotions. They balance the pain with periods of respite, giving themselves permission to set the grief aside for a time. People with prolonged grief have trouble doing this; instead, they often focus on things that increase emotional activation. Behaviors are typically related to avoiding reminders of the loss and/or escaping from the painful reality. A bereaved person may try to feel close to the person who died through sensory stimulation and day dreaming about being with them – looking at pictures, listening to their voice, smelling their clothes, trying to recall what it was like to be together. Bereaved people are often inclined to avoid places, people or activities that hold reminders of the person who died. These behaviors are problematic when they become the only way of managing painful emotions. Regular routines including adequate sleep, nourishing meals, adequate exercise and social contacts may be disrupted, making emotions more difficult to manage.
- Brief Grief Questionnaire: Use this 5-item questionnaire if you think a patient might be experiencing complicated grief.
Webinars & Podcasts
- Grieving Those Lost From The Pandemic: Dr. Katherine Shear discusses how saying goodbye is even more complicated than usual with WPR and listeners call in to share about their loved ones who have died during the pandemic.
- Complicated Grief: Dr. Katherine Shear discusses grief with WNYC host Brian Lehrer and listeners call in to pay tribute to their loved ones who have died during the pandemic.
- Loss and Grief During the Coronavirus Pandemic: A conversation with Dr. Katherine Shear hosted by Columbia School of Social Work
- How the Discomfort of Grief Can Help Us: Recognizing and Adapting to Loss During COVID-19: A forum with Drs. Christy Denckla and Katherine Shear hosted by the Harvard School of Public Health
- COVID-19 and Complicated Grief: A conversation with Dr. Katherine Shear hosted by ADEC
- HEALING Milestones: What to expect from grief
- NHS Guidance for Providing Bereavement and Grief Support in the Context of COVID
- Supporting Individuals with Grief: Using a Psychological First Aid Framework
- APA Guidance for Healthcare Workers and Staff Exposed to Death and Dying
- Managing bereavement
- Grief-informed leadership
- Mental health tips
- Guide to mental health resources
- Mental health resources and helplines
- Stigma awareness
- Talking to children
- Finding the right words for children and teens
- Infographic on talking with children
- Helping teens manage pandemic challenges
- Grieving Is Hard. Grieving During A Pandemic Is Even Harder. (Julia Paskin, LAist)
- How to Grieve During a Pandemic (David Montgomery, Washington Post)
- My disability doesn’t shorten my life expectancy. Medical rationing might. (Jessica Slice, Washington Post)
- 6 ways to help loved ones grieving deaths during the coronavirus pandemic. (Siobhan Neela-Stock, Mashable)