- How we think about grief
- Formal theorising about grief has only really taken place in the last hundred years, with concerted efforts made only since the 1960s. Since then, various formulations have emerged which are helpful in describing and explaining what happens and can help give us insight into what we may expect in reaction to loss.
- We talked in the last post, following the second major Christchurch earthquake, about the importance of understanding the sheer breadth of reaction to loss. While grief is an absolutely normal reaction to loss, its impact is unique, and our responses are as varied as the individuals that make them.
- What I’m going to do, then, is give you a bunch of background on some of the thinking around grief so that you can
- recognize this for yourself
- help others if you recognize it for them
- After that we’re going to take all of the thinking and shape it into some down-to-earth, really practical stuff that you can use. This is like squashing a textbook into a few blog posts so, to get us underway, this post is seriously long. Yeah, it really is. Otherwise I’ve got to chop it into bits that wouldn’t make as much sense, so, there you go.
- Naturally, if you’ve friends and family in Japan, thoughts with them too.
- A caution
- First off, I need you to understand that there is no neat and tidy, pre-packaged system of grief. There are various ways of looking at it, and I’ll give you some in a bit, but, for now, you need to accept some of the inherent messiness of the whole thing.
- I say this because, in the academic sense, models of grief are lovely on paper or in textbooks, but, in the thick of it, really can be hard to get your head around.
- While we might experience many of the same issues as other people, what’s different is the intensity and expression of each issue, the order in which we meet them, whether we meet them, how we approach each issue, and the coping strategies we develop—not to mention external factors such as support from family, friends and our wider social networks, including digital networks.
- Traditionally, we’ve packaged it in stages
- Conceptually speaking, using the idea of stages makes grief a much less shapeless entity by giving the process a structure of one form or another. The benefit is that we can identify whereabouts in the process or on the continuum we are and, thus, have some understanding of what is involved at a given point.
- Moreover, the thinking goes, we can also reasonably suppose what might come next and be more prepared for it. Here’s how it looks…
‘Stages of Grief’ Theory
For many years, the greatest proponent of a ‘stages of grief’ idea was Elizabeth Kubler-Ross who, in working with terminally ill people, noticed that there seemed to be a regular pattern for people diagnosed with a terminal illness. Her work was later applied to everyone enduring some form of loss – she thought it was a concept with universal application.
In brief, the stages proposed are as follows:
- Denial and isolation
Kubler-Ross ultimately concluded that there is no set order in which we experience these stages.
She suggested that Denial/Isolation were used by nearly all people in some form or other, but usually as a shocked response to realization or the news of a terminal diagnosis.
Isolation was likely to occur when people tended to avoid the grief of another person, particularly if that person is dying.
Anger is obvious as to meaning, but it is naturally expressed in different ways: at friends and family, at nursing and medical staff, and commonly at God.
Bargaining is often a brief stage and difficult to study because this is usually between the person and God (or whatever ‘higher power’ to which they ascribe the power of life and death), typically involving an attempted negotiation or plea for more time. Generally it takes the form of, “If I repent and promise to live a good life, would you please let me live longer?”, or postponing tactics such as, “If I could just live to see such and such then……”. This is extremely common even for those people without an organised faith.
Depression follows bargaining during which time we usually mourn for our loss. Mourning is simply the outward or public expression of grief. We can react in two ways, according to Kubler-Ross. Reactive depression is, as the name suggests, a reaction to past losses. By contrast, Preparatory depression is to be depressed about those things yet to come. Depression is covered in more detail subsequently.
Lastly there is Acceptance. For those people with terminal illness this consists of realising that death is inevitable. This is not necessarily a happy and contented period of waiting, although it can be. For those without terminal illness, this involves the realisation that their loss is permanent and requires sometimes significant life adjustments.
Kubler-Ross maintained that hope was an important aspect of all stages and was necessary for us to move through the stages.
Since its publication in 1965, this model has influenced experiences and expectations of grief probably more than any other and remains a popular version, despite its shortcomings. While it does provide a theoretical framework to aid our understanding of the grief process, it also tends to formalise what is an extremely subjective and individual event. Certainly, there is substantial appeal in a tidy system such as this which clearly identifies what should or could be happening.
Many people find it comforting to have a framework like this and it is rather nice to have a process so well organised that it predicts a beginning, middle and end for a situation which feels anything but organised if you’re stuck in the middle of it!
Unfortunately, ‘stage’ models, while attractive, tend to become prescriptive rather than descriptive, so that we get ‘right’ and ‘wrong ways’ to grieve, ‘rules’ for progressing through stages and often unrealistic expectations about what is involved, both for the person doing the grieving and their support people.
Stage models can really only paint a very broad picture, and tend to lose explanatory power when applied to individual cases. People do not move through these stages in an orderly fashion. Rather, they can hop about, in and out of stages, visiting some numerous times along the way. In addition, stage models tend to focus on the emotional component of grief, which ignores some other significant facets of the grief process. Cognitive (to do with thought) processes work in parallel, as do models considering behavioural reactions and physical reactions. All aspects must be considered.
Then we’ve got to find out what’s useful.
More Recent ‘Models’
While there are other stage models of grieving, they all tend to have a similar overall structure. As a rule, stage models suggest a broad period of disorganisation, followed by a period in which we undergo extremes (generally of emotion), followed by some form of resolution where we accept the new reality we have. We then move on with our lives. Kubler-Ross’ model is no different, but in more recent times other models have begun to focus on different perspectives.
In the same way as Kubler-Ross, they present a particular viewpoint on grief which is then applied to every situation. The goals of any model are firstly to describe what is happening, next to explain it, to predict behaviour then so that lastly we might exercise some form of control or influence over it. For it to have any kind of practical utility, a model of grief must meet these criteria. In real terms though, grieving is a multifaceted process, different for every individual and even within individuals depending on the loss. A combination of approaches is generally most beneficial.
A more recent construction of grieving sees it as a very active and involved process whereby we seek to reconcile the reality that was in place before our loss with the new reality that faces us. We are motivated to search for meaning and understanding. The simple premise is that we are bringing together two different worlds which usually results in some form of conflict.
Our goal—and this is a very goal-directed model—is to resolve this conflict so that our world is again understandable and stable. At times, this requires a shift in some of our thinking about ourselves. At others it requires a shift in how we view the world. Sometimes a combination is required. One of the great complications of this model is that we are seeking to restore stability and normality, but the ‘normal’ we experience now is not the normal of before. The paradox is needing a normalcy that is understandable, stable and predictable, while seeing and living in a world that is not.
This is a view of grief that sees it as highly active. Rather than being a model focused predominantly on our feelings, this suggests that we are much more involved in the grieving process. Grief is not something that happens to us, but something that we do.
One of the great benefits of a model such as this is that it can offer more control, since we are active participants in grief rather than passive recipients. One of the great costs is that it provides scope for others (and for ourselves) to tell us to become actively involved and assert control so that we can “get over it”—otherwise known as the “pull yourself together and get on with it” model, an approach which has rarely been useful.
Grief as an Illness
Many medical practitioners view the human being as an entity that gets sick because one or more of our internal systems gets out of balance: too little iron gives us anaemia; too little serotonin gives us depression, and so on. There is a substantial body of evidence showing the ‘disease’ state that results when we suffer significant loss. Our immunological responses are suppressed, which is to say, we are more susceptible to other illness. We also tend to heal from injury more slowly, have various stress reactions, sleep worse than normal and so forth.
Thinking of grief through this lens also makes clear how we developed the concepts of normal and pathological grief. Because the medical model is focused on normal states (health) and abnormal or pathological states (illness) it is easy to see how this applies also to grief. The question that this begs, of course, is that unless we have some concept of what grief is and what normal is, how can we determine what pathological is?
The idea can only exist within this model, which must be developed first in order for us to have a contrast at all. Nevertheless, medical models do contribute a useful perspective, and for some people medical intervention by way of medication can be extremely useful in the early stages of grief.
Because what is normal depends upon a number of variables, not the least of which are gender, age and culture, most clinicians have abandoned the idea of pathology in conceptualizing grief, moving instead toward the idea of complicated grief. This allows for the notion that, while there may be a common range of responses to loss, there are also a number of complicating factors.
• Masked grief results in a condition where the symptoms of grief are experienced by people who don’t recognise or understand that these are related to a loss
• Exaggerated grief occurs when feelings of fear, hopelessness, depression or other symptoms become so excessive they interfere with usual activities of daily living and impair basic day-to-day functioning. This may worsen over time and result in psychiatric disturbances
• Delayed grief is when the grief reaction has been postponed, suppressed or inhibited
• Chronic grief is a reaction that is prolonged, of excessive duration and usually has no satisfactory conclusion. The bereaved person may know that they are grieving beyond what is considered ‘usual’ but seems unable or unwilling to resolve their difficulty
Interestingly, the DSM V (Diagnostic and Statistical Manual of Mental Disorders 5th edition) due for release soon, is likely to include complicated grief as a diagnostic category. This is the manual to which every psychiatrist or clinician (at least outside of Europe) must refer in order to diagnose mental illness. The insertion of complicated grief is a little contentious, but does show that the medical fraternity does recognise the possibility of grief itself being problematic.
While grief is normal and an expected part of life, how we actually come to grieve can make the grief process murkier and more confusing. If the loss is expected, such as death following a long period of illness, or indications of restructuring at the workplace followed by redundancy, then we tend to work through many of the associated issues in advance of the actual loss. Grief is more complicated when the event is unexpected and traumatic.
Traumatic grief is usually related to death and typically occurs when the death was
• sudden and/or violent, such as a workplace accident
• caused by other people, such as homicide, medical misadventure or car accident
• from natural causes but without a history of illness.
In more ways than other forms of grief, this can shatter those that are bereaved, as it is usually seen as a meaningless loss, from which we feel compelled to drag some kind of meaning. At some point we are forced to confront the reality that life is not fair and, yes, bad things do happen to good people.
Occasionally, because the loss seems so utterly senseless, one’s spiritual belief system can collapse, as it seems to remain silent on why this should have happened. Along with the issues of questioning the validity of one’s faith goes the possibility of abandoning it completely: another loss for the bereaved.
In the initial days, then the ensuing weeks, and months, the bereaved may cycle over brief time spans between periods of intense emotions and hypersensitivity to emotional flattening and numbing. The previous article provided a general guideline of up to two years for most people to come to terms with loss. When trauma is involved, it may be longer still.
Other complicating factors that make grieving more difficult are, for example:
• The death not being positively confirmed, in the case of a missing person
• Lack of a body
• Inability to view the body
• Near miss for survivors (such as those who live through a car accident when others die)
• Intense media involvement
• Death of a parent when you are a child or adolescent
• Deaths where the bereaved may be responsible
• Miscarriage or death of a baby
• Legal and financial complications and stress
• Deaths requiring a post-mortem or inquest
• Multiple deaths (such as a car accident)
• Re-traumatization by the judicial system
• Uncertain family security
• Being male
• Several previous bereavements
• A history of mental illness, such as depression, anxiety or previous suicide attempts
• A dependent relationship with the person who has died, or a relationship where you had troubled or negative feelings about the deceased
• Low self-esteem
• A lack of support from family and friends.
Grief as Tasks
Others consider grief to be a series of tasks, the completion of which are necessary for us to recover and form new relationships. One prominent view works through four of these tasks.
• Accept the reality of the loss
• Work through the pain of grief
• Adjust to the environment in which the deceased is now missing
• Emotionally relocate the deceased and move on
Subsequent to the completion of these tasks, grief is considered to be resolved. Others would argue that we don’t actually leave grief behind, but that we learn to incorporate the new situation into our lives. In this way the deceased is not left behind, but continues to be included in memories, celebrations, rituals and so forth. The relationship becomes transformed from the literal into the symbolic.
For all of us, grief feels different from anything we’ve experienced before, and different from what others have felt. Each loss is unique and within a unique set of circumstances. Each of us is unique. It stands therefore, that our grief is also unique. It is a confusing, complicated time where we need others and yet want to be alone, want be part of something and yet apart from everything because the life we have today is not what it “should be”.
It is different because of loss, and much of our emotion, confusion and struggle comes from trying to understand the loss and seeking to regain some control and predictability by re-establishing what “normality” now means. We don’t get over it, we adapt, and indeed tend to remain more in control by engaging with the emotions and thoughts we experience rather than avoiding them.
We also need to ensure that we consider the full range of responses we make in grieving. Many of the models of grief come from a particular bias and can be quite narrow, focusing only on emotions (stage models), some physical responses (illness models) and so on.
We must be mindful therefore to consider grief from multiple perspectives and to see them as descriptive rather than prescriptive. That is, they can tell us what might happen, but not set rules around how we react or what we do. Anger, isolation, and depression are normal emotional responses. Sleeplessness, weight loss or gain, and lowered immune responses are normal physical responses. In addition we have cognitive responses and behavioural responses and our strategies for working with grief need to account for many possibilities. How we respond in these ways is the subject of the next article.
We’ll cover this in coming blogs, as well as the following
- the various stages of the grief process (anger, depression etc)
- a two-part consideration of the components of reaction to stress (behavioral, emotional, cognitive and physiological). What is normal and what is abnormal? When should we seek professional assistance?
- some dos and don’ts of helping others who are grieving
So here’s the take home bit
Using stages to explain grief is a tidy way of explaining a messy process. While there are a number of ways of thinking about stages like this, they all have shortcomings and, importantly, can be hard to apply to real life.
Having a name for something doesn’t necessarily mean we understand it any better!
So, now that you’ve got a background to how the thinking has developed in the last few decades, next time we’ll start to get into some of the real nitty gritty.
Impressive words to drop into the morning coffee chat
Complicated grief, traumatic grief, Kubler-Ross
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