- How we think about grief
- If we are suffering from loss, or if we are supporting others through loss, it is helpful to have some idea of what we can expect as ‘normal’ and what is considered ‘abnormal’.
- Last post we talked about different ways of thinking about grief and how research has conceptualized it as a process. While there are different ways of grieving and different ideas of whether we go through stages or phases—and if we do what these stages might be—what are common to all notions are the types of reactions we experience.
- This post covers the range of normal and abnormal reactions to loss, while the next focuses largely on depression in the grief process.
• our feelings and their expression—emotional (also called affect)
• our bodily processes and mechanisms—physiological or physical
• our thinking and thought processes including memory—cognitive
• the things that we do—behavioural
Together, these make up the richness of everyday life. I say together because our behavior is rarely anything but a combination of them.
Grief—A Unique Experience
When we look at grief, we see that this also brings about a number of complex responses. Our backgrounds, age, previous experiences, expectations, personality, genetics, and whether we are male or female—all these factors contribute.
What we notice is that we experience a cluster of responses which give us our unique experience. At any one time therefore, we will exhibit a range of grief responses, many of which are predictable even though our responses change as the course of our grief changes. Emotions so obvious in the first few days or weeks can give way to different emotional responses in the later months.
Listed below are the more common responses we might make during grieving.
Emotional Responses: sadness, anger, rage aggression, panic, feelings of hopelessness and helplessness, loss of pleasure, irritability, guilt, anxiety, relief, loneliness, feeling persecuted, resentment, embarrassment, jealousy, blame, self-doubt, lowered self-esteem, paranoia, fear, inappropriate emotional expression (nervous smiles and laughter), feeling out of control.
Physiological Responses: appetite changes, weight gain or loss, crying, increase in aches and pains, shaking or tremor, tightness in the chest, restlessness, rashes, eczema, stomach ache, shingles, lowered immune response, palpitations, hair loss, shortness of breath, exhaustion or fatigue, dizziness, headaches, sleep disturbances.
Cognitive: denial, altered perception of time or reality, hallucinations (of all senses), recurring or obsessive thoughts (also sometimes called ruminating), inability to concentrate, confusion, disconnected thoughts, errors in judgment, irrationality, rationalizing or intellectualiziing, thoughts or fantasies about suicide (not accompanied by concrete plans or behaviours), difficulty with memory.
Behavioural: social withdrawal, isolation, or alternatively over-engaging socially, “searching” for meaning (enrolling in courses, bargaining with God, trying different spiritualities), substance use or abuse, exercise, new projects, rejecting others, changing appearance, changing house or job, spending money, establishing rituals.
As already mentioned, different people manifest different clusters of these responses. When you look at this list of symptoms and think about patterns we can find, you can see how people have developed the theories and models we’ve talked about.
But because grief is so individual, any model of grief remains just that, a model, and it cannot represent us completely. It might though help us to understand how a normal process of grief might evolve so that we can also understand when normal grief becomes abnormal grief.
It is normal for people to experience the sudden trauma of loss, and then to feel better for a period, only to then deteriorate and become sad again. In terms of the process of grief, we usually call this a shock or numbness period, followed by a period of emotional upheaval, before we reach a time of resolution and acceptance. Let’s look at these in turn.
Shock and Trauma
Lasting from a few hours to days or even weeks is this initial period in which we feel shut off from the world, as if suspended in timelessness while the world marches relentlessly on.
We typically experience disbelief, shock and numbness, often with waves of distress. On many occasions we can feel aimless, easily upset and agitated. Appetite often changes as does sleep, and our thoughts can become muddled and illogical. Mourning rituals such as arranging for funerals can be a useful form of structure during this time, and other people tend to take some of this burden. Once the mechanical details have come and gone, say two weeks after a bereavement, the numbness can persist. Unfortunately it is usually at this time that social support drops off.
There is a real lesson here for those of us who watch people mourn the loss of a loved one. We need to take notice of the fact that the need for care and encouragement is ongoing – we need to be sensitive to the new situation that our friend or loved one brother or sister continues to face.
At some point the disbelief begins to falter, and the numbness wears off. Other things have continued as normal and now the reality of the loss becomes obvious and real. Some researchers call this time a period of confrontation, and it is during these weeks and months, when the feelings of loss are the most intense, that we are also the most alone while we endeavour to come to grips with the loss and the change it has wrought in our lives.
As the day-to-day reality sinks in and the new situation we find ourselves in becomes starkly obvious, a general pattern emerges which might include one or more of the following: restlessness, lowered mood, fatigue, guilt for the loss or for surviving, anger at or envy of others united with loved ones, sad appearance, difficulty concentrating, social withdrawal, sleep and weight disturbances.
When we enter this last period we’ve usually come to terms with our loss in some way, and we can now develop a more thorough and grounded acceptance. This can be a gradual process, up to a year or more in many cases, where we find that the intensity of our feelings lessens and we gradually adjust to our new life. This is not to suggest that we might not experience setbacks and many of the symptoms of the previous period, but these too diminish in intensity and frequency. Now, we accept the loss and can, in modern parlance, “move on”. At this point, modern theorists would suggest that we have completed the grieving process.
Well that’s the neat and tidy bit.
When Grief Lasts Too Long …Or Is Too Intense
At 76 Mary is a healthy, active woman. Sadly though, she lost her husband to cancer 11 years ago. Every night however, she sets the table for two, cooks for two, and eats her dinner while waiting for her Doug to come home. He never does, and every evening she disposes of the uneaten dinner, reads for a bit in her chair and heads off to bed. She gets Doug’s pyjamas out, puts his slippers where he liked them and leaves a glass of water on the table by his side of the bed. How would you attempt to understand Mary’s actions? Has she adjusted to life without Doug? Is Mary, as we would like her to be, “over it”?
By contrast, Allan is a 45-year-old lecturer in business studies. He is happily married with two sons. Four years ago, while reversing down his driveway, Allan drove over his three-year old daughter. She died on the way to the hospital. Allan was with her in the ambulance as she died. From the outside looking in, Allan seems to have picked up well, returning to work and having no apparent mood problems. His family does not blame him for what happened, but as he says “they don’t have to live with it”. He still drives, but at work is unable to park in the staff car park because to get there he must drive over four speed humps. Instead, he parks on the road and walks the rest. Is Allan, as we would like him to be, “over it”? Is what he is doing “normal”? Does the idea of normality have any currency here? How could we have helped?
Magnified and Prolonged Symptoms
Grief is typically viewed as a normal, though intense, form of sadness; some would say passionate sadness. However, grief can at times cause extreme or prolonged problems as the sadness evolves into serious disorders of anxiety and depression.
In the last blog we talked about this form of grief complicated grief and it’s here that depression and anxiety most commonly become severe and persistent. Along with the schizophrenia type disorders, anxiety and depression make up the bulk of referrals to psychiatrists and clinical psychologists. In mild cases of anxiety or depression, only low levels of professional help may be needed, as it is normal to experience some depression and anxiety.
It is important to recognize when these are occurring, and when they can become severe and abnormal. In short, when these reactions significantly interfere with the everyday functioning of the particular person as we knew them before grief overwhelmed them, and has noticeably been continuing for six months or more after the loss, we could safely say this is unusually long for the reaction to persist.
If this occurs, it’s an indication that additional help or support is recommended. Usually many physicians will suggest medication or ‘talking therapies’ from as early as two to three months and sometimes earlier, if the level of disruption to one’s life is severe. The most salient characteristics to watch for are magnified and prolonged symptoms.
In the early days after a loss, our bodies respond with a barrage of stress hormones to assist us with the shock of the loss. All of our emotions seem somehow more intense and the pain can seem so breathtaking. Everybody understands that this is normal, and onlookers have no difficulty in understanding the keenness of the response.
Many people continue to experience grief symptoms for up to two years, but the symptoms change over this time and become less and less intense as time moves on. When however, time has moved on, but the grief response seems as raw and visceral as it was in the first few days, then we could with confidence suggest that something is awry.
Extreme reactions may include:
• feelings of overwhelming panic and/or frenzy
• feeling overwhelmed and incapacitated by fear and grief
• emotional numbness that does not go away
• persistent flashbacks, nightmares and intrusive memories
• going to extremes to avoid thinking about the loss, such as abusing drugs or alcohol, or becoming totally immersed in work, hobbies or exercise
• severe and persistent symptoms of depression which may include: significantly depressed mood most of the time, sleep disturbances, appetite change, loss of pleasure in usual activities, thoughts of or attempts at suicide
• maintenance of a fantasy relationship with the deceased, feeling that they are watching you
• lack of basic personal self-care
• magnified and prolonged symptoms
• unusual and alarming behaviour patterns
• breaking off all social contact
• continued disbelief in the death or loss
• inability to accept the loss
• radical lifestyle changes
• continuous yearning and searching for the deceased
It’s this smaller category of people who need special assistance. Fortunately there are some clues to help us think about complicated grief, and this requires us to step back from the process of grief, and to consider the people who grieve, for they too tend to gather in certain clusters.
We know already that people experience grief to a greater or lesser degree and this, too, can indicate how ably we cope over time. It is helpful then to place people on a simple continuum. At the left hand end of the continuum are those who display intense and severe reactions. At the other end are those who display little or sometimes nothing in the way of a grief response. All of us fall somewhere along the continuum.
The People Who Grieve
It was once thought that if we grieve intensely and severely early on, that this was condensing a longer period of grieving into a short time, and so we would be likely to be “over it” sooner; short and sharp versus long and gentle. Similarly, it was believed that those who display little in response are usually in denial, struggling to express their grief, need generous doses of therapy or medication or both, and are, therefore, abnormal. In reality, the reverse appears to be true. Intense reactions are, unfortunately, an indicator, at least in Western society, of things not going well.
Those who dwell on the loss, who constantly revisit it in their minds while experiencing intense and sometimes uncontrollable emotions are those most likely to develop complicated grief and its attendant problems.
Usually we have tasks to distract us or other people around us who can take our mind off the concentrated problem. Friends also help us to regain a sense of control and a sense of being productive. If we are unable to feel these things, we are more likely to become significantly depressed and possibly anxious.
What develops is the sense that in some way the loss has expanded and taken over the person, so that it’s as if they have lost their own life, rather than a loved one. They have so identified with the person’s death that they cannot wrench themselves free and relate realistically to the present. It is as if they have been swallowed up by death.
Loss involving sudden, violent events is also a strong indicator of the possibility of complicated grief, as is early depression. Sudden and violent deaths, for example by car accidents, generate trauma symptoms such as thoughts that dominate the mind and become all-consuming and beyond control. They intrude and become more and more persistent to the point where we lose the ability to manage them and finally end up being controlled by them.
People who are able to regulate themselves, by which we mean to have some control over when they might think about the loss, sometimes being able to put it from their minds, are those people who tend to be reasonably able to cope in the coming months of grief. This is the largest of the three groups and falls around the middle of the continuum. If some of this sounds familiar, you might recognize flavors of resilience and attributions.
In contrast is the last group, composed of people who tend not to show much in the way of grief symptoms at all. With these we would, in fact, do more damage by intruding, for we are presuming that they are in complete denial and need of help. While not a large group, they are clearly identified by their seeming lack of response to grief.
Running against conventional wisdom, (particularly that of the self-help section of your bookshop and most ‘pop’ psychology programmes), these people don’t need to “talk about it”, nor do they need to get in touch with their “inner child”, nor do they need to show their emotions. In the main, they have very good control, and can regulate their thoughts and feelings perfectly well, including in situations like this. This is not to say that they feel nothing, only that their response is low-level and managed well, independent of anything else. They may avail themselves of supports that are available but also know what is and what is not useful for them.
So here’s the take home bit
There a many ways we can respond to loss, and they tend to occur in clusters. Identifying the clusters and patterns has led to the theories we have today.
When we see too many for too long, then we know there are greater risks for those people, and they might need additional help. We’ll talk a little about a subset of this next time
But the people who display fewer symptoms, who really do seem to have got on with it, probably have, particularly is they have good self-regulation of thoughts. We’ll come back to them in a bit.
Impressive words to drop into the morning coffee chat
Symptoms, Shock and Trauma, Reality, Resolution, Magnified and Prolonged Symptoms
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