The Complexity of Grief
Often times, grief is the reason people seek mental health services for the first time. Given that every person will most likely be touched by grief at some point in their lifetime, I thought it would be important to delve deeper into the topic.
In March 2022, the American Psychiatric Association released a text revision (TR) of the DSM-5, which was originally published in 2013. For those of you who are not familiar, the DSM is the Diagnostic Statistical Manual of Mental Disorders and serves as a common language by which mental health professionals communicate with one another, insurance companies, and clients. While there are certainly advantages in establishing labels and language around mental illness, the DSM has been criticized for its bias in determining what constitutes a diagnosable illness and what is considered “normal.” A complete review of the DSM and its past editions is out of the scope of this post. However, there was an addition to the DSM-5-TR that caught my attention: Prolonged Grief Disorder (PGD). With this post, I will discuss what grief is and what types exist, theories of grief and bereavement, and why it’s difficult to define what “normal” grief looks like.
What is Grief?
Grief can be defined as the pain and sadness that accompanies loss. Grief is typically associated with the loss of a loved one. However, grief can accompany many types of loss (e.g., job, relationship). Grief is often used interchangeably with bereavement. Bereavement is specific to the loss of a loved one. In the mental health field, grief, loss, and bereavement are all utilized. Grief is a fluid process that can look different depending on the type of grief that is being experienced. In the next section, I’ll go over types of grief.
Types of Grief
There are many types of grief a person can experience. In the following sections, I will summarize some of the more commonly known types of grief.
Normal Grief
As I’ll discuss later, normal grief is extremely difficult to define. Who’s to say what’s “normal” when it comes to grieving? At the start of the grieving process, it’s natural to be flooded with many different emotions: despair, loneliness, shock, anger, fear, etc. Ideally, a person would be able to make peace with their loss in some way of acceptance and meaning-making within months after suffering from the loss. Additionally, intensity of feelings and symptoms would gradually decrease.
Anticipatory grief
This type of grief is usually experienced when a person is aware of the impending death of a loved one. Many people experience anticipatory grief when a loved one is diagnosed with a terminal illness. In contrast to a sudden loss, anticipatory grief allows for the individual to somewhat prepare for the loss that will soon occur. However, many conflicting emotions can arise as the individual desires to be present with their loved one while simultaneously feeling sadness, confusion, or anger over their upcoming death.
Complicated grief
Generally speaking, complicated grief is characterized by long-lasting and debilitating effects of experiencing a loss. Complicated grief is the basis for newly added Prolonged Grief Disorder (PGD). According to WebMD, symptoms of PGD include the following:
Feeling as though part of you has died
A sense of disbelief about the death
Avoidance of reminders that the person is dead
Strong emotional pain related to the death
Difficulty moving on with your life
Emotional numbness
Feeling that life is meaningless
Extreme loneliness
Delayed grief
Delayed grief is what it sounds like: experiencing symptoms of grief after a certain period of time. This can take days, weeks, or months. Delayed grief is common in situations where the loss was unexpected and shocking. Feelings of denial and dissociation can take over in the immediate aftermath of the loss. After some time, however, those feelings subside and reality kicks in, initiating the start of the grieving process.
Disenfranchised grief
Disenfranchised grief occurs when a person isn’t given the proper space or adequate emotional support from others during the grieving process. Others may not see this person’s grief as legitimate and may question their grief. Emotional support is especially important during the grieving process. This type of reaction from others can lead to feelings of loneliness and hopelessness.
Collective grief
Collective grief occurs when a community collectively experiences loss typically as a result of some kind of large-scale traumatic event. Examples include natural disaster, death of a public figure, or mass shootings. What’s important to note about collective grief is that a person doesn’t have to be directly impacted by the event to feel grief.
Inhibited grief
Inhibited grief occurs when an individual represses their emotions surrounding a loss, which leads to somatic symptoms such as loss of appetite, fatigue, etc. Because the individual may intellectually feel okay, they may not realize that these physical symptoms are a result of unprocessed grief. In any grieving situation, it’s important for individuals to find ways to heal and process their emotions surrounding the loss.
Absent grief
Absent grief is similar to inhibited grief but lacks physical symptoms. It is typically characterized by a strong feeling of denial. Those who experience denial in the aftermath of a loss essentially avoid experiencing natural feelings related to grief. This avoidance can only last for so long, however. At some point, absent grief may turn into either inhibited grief and/or delayed grief.
Models of Grief
Since grief differs drastically from person to person, it’s difficult to fit all experiences into one clear model. However, there are a handful of theories that attempt to explain what a person may go through during the grieving process. The following sections briefly describe these theories.
Kubler-Ross’s Five Stages of Grief
Elisabeth Kubler-Ross’s theory is the most well-known model of grief but is often misunderstood. Stage models often portray a neat, linear process. However, the grieving process is anything but straight-forward. The following stage model is a helpful framework for understanding the process someone who is grieving may go through, but keep in mind that it is not set in stone:
Denial
Anger
Bargaining
Depression
Acceptance
Bowlby and Parke’s Four Phases of Mourning
John Bowlby made significant contributions to the mental health field through his development of attachment theory. Attachment theory is a theory of development that emphasizes the caregiver-child relationship. In regards to grief, Bowlby and British psychiatrist Colin Murray Parkes identified four phases of mourning:
Numbing: feelings of numbness arise in the immediate aftermath of a loss as a self-protective measure
Yearning and searching: longing for the deceased person and experiencing intense emotions
Disorganization: withdrawing and disengaging
Reorganization: identifying a new “normal” and recalling positive memories of the deceased
Wolden’s Tasks of Mourning
William Wolden’s model of grief emphasizes taking an active role in engaging in four tasks of the grieving process. These four tasks include:
Accepting the reality of the loss
Experiencing the pain of grief
Adjusting to an environment where the deceased is missing
Finding an enduring connection with the deceased while embarking on a new life
Silverman and Klass’s Continuing Bonds
Phyllis Silverman and Dennis Klass set aside the stage/phase models of grief. They proposed that grief is a continuous process that consists of maintaining bonds with the deceased loved one. In other models of grief, continuing a relationship with a deceased loved one and coping adaptively appeared to be mutually exclusive. Silverman and Klass’s model challenged that notion by promoting the idea that continuing bonds with the deceased can be utilized as a healthy coping tool for loss and adjustment. Silverman and Klass’s model seems to allow for more flexibility in the grieving process, making it more culturally sensitive as well.
Stroebe and Schut’s Dual Process Model
Margaret Stroebe and Henk Schut’s Dual Process Model of Coping with Bereavement takes a unique approach to explaining the grieving process. Instead of laying out tasks, stages, or phases, Stroebe and Schut proposed that individuals oscillate between being loss-oriented and restoration-oriented. In loss-oriented mode, a person may be focusing on processing emotions. In restoration oriented mode, a person may be focusing on moving forward and adapting to life without the deceased. The figure to the right describes the tasks associated with each mode.
How Do We Define “Normal” Grieving?
In providing information on the different types of grief and the models used to explain the grieving process, I hope to normalize whatever experience you or someone you know has had with grief. The truth is, grieving looks different for each person. There are so many factors that impact the grieving process: the timing of the loss, the shock of the loss, the type of loss, the quality of the relationship one had with the deceased, religious and spiritual beliefs, past experiences of trauma and/or grief, societal expectations, and cultural practices, just to name some. Grief is complicated and painful as it is; feeling like your grief is “abnormal” just makes the healing process more difficult. I would encourage you to let go of any preconceived notions of what grieving “should” look like and allow yourself to experience your grief as is. If at some point, you feel like your grief is too much to bear, seek out professional help from someone who has some training and/or expertise in grief counseling. Diagnoses and frameworks exist to help us utilize a common language and help normalize certain experiences, but only you know what your internal experience is.
“Grief can be the garden of compassion. If you keep your heart open through everything, your pain can become your greatest ally in your life’s search for love and wisdom.”
Sources
https://www.healthline.com/health/mental-health/types-of-grief#prolonged-grief
https://whatsyourgrief.com/types-of-grief/
https://www.talkspace.com/blog/types-of-grief/
https://www.webmd.com/mental-health/prolonged-grief-disorder
https://www.mayoclinic.org/diseases-conditions/complicated-grief/symptoms-causes/syc-20360374#:~:text=This%20is%20known%20as%20complicated,paths%20through%20the%20grieving%20experience.
https://www.sth.nhs.uk/clientfiles/File/Theory%20of%20Loss%20%20bereavement.pdf
https://www.psychologytoday.com/us/blog/mental-health-nerd/201911/the-4-tasks-grieving
https://whatsyourgrief.com/grief-concept-care-continuing-bonds/
https://griefcompass.com/dualprocess
https://www.verywellhealth.com/the-four-phases-and-tasks-of-grief-1132550#citation-1
