Everyone deals with grief differently. Some cry for days, hardly taking a moment to care for themselves. Others laugh, whether nervously, or because they manage pain with humor. Others feel numb, and wonder why they aren't crying or laughing like the others.
Each of these reactions is normal—there's no right way to grieve. As therapists, our job isn't to force clients to pass through specific stages, to "let it all out", or to grieve how we would. Our job is to help our clients come to terms with their loss in their own personal way.
That being said, grief can become a problem. Grief can trigger dormant mental illness, bring back old traumas, or the grief itself might persist far longer than it should.
The goal of our psychoeducation guides is to help mental health professionals better understand a topic, while providing helpful language, metaphors, examples, and tools to easily impart this knowledge to clients. This guide will provide a basic education of grief as it relates to psychotherapy, including a look at a typical grieving process, models of grief, and relevant diagnoses.
What is Grief?
Grief refers to the thoughts, feelings, and behaviors connected to the loss of something important. It could be the loss of a relationship, a loved one, a job, an object, or anything else a person values. However, when we talk about grief, it's usually in the context of bereavement.
Bereavement refers specifically to the period of mourning after the death of a loved one. In this guide we will be focusing on bereavement, but the information can pertain to other forms of grief, as well.
The Process of Grieving
Before describing the "normal" process of grieving, we should note that what's normal varies wildly between cultures, individuals, and situations. The following information serves as only a small window into what one should expect.
For several months after the loss of a loved one, a person may experience symptoms of acute grief.
- Feelings of shock or numbness
- Intense distress occurring in waves of 20 to 60 minutes that often include physical and emotional discomfort, shortness of breath, and a tightness in the throat
- Sleep difficulties
- Loss of appetite
- Loss of sex drive
- Guilt associated with the deceased
- Poor concentration
- Intense sadness
Symptoms of Acute Grief
Although these symptoms are common, they are very intense. They usually do not warrant a diagnosis by themselves, as they are considered to be a normal part of the grieving process. However, there may be exceptions, and sound clinical judgment is required.
Typically, those who are grieving will still be able to experience moments of happiness. This differentiates grief from depression, where even brief glimpses of happiness are rare.
The symptoms of acute grief will generally begin to resolve themselves naturally. Over the course of several months, the sadness associated with grief will lose some of its intensity, and other symptoms will become less frequent.
As the deep wound of acute grief heals, integrated grief begins. During this stage, a person resumes normal activities as the pain of grief slowly subsides. This does not mean that the bereaved misses their loved one any less, or that the pain fully disappears. Instead, the bereaved has learned to integrate the loss into their life. They have found a way to stay connected with the deceased within the context of a new reality without their loved one.
Occasionally, the bereaved will fall back into acute grief (especially around significant events, such as holidays and anniversaries). This is normal, and does not represent a failure. It's simply another part of the process.
For many, integrated grief will be a permanent, normal, and healthy stage. The bereaved will continue to feel heartache for the rest of their lives, and they will never stop missing their loved one, but the symptoms of grief are no longer debilitating. They have made sense of the loss, and they accept its reality.
When a person fails to transition from acute to integrated grief, they may develop complicated grief. During complicated grief, the bereaved experiences symptoms of acute grief for years after the loss. Memories of the deceased continue to be frequent, deeply painful, and debilitating.
A person with complicated grief may become ashamed of their grief, and wonder why they haven't managed to recover. Other times, they feel that enjoying their life, or overcoming grief, is a betrayal to the deceased.
- The loss was unexpected or violent.
- The bereaved has a history of mood or anxiety disorders.
- The deceased was a child, or very young.
- The bereaved has poor social support.
- The bereaved experienced poor relationships, neglect, or abuse as a child.
Risk Factors for Complicated Grief
Psychotherapy can help those who are experiencing complicated grief. Typically, the goals of therapy for complicated grief revolve around overcoming obstacles to the normal grieving process, and to coming to terms with the loss.
A Metaphor for the Grief Process
Imagine acute grief as a deep and fresh wound. You feel intense pain, but that's part of your body's healing process. Without the pain, you might ignore the wound and let it fester.
As time passes, the wound slowly heals, and turns into a scar. This is integrated grief. The deep wound has closed, but the scar will always be there, raw to the touch.
Sometimes, our wounds become infected and fail to heal. This is complicated grief. The wound continues to cause immense pain, and only seems to get worse. At this point, professional help may be needed.
We suggest using the above metaphor of grief when clients have a hard time understanding how grief can be so painful, yet important. Understanding this concept will help to normalize the process for those who are frustrated by their own unrelenting grief.
Other Models of Grief
Because of the many unique ways that grief is experienced, no model of grief can perfectly describe every person's experience. However, learning about the various models of grief can help clients make sense of their own feelings, and learn that they are not alone in their experience.
The Tasks of Mourning
J. William Worden identified four tasks for successfully resolving grief. This model describes grief as an active process that individuals can work through, rather than a passive experience that happens to them. The tasks include accepting the reality of the loss, processing the pain of grief, adjusting to a changed world, and remembering the deceased while moving forward.
- Task 1: To accept the reality of the loss. Oftentimes after a death, survivors struggle to accept the reality of what has happened. They may also deny the significance of the loss. Accepting the reality of the death means coming to terms with the loss both emotionally and intellectually.
- Task 2: To process the pain of grief. This task involves confronting emotions, even painful emotions. This means recognizing you are experiencing pain, naming your emotions, and learning how to cope with them.
- Task 3: To adjust to a world without the deceased. After a loss, survivors must face a world without their loved one. This task involves making internal, external, and sometimes spiritual adjustments to the loss.
- Internal adjustments are changes to one’s identity. Survivors must ask themselves, “Who am I now, without my loved one?”
- External adjustments including taking on different roles and responsibilities. For example, a spouse who was previously responsible for childcare may now have to seek employment outside the home.
- Spiritual adjustments involve changes to a person’s worldview, beliefs, and assumptions. For example, someone who believes “the world is a fair and kind place” may no longer feel this way after a loss.
- Task 4: To find a way to remember the deceased while moving forward in life. This means keeping a place in your heart for the person you lost, while being willing to move on with your own life. This may also mean allowing yourself to be happy and to love again.
Mourning is not a linear process. The tasks are often completed in order, but not always. Also, a task may be revisited many times before it is completed.
The Two Styles of Grief
The ways that people grieve can usually be categorized into two basic styles: instrumental and intuitive grief. In reality, these styles exist on a continuum. A person might lean toward one or the other, but no one experiences exclusively one style.
|Instrumental Grief||Intuitive Grief|
Stereotypes tell us that men are instrumental grievers, and women are intuitive grievers. While men and women are more likely to grieve in these ways, there's significant crossover between genders. Many men grieve with the "emotional" style, and vice versa.
Five Stages of Grief (The Kübler-Ross Model)
Denial, anger, bargaining, depression, and acceptance. These stages make up what is perhaps the most well-known model of grief: the Kübler-Ross model. Each stage represents a common emotional response to significant loss.
- Denial: During the first stage, the reality of the loss is questioned. A person might believe there was some sort of mistake, such as a mixup, or an incorrect diagnosis.
- Anger: Those who are grieving may begin to cast blame, ask questions like "Why me?", or become angry with the deceased (e.g. "They were so selfish to take their own life!").
- Bargaining: The individual may attempt to bargain as a way to avoid the cause of grief. For example, after receiving a terminal diagnosis, they might plead: "I will eat healthier, I'll quit smoking, and I'll do everything right if I can just get better."
- Depression: During the fourth stage, the grieving enter a period of depression. They may lose motivation for living, isolate themselves, and enter mourning.
- Acceptance: The individual comes to accept the loss, although there may still be pain. During this stage there is a sense of calm, and a resumption of normal life activities.
The Kübler-Ross model is no longer supported by science as a valid model or predictor of grief. Not everyone experiences every stage of the Kübler-Ross model, and the stages don't necessarily occur in order. Imagine the stages as a very loose depiction of what a person may experience during grief. However, clients can often identify with these stages, which provides a valuable tool for self-understanding and introspection.
Diagnosing Grief and Bereavement
The diagnosis of grief and bereavement-related disorders poses unique challenges, and warrants special care. Because people who are grieving are expected to feel pain, it can be difficult to know when a client's symptoms have reached clinical levels. Some studies have found that the pathologization of normal grief can actually complicate the recovery process, and prolong negative symptoms.
When assessing a client who presents with grief, it's especially important to look beyond their immediate symptoms. Do they have a history of mental illness? How does their culture traditionally respond to grief?
Diagnoses related to bereavement usually fall under the umbrella of another mental illness, the most common of which is major depressive disorder. Complicated grief is not recognized as a diagnosis itself due to uncertainty whether it is a unique diagnosis, or a combination of other diagnoses.
Depression and Bereavement
The DSM-5 acknowledges that normal grief looks very similar to depression, yet does not always warrant a diagnosis. However, the manual goes on to state that grief can act as a catalyst for traditional depressive episodes.
The DSM lists several identifying characteristics that can be used to differentiate grief from depression. They include:
- Negative emotions associated with bereavement are usually focused on feelings of emptiness and loss related to the deceased, especially when triggered by reminders. During depression, these feelings are focused on an inability to experience happiness or pleasure, and are much more constant.
- A person who is grieving can still experience moments of positive emotion. During depression, these positive feelings are almost completely inaccessible.
- Sadness related to grief tends to steadily decrease over time (although there may be waves of worsening mood). During depression, feelings of sadness tend to be constant and unwavering.
- During depression, feelings of self-loathing and poor self-esteem are common. If these occur during bereavement, they are usually focused upon guilt about the deceased (e.g. not calling them enough, or ending the relationship on a sour note).
- If a grieving individual has thoughts of death, they are more likely to be in the context of joining their loved one. During depression, thoughts of death are focused on ending one's life due to feelings of worthlessness, or escaping the pain of depression.
Grief & Depression: Differential Diagnosis
Clinicians are urged to consider a client's history of mental illness and cultural norms related to bereavement, when differentiating between normal grief and a depressive episode. A history of past depressive episodes is a significant predictor of a new episode stemming from grief.
Persistent and Complex Bereavement DisorderBuried deep within the DSM-5, in a section titled "Conditions for Further Study", we find Persistent and Complex Bereavement Disorder (PCBD). The disorders in this chapter are not intended for clinical use due to a lack of research, but the information still gives us a good idea of what to look for in clients who are struggling with loss.
For an adult, PCBD presents itself as preoccupation with the death of a loved one 12 months after the loss occurs (for children, this preoccupation only needs to last for 6 months). Several other symptoms, such as a wish to die to be with the deceased, self-blame related to the loss, excessive avoidance of reminders related to the deceased, and feeling that life is meaningless without the deceased are also indicated.
Although PCBD has not yet been identified as its own diagnosis, it can be specified as a cause of Other Specified Trauma- and Stressor-Related Disorder.
Psychoeducation about grief is important for clinicians and clients alike. Without a proper understanding of grief, clinicians can over-treat grief that's healthy, or miss the warning signs when someone needs help.
The bereaved will benefit by learning that the pain they are feeling serves a purpose—it will help them heal. They are not alone, their grief isn't bad, and the process requires time.
Here are several helpful books if you would like to learn more about the treatment of grief:
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
2. Neimeyer, R.A. (2000). Searching for the meaning of meaning: Grief therapy and the process of reconstruction. Death Studies, 24, 541-558.
3. Versalle, A., & McDowell, E. E. (2005). The attitudes of men and women concerning gender differences in grief. OMEGA-Journal of Death and Dying, 50(1), 53-67.
4. Zisook, S., & Shear, K. (2009). Grief and bereavement: what psychiatrists need to know. World Psychiatry, 8(2), 67-74.