# Motivation and emotion/Book/2011/Grief

* Multimedia presentation (5 min)

## Overview

* To spare oneself from grief at all cost can be achieved only at the price of total detachment, which excludes the ability to experience happiness - Erich Fromm
Grief is extremely stressful and can have a massive impact on an individual’s daily functioning. Grief is common and it is likely that you will experience grief if you haven’t already or grief will affect someone close to you. Knowing how to effectively deal with personal grief and the grief of others can be difficult. The present chapter aims to provide a comprehensive understanding of grief, how to effectively manage personal grief and the grief of others.

## What is grief?

Grief is universal phenomenon that a can be thought of as any form of distress in response to loss (Howarth, 2011a). Grief is complex as it involves emotional, cognitive, physiological and behavioural manifestations. Grief is universal but its symptoms are not (Howarth, 2011a). People grieve for different lengths of time and in different ways as grief encompasses many emotions and its expression is unique to the individual (Howarth, 2011a). Grief effects people of all cultures and has been found to consistently effect people throughout history (Granek, 2010).
Often the words grief, bereavement and mourning are used interchangeably but they do have different meanings. Bereavement is grieving in response to the death of someone significant. Mourning refers to public displays of grief (Granek, 2010). Mourning is different cross culturally as it relates to cultural practices through which grief and bereavement are expressed (Stroebe, Hansson, Schut, & Stroebe, 2008). Mourning is related to the customs of a society as it is influenced by social context. Differences in mourning customs between cultures can be seen in religious funeral services (Stroebe et al., 2008).

## Theories of grief

[Provide more detail]

### Bowlby

John Bowlby is most recognized for his work on attachment theory and has used attachment theory to provide a biological explanation of grief (Stroebe, 2002). Attachment can be defined as a meaningful bond that is made with a significant something or someone and is important for maintaining relationships (Field, 2006). Bowlby thought that people formed attachments for protection and survival. An attachment relationship that serves a protection and survival function can be seen in the attachments made between mother and child (Mikulincer & Shaver, 2008).
Bowlby theorised that when someone feels threatened or distressed their attachment behavioural system is activated and they will seek protection and comfort from those who they have formed an attachment with. When a significant attachment figure dies or is lost the individual will experience extreme distress which Bowlby called separation distress (Mikulincer & Shaver, 2008). The individual fears life without their attachment figure as they can no longer receive support from them. The individual will experience grief until they become detached from their former attachment. According to Bowlby reorganisation happens when the individual accepts the loss and integrates the loss into their future (Mikulincer & Shaver, 2008). This model of grief has been criticised as not all individuals grieving styles follow distinct stages however stages are useful in informing people what is involved in the grieving process (Mikulincer & Shaver, 2008).

### Kübler-Ross

Swiss psychiatrist Elizabeth Kübler-Ross proposed a stage theory of grief from her work with terminally ill hospital patients (Krueger, 2006). Kübler-Ross’ theory of grief was used to explain the process of grief in terminally ill patients and their loved ones reactions to loss (Krueger, 2006). Kübler-Ross’ theory consists of five stages: denial, anger, bargaining, depression and acceptance. The theory has been criticised as it comes from Kübler-Ross’ Subjective experiences with dying people and the theory does not take into account individual differences (Retsinas, 1988).
* Kübler-Ross' Stage Theory of Grief
* Denial – when people first face loss they enter a state of denial which may last for months. In this stage of Kübler-Ross’ theory people are in shock and find it easier to deny the reality that they have a terminal illness (Bolden, 2007).
* Anger – after denial comes anger. The grieving person becomes extremely angry about anything and everything as they may feel it is unfair that they have been singled out. this stage can be difficult for carers or loved ones of the grieving person as they can become a target of the anger (Bolden, 2007).
* Bargaining – once the grieving person has passed the anger stage they enter a bargaining stage. Within this stage the individual realises that death is inevitable but pleads for more time and feels that they would do anything for more time. The individual bargains with doctors, their god or just with themselves. It is within this stage that any unfinished business or loose ends are dealt with (Bolden, 2007).
* Depression – the individual becomes depressed after they have taken care of unfinished business as they are starting to accept the inedibility of the loss. it is thought that the individual will experience reactive depression which refers to grieving losses that have already been experienced. After reactive depression comes proactive depression which is the grieving of future losses (Bolden, 2007).
* Acceptance – the last stage of Kübler-Ross’ theory is acceptance. The individual becomes detached and accepts the inevitability of death (Bolden, 2007).

## Trajectories of grief

A study was conducted by Bonanno et al. (2002) that aimed to identify the most common trajectories of grieving. Bonanno et al. used data from previous studies that had interviewed widows before and after their partners had died. Bonanno et al (2002) found five trajectories of grief.
* Trajectories of Grief
* Common grief – these people have low preloss depression, high postloss depression 6 months after loss but recover at 18 months after the loss (Bonanno et al., 2002).
* Stable low distress – these people have low preloss depression and low postloss depression at 6 and 18 months after the loss (Bonanno et al., 2002).
* Depression then improvement – these people have high preloss depression but low postloss depression at 6 and 18 months after the loss (Bonnano et al., 2002).
* Chronic grief – these people showed low preloss depression and high postloss depression at 6 and 18 months after the loss (Bonanno et al., 2002)
* Chronic depression – these people have high preloss depression and high postloss depression 6 and 18 months after the loss (Bonanno et al., 2002).

## Physiology and grief

Research by Kowalski and Bondmass (2008) have found that grief causes significant physiological change. Participants of the study were 173 widowed women who completed questionnaires relating to their grief. The women were asked if they had experienced any physical symptoms after the death of their partner. Results of the study found that the women reported having experienced pain, trouble sleeping, symptoms that required surgery, gastro intestinal issues and neural and circulatory problems (Kowalski & Bondmass, 2008). A similar study by Fogel (2007) found that grief and depression affect cardiovascular health.

## Types of grief

[Provide more detail]

### Normal grief

Grief involves complex emotions that affect people differently. Grief is subject to cultural variation and at times can be difficult to distinguish from Major Depressive Disorder (Howarth, 2011a). This makes it hard to define what normal grief is, but a defining feature of normal grief is reconciliation (Doughty, 2009). Reconciliation is achieved when an individual no longer grieves a loss and can move on with their life. To achieve reconciliation, it is thought that people must accept the loss, fully grieve the loss, make adjustments to their life, incorporate the loss into their self-concept, acknowledge that what was lost will not be a part of their future but rather a memory, find meaning from the loss to be able to move on and make new bonds in life (Doughty, 2009).
As grief affects people differently research suggests that there may be different styles of grieving that are shaped by personality, gender and culture (Doughty, 2009). Research proposes that individuals have adaptive grieving styles that influence their behaviour, cognitions and strategies used to deal with loss. Adaptive grieving styles are distinguished by how an individual outwardly expresses a loss and how a loss is experienced internally (Doughty, 2009). According to the adapting grieving styles theory, an individual’s grieving style can range between intuitive and instrumental grieving (Doka, 2002).
Intuitive grief refers to a greater expression of emotion as a result of the loss and a desire to talk about the loss. Intuitive griever’s outward expressions reflect their inner feelings (Doughty, 2009). Intuitive grievers feel sad and express their sadness through crying and talking about their loss. Intuitive grief is stereotyped as a female grieving style (Doka, 2002). Instrumental grievers do not display their emotions as intuitive grievers do because they do not feel the need to (Doughty, 2009). This may be because their grief is not experienced as intensely as an intuitive griever experiences grief. Instrumental grievers aim to control their emotions and may see their grief as a problem solving challenge (Doughty, 2009). People with an instrumental grieving style appear unaffected by loss as they do not express grieving related behaviours such as crying (Doughty, 2009). Instrumental grief is stereotyped as a male grieving style (Doka, 2002). The most common adaptive grieving style is a blended style that incorporates both intuitive and instrumental grief (Doughty, 2009).

### Complicated grief

Complicated grief is experienced by people who are unable to overcome grief (Strada, 2011). Their grief response is considered abnormal as it is persistent in its intensity and duration. It is thought that complicated grief arises as a result of deficits in emotional regulation (Gupta & Bonanno, 2011). The symptoms of complicated grief are similar to Major Depressive Disorder symptoms but can be distinguished by an individual’s extreme longing for what is lost, strong disbelief of the loss and feelings of loneliness and detachment (Strada, 2011). People with complicated grief also feel that their life no longer has meaning after loss (Strada, 2011). As complicated grief is different from Major Depressive Disorder it will be included in the next edition of the Diagnostic and Statistical Manual of mental Disorders as Prolonged Grief (Strada, 2011).

### Disenfranchised grief

Disenfranchised grief is when a person is denied their right to grieve. The individual still experiences grief but it is not socially acknowledged or validated (Doka, 2002). The grief is not acknowledged for many reasons, such as the nature of the relationship to what is lost is not socially acceptable, or the manner in which the individual mourns is not socially acceptable (Doka, 2002). Loss that is not socially acknowledged can include the death of a pet, the death of a unborn baby, a missing family member or friend, losing a job, having a family member on death row or losing property in a fire (Attig, 2004). When an individual’s grief is disenfranchised, society denies them a grieving role which limits their support networks and they are denied compensations such as time off from work (Doka, 2002).
It is important to understand that people can become attached to many things and any form of loss can cause someone to grieve. To help someone recover from loss, their grief needs to be recognised and acknowledged (Attig, 2004). Being empathetic and respectful towards someone’s loss is ethical and prevents their grief from becoming disenfranchised (Attig, 2004).
* Grief is disenfranchised when
* The relationship is not recognised – most societies consider family relationships to be the most important. Friendships and attachments to material possessions are considered less important (Doka, 2002).
* The loss is not acknowledged – societal rules decide what losses are significant and what losses are not (Doka, 2002).
* The griever is excluded – sometimes people are socially defined as incapable of grief. This can be seen in situations where a person has a disability or mental illness and is excluded from grieving rituals such as planning funeral services because their grief is not acknowledged (Doka, 2002).
* Circumstances of the death – the way in which a loved one dies can disenfranchise grief. People who lose a significant person in their life to AIDS, homicide or suicide feel stigma which prevents them from receiving full support (Doka, 2002).
* The way an individual grieves – grief effects people differently. Support is more likely to be given to people who have strong immediate reactions in response to loss than people who grieve later (Doka, 2002).

### Anticipatory grief

Anticipatory grief is grief that results from the knowledge of an impending loss (Cheng, Lo, Chan, Kwan & Woo, 2010). Grieving prior to a loss can be experienced by the carers of loved ones with a terminal illness or people who have a terminal illness (Cheng et al., 2010). Anticipatory grief refers to any loss that is anticipated, not only to anticipating death from terminal illness. Yet most of the research available on anticipatory grief involves people who are terminally ill and the effect anticipatory grief has on their families (Cheng et al., 2010).
Research has found that terminally ill cancer patients deal with many losses that are associated with anticipatory grief when they learn that they only have a certain time left to live (Cheng et al., 2010). Their losses include the loss of a future with friends and family, loss of hopes and dreams for the future, loss of cognitive functioning, loss of identity and role definition and the loss of independence as their cancer worsens (Cheng et al., 2010). Carers of people with terminal illnesses experience anticipatory grief as they fear the eventual death of their loved one but also experience loss related to the kind of illness their loved one has died from (Holley & Mast, 2010). Carers of people with dementia grieve the loss of the relationship that they had with the dementia sufferer as dementia symptoms worsen and affect cognitive and physical abilities (Holley & Mast, 2010). Caregiver’s anticipatory grief is also associated with the sacrifices, burdens and isolation that come with caring for someone with a terminal illness (Al-Gamal & Long, 2010).

## Grief in childhood and adolescence

Children experience grief but experience it differently to adults. Depending on the age of the child they may not understand that death is forever (Willis, 2002). As children develop they learn that some things are lost forever, can grieve previous losses that were not originally understood (Willis, 2002). Children grieve in bursts that are expressed behaviourally and emotionally. For children to effectively recover from loss they need a safe and stable environment and an adult who they can depend on (Himebauch, Arnold & May, 2008).
* Age and Grief
* 0-2 years – children under 2 years of age do not understand death and loss but do experience grief in situations such as when they are separated from their parents or carers (Himebauch et al., 2008). in accordance with Bowlby's attachment theory, when infants are separated from their parents or carers they will experience separation distress.
* 2-6 years – preschool aged children do not understand the permanency of death and loss. They do feel grief when they lose something close to them and will often feel that the loss was their fault. It is important to let the child know that they did not cause the loss and provide them with factual explanations (Himebauch et al., 2008).
* 6-8 years – primary school aged children know that death is permanent. They experience grief and may fear death. To help the child cope with their grief school teachers should be informed of the loss (Himebauch et al., 2008).
* 8-12 years – teenagers understand death as adults do and grieve in much the same way but may have trouble expressing their feelings. It is not uncommon for teenager to engage in risky behaviour to challenge their mortality. Grieving teenagers need freedom to spend time with their friends and supportive environment (Himebauch et al., 2008).

## Managing and overcoming grief

Grief counselling is a method used to alleviate peoples grieving and aims to help people grow from the traumatic experiences caused by grief (Altmaier, 2011). Most people will overcome their grief in time but for those whose grief appears to be chronic or for people with anticipatory grief, grief counselling is a useful treatment. It is thought that grief counselling creates a sense of hope for the future in the grieving client (Cutcliffe, 2006). By experiencing a caring human connection with the counsellor the client is able participate in a positive relationship. The counselling relationship is a stable relationship that provides the client with consistent support (Cutcliffe, 2006).
Another approach to managing grief could be writing about it. Research by Lichtenthal and Cruess (2010) studied the effect that writing about loss has on grief. The grieving participants in this study wrote for 20 minutes about their grief. Their writing focused on trying to make sense of their grief and trying to identify the good aspects of their life (Lichtenal & Cruess, 2010). The results found that spending time writing about the good aspects of their life after loss and trying to make sense of personal grief was effective in helping people adjust to life after loss (Lichtenal & Cruess, 2010).
For children to overcome grief they must be able to accept that what they have lost is gone forever. For this to happen they need to be informed of the facts surrounding the loss (Howarth, 2011b). Children need to be given time to grieve the loss and experience the pain that is associated with the knowledge that the loss is permanent. After children have grieved the loss the feelings of grief becomes less frequent and they can learn to how to live without what was lost and convert the loss into a memory rather than something that remains present (Howarth, 2011b). Specific factors that influence how children overcome and manage grief is the child’s age, the safety of their environment and stability and support of their caregivers. Children manage their grief better when they are supported emotionally by their caregivers and when they feel safe in their environment. If children grieve as a result of the death of someone close to them, they should be allowed to participate in rituals such as funeral services to help them overcome their grief (Howarth, 2011b).

## Conclusion

* Grief is any distress in response to loss.
* Grief is universal and effects people differently.
* The five most common trajectories of grief are: Common grief, Stable low distress, Depression then improvement, chronic grief and Chronic depression.
* It is thought that that people grieve because they experience separation distress when they can no longer make contact with what is lost.
* When faced with loss people will pass through the stages of denial, anger, bargaining, depression and acceptance.
* Grief causes significant physiological change and has been found to affect physiological health.
* Different types of grief include; normal grief, complicated grief, disenfranchised grief and anticipatory grief.
* Normal grief involves reconciliation and recovery from grief.
* Complicated grief is experienced by people who are unable to overcome grief.
* Disenfranchised grief is when a person is denied their right to grieve.
* Anticipatory grief results from the knowledge of an impending loss.
* Children grieve differently to adults. 2 year old do not understand loss, 2-6 year olds do not understand the permanency of death and loss, 6-8 year olds know that death is permanent and 8-12 year olds understand the permanency of death and grieve in much the same was as adults do.
* Ways to manage and overcome grief include grief counselling and writing about loss.
* Grieving children need a safe environment and support from their caregivers to be able to overcome grief effectively.