Grief

# Overview
Grief is a multi-faceted response to loss. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social and philosophical dimensions. Common to human experience is the death of a loved one, whether it be a friend, family, or other close companion. While the terms are often used interchangeably, bereavement often refers to the state of loss, and grief to the reaction to loss. Losses can range from loss of employment, pets, status, a sense of safety, order or possessions to the loss of the people nearest to us.  Our response to loss is varied and researchers have moved away from conventional views of grief (that is, that people move through an orderly and predictable series of responses to loss) to one that considers the wide variety of responses that are influenced by personality, family, culture, and spiritual and religious beliefs and practices.
Bereavement, while a normal part of life for us all, carries a degree of risk when limited support is available.  Severe reactions to loss may carry over into familial relations and cause trauma for children, spouses and any other family members: there is an increased risk of marital breakup following the death of a child, for example.  Many forms of what we term 'mental illness' have loss as their root, but are covered by many years and circumstances this often goes unnoticed.  Issues of personal faith and beliefs may also face challenge, as bereaved persons reassess personal definitions in the face of great pain.  While many who grieve are able to work through their loss independently, accessing additional support from bereavement professionals may promote the process of healing. Grief counseling, professional support groups or educational classes, and peer-led support groups are primary resources available to the bereaved. In the United States, local hospice agencies may be an important first contact for those seeking bereavement support.

# Stage theories and processes
Some researchers such as Dr. Elisabeth Kubler-Ross and others have posited sequential stages including denial, anger, bargaining, depression and acceptance, which are commonly referred to as the "grief cycle".  As research progressed over the past 40 years, many who worked with the bereaved found stage models too simplistic and instead began to look at processes, dynamics, and experiences common to all.  John Bowlby, a noted psychiatrist,  outlined the ebb and flow of processes such as Shock and Numbness, Yearning and Searching, Disorganization and Despair, and Reorganization.  Bowlby and Parkes both note psychophysiologic components of grief as well.   Included in these processes are:

## Shock and denial
Feelings of unreality, depersonalization, withdrawal, and an anesthetizing of affect.
Unable to come to terms with what just occurred.

## Volatile Reactions
"Whenever one's identity and social order face the possibility of destruction, there is a natural tendency to feel angry, frustrated, helpless, and/or hurt.  The volatile reactions of terror, hatred, resentment, and jealousy are often experienced as emotional manifestations of these feelings." (see the article entitled The Grieving Process by Michael R. Leming and George E. Dickinson)

## Disorganization and despair
These are the processes we normally associate with bereavement, the mourning and severe pain of being away from the loved person or situation.

## Reorganization
Reorganization is the assimilation of the loss of something or someone and redefining of life and meaning without the deceased.

# Risks
Many studies have looked at the bereaved in terms of increased risks for stress-related illnesses.  Colin Murray Parkes in the 1960s and 1970s in England noted increased doctor visits, with symptoms such as abdominal pain, breathing difficulties, and so forth in the first six months following a death.  Others have noted increased mortality rates (Ward, A.W. 1976) and Bunch et al
found a five times greater risk of suicide in teens following the death of a parent. Grief puts a great stress on the physical body as well as on the psyche, resulting in wear and tear beyond what is normal.

# Normal and complicated grief
Complicated grief can be differentiated from normal grief, in that, normal grief typically involves at least two of Elisabeth Kubler-Ross' 5 grief stages, though not necessarily in any order.  Complicated grief typically cycles through these 5 stages and then some, processing them out of order and often much more rapidly. Some people commit suicide to end the pain and suffering of grief.  Examples of complicated grief can often be found in those who have survived a suicide attempt (Hsu, 2002). While the experience of grief is a very individual process depending on many factors, certain commonalities are often reported.  Nightmares, appetite problems, dryness of mouth, shortness of breath, sleep disorders and repetitive motions to avoid pain are often reported, and are perfectly normal.  Even hallucinatory experiences may be normal early in grief, and usual definitions will not suffice, necessitating a lot of grace for the bereaved.  Complicated grief responses almost always are a function of intensity and timing: a grief that after a year or two begins to worsen, accompanied by unusual behaviors, is a warning sign, but even here, caution must be used; it takes time to say goodbye.
Complicated grief is usually grief where the story of the loss is in some ways difficult to tell.  Deaths such as suicides, murders, car crashes, and almost any other sudden and unexpected death can result in complicated grief simply because they leave people in such shock that they have great difficulty in integrating what happened into their reality.  A simple way to describe this is that there is something that keeps the person from being able to integrate the "story" of the loss and therefore it leaves the person struggling with an initial task of simply believing that the loss has occurred. Variables surrounding the death such as expectedness, naturalness, presence of violence, ambivalence, degree of attachment, and others play into the presence of complicated grief. All too often complicated grief can last for years and most people (friends of the mourner) will recoil when hearing that this sort of grief may still be present after several years.  This needs to be differentiated from the clinical problem of becoming "identified" with the grief where people are reluctant to release the grief due to the grief having become a static part of who the person sees themselves as being.  It takes a good therapist to be able to tell the difference.  It is sometimes very difficult for a layperson to tell the difference.  Use caution.  It is worth mentioning that many have found that EMDR can be very helpful with complicated grief particularly when the therapist is knowledgable about grief and trauma.

# Types of bereavement
Differing bereavements along the life cycle may have different manifestations and problems which are age related, mostly because of cognitive and emotional skills along the way.  Children will exhibit their mourning very differently in reaction to the loss of a parent than a widow would to the loss of a spouse.  Reactions in one type of bereavement may be perfectly normal, but in another the same reaction could be problematic.  The kind of loss must be taken under consideration when determining how to help.

## Childhood bereavement
When a parent dies, children may have symptoms of psychopathology, but they are less severe than in children with major depression (Cerel, 2006). The loss of a parent, grandparent or sibling can be very troubling in childhood, but even in childhood there are age differences in relation to the loss.  A very young child, under one or two, may be felt to have no reaction if a carer dies, but this is far from the truth.  At a time when trust and dependency are formed, a break even of no more than separation can cause problems in wellbeing; this is especially true if the loss is around critical periods such as 8-12 months when attachment and separation are at their height in formation and even a brief separation from a parent can cause distress. (Ainsworth 1963) A change in carers can have lifelong consequences, which may become so blurred as to be untraceable.  As a child grows older, death is still difficult to assimilate and that fact affects the way a child responds.   For example, younger children will find the 'fact' of death a changeable thing: one child believed her deceased mother could be restored with 'band-aids', and children often see death as curable or reversible, more as a separation. Reactions here may manifest themselves in 'acting out' behaviors: a return to earlier behaviors such as sucking thumbs, clinging to a toy or angry behavior: they do not have the maturity to mourn as an adult, but the intensity is there. As children enter pre-teen and teen years, there is a more mature understanding. Adolescents may respond by delinquency, or oppositely become 'over-achievers': repetitive actions are not uncommon such as washing a car repeatedly or taking up repetitive tasks such as sewing, computer games etc.  It is an effort to stay 'above' the grief. Childhood loss as mentioned before can predispose a child not only to physical illness but to emotional problems and an increased risk for suicide, especially in the adolescent period.

## Death of a child
Death of a child can take the form of a loss in infancy such as miscarriage, stillbirth or neonatal death, SIDS, or the death of an older child.  In all cases, parents find the grief almost unbearably devastating and while
persons may rate the death of a spouse as first in traumatic life events, the death of a child is still perhaps one of the most intense forms of grief, and holds greater risk factors.  This loss also bears a lifelong process: one does not easily get 'over' the loss but instead must assimilate and live with the death.  Intervention and comforting support can make all the difference to the survival of a parent in this type of grief but the risk factors are great and may include family breakup or suicide.  In the event of a miscarriage or abortion it is important for friends and family members to acknowledge the loss of the pregnancy, and not to attempt to minimalize the significance of a pregnancy that did not come to term.  Feelings of guilt, almost always unfounded, are pervasive, and the dependent nature of the relationship disposes parents to a variety of problems as they seek to cope with this great loss.  Parents that suffer miscarriage or abortion may experience resentment towards others who experience successful pregnancies.

## Death of a spouse
Although the death of a spouse may be an expected change, particularly as we age, it is a particularly powerful loss of a loved-one. A spouse, though, often becomes part of the other in a unique way:  many widows and widowers describe losing 'half' of themselves, and after a long marriage, at older ages, the elderly may find it a very difficult assimilation to begin anew.  Further, most couples have a division of 'tasks' or 'labor', e.g. the husband mows the yard, the wife pays the bills, etc. which in addition to dealing with great grief and life changes means added responsibilities for the bereaved.  Social isolation may also become eminent as many groups composed of couples find it difficult adjust to the new identity of the bereaved.  When queried about what in life is most troubling, most rate death of a spouse first, although the death of a child presents more risk factors.

## Death of a parent
Responses and reactions of older children or adults to the death of a parent. There is also an increase in awareness of one's own health and mortality.

## Death of a sibling
Responses and reactions of older children or adults to the death of a sibling.
There is a saying (Compassionate Friends} that if you have lost your parents, you have lost your past; if you lost your children, you have lost your future; if you have lost your spouse, you have lost your present; and if you have lost your sibling, then you have lost a part of your past, present and future.

## Loss of children through divorce or kidnapping
Responses of parents accepting permanent loss of children through the reality of the divorce system, or through kidnapping.  This loss differs from the death of a child in that the grief process is prolonged or denied because of hope that the relationship will be restored.  This is often not the case.

## Other losses
Many other losses predispose persons to these same experiences, although often not as severely.
Loss reactions may occur after the loss of a romantic relationship (i.e. divorce or break up), a vocation, a pet (animal loss), a home, children leaving home (empty nest), a friend, a favored appointment or desire, etc.  While the reaction may not be as intense, experiences of loss may still show in these forms of bereavement.