On Grief

In my 20 years of work in the palliative care and bereavement fields, it has become clear to me that the general public isn’t well informed about what to expect when we’re grieving. This can create problems for grieving people like:

• Experiencing pressure from others about your grief process and how you’re meant to do it, be it that there is an expectation to talk about how you feel when you don’t necessarily want to, or alternatively, you want to talk, but no one wants to listen.

• Platitudes (for example: ‘Everything happens for a reason.’, ‘Sometimes bad things lead to good things.’) can be a sign of people simply not knowing how to be around the bereaved. Encouraging someone to “move on” can become internalised, haunting the bereaved into becoming self-critical and feeling that they’re not moving on “quickly enough” or dealing with their grief “correctly.”

• The duration of the grief process confuses many. I have come across assumptions from anything from a week (!) to six months. The truth is that the timeline is very individual and tends to be significantly longer than most assume. In professional circles, one is considered ‘newly bereaved’ up until two years post-death. People are often shocked to hear this.

• The nature of the relationship with the deceased. The closer you were to the person that died, and the more entwined your life was with them, the more likely it is that you will have a strong response to it.

• How you handle your emotions generally. For example, if you don’t tend to have strong emotional responses to life events, it’s not unusual for this to be similar with a loss.

• Dealing with the deceased’s belongings and explicit or implicit pressure from others to dispose of them quickly. There is no right way of doing this; people’s ways of dealing with this are very individual. Some people feel happy to dispose of belongings the week after the funeral, whilst others hang on to them for years.

Most bereaved people that have come to see me tell me that they just need to talk. This implies that people willing to just listen, rather than being focused on giving well-meaning advice, are in short supply, which is a sad state of affairs - this probably reflects a lack of understanding in the community - which we can hopefully change with community information such as this blog.

Throughout much of the 20th century. The overall aim of the grief process and its timeline has been dominated by Sigmund Freud’s ideas. In his work Mourning and Melancholia, he used mourning to illustrate his ideas about melancholia, or what we would nowadays call depression. Central points are that the bereaved are meant to grieve within a certain, unspecified time frame, which, however, is not meant to be too long, and that people should ultimately arrive at a point of ‘acceptance’ of the loss following a process of ‘working through’. Acceptance is about coming to terms with the pain of the loss and ultimately investing our energies in new relationships. In Freud’s own words: “…when this work [of mourning] has been accomplished, the ego will have succeeded in freeing its libido from the lost object”, or in other words, ‘total relinquishment [of the emotional attachment to the lost person] is the goal of the mourner’.

Freud proposed that ‘grief work’ was a central task for the bereaved during this period. He left this concept rather vague, and it was subsequently defined as “a cognitive process of confronting a loss, of going over the events before and at the time of the death, of focusing on memories and working towards detachment from the deceased” (Stroebe 1992). In other words, the bereaved are meant to work through their grief for a certain period until they arrive at a point of accepting their loss, which enables them to put the relationship with the deceased behind them in order to invest their energies in new relationships.

From the 1990s, the notion that ‘grief work’, particularly its requirement that the bereaved emotionally confront the loss, has become more critically scrutinised (Wortman & Silver, 1989). The centrality of ‘grief work’ implied that anyone who didn’t engage in it would find themselves having undesirable or prolonged grief symptoms, preventing a healthy grief trajectory. However, more recent research has shown that this is not actually people‘s experience; people who didn’t display obvious grief symptoms did not necessarily have deleterious effects. In fact, bereaved people who didn’t show any strong signs of grief following the loss often did better than the ones who displayed significant responses early on.

Another blow for the grief-work hypothesis occurred in the 1990s when different grieving styles were identified, which were initially tied to gender roles. An instrumental style is said to be focused on coming to terms with a loss by doing things, whereas the intuitive style is more focused on emotional expression, thus corresponding with the ‘grief work’ idea. The truth is many people have a blended style incorporating both aspects (Martin & Doka 2000).

The prominent and surprisingly persistent model of grief, which Elizabeth Kübler-Ross first elucidated to the world in her 1969 book entitled On Death and Dying, proposes five stages of grief. This model has lodged itself into the cultural consciousness ever since. The problem is that the stages have frequently been interpreted too rigidly, meaning that if the bereaved are not going through the stages in sequence they may be told they have a problem - when there really isn’t one (Avis, Stroebe & Shut, 2021).

Fortunately, the field has moved on and developed other ways of thinking about grief which are more reflective of people’s actual experiences.

One significant shift is about the notion of ‘acceptance’ - the last stage of Kübler-Ross’ model. The assumption is that the bereaved has to reach a stage of acceptance as an indicator of having successfully ‘worked through’ the loss. Interestingly this was not even Freud’s personal experience who lost two of his own children. In a private letter to a colleague, Ludwig Binswanger, who had lost a son, Freud wrote: “we know that the acute sorrow we feel after such a loss will run its course, but also that we will remain inconsolable, and that we will never find a substitute.” (Freud 1929). The contradiction between Freud’s published work and his personal experience is at the heart of much of the discrepancy between professional attitudes and people’s lived experience of grief during much of the 20th century.

In 1996 the book Continuing Bonds put forward the notion that the connection with the deceased continues to live on in the bereaved long after their actual death. Its slogan ‘death ends a life, it does not end a relationship’ is an acknowledgement that the bereaved will continue to relate to the deceased after they’ve died. Prominent evidence for this, which most bereaved people are familiar with, is that the bereaved frequently talk to the deceased, go to the cemetery, do things in their memory and honour etc.

This contrasts sharply with Freud’s idea of letting go and making room for a replacement relationship. Since such an ongoing relationship has become normalised, the question has arisen when this is within a normal range and when too much preoccupation with the deceased becomes a problem. The jury is still out on this.

Another prominent and, to my mind, ‘experience-near’ new way of thinking about grief is the Dual Process Model of Coping with Bereavement (DPM). In essence, it proposes two stressors that the bereaved struggle with A “loss orientation” and a “restoration orientation”.

• “loss orientation” means that the bereaved have to spend some time dealing with memories, feelings, and experiences to do with the loss.

• “restoration orientation” suggests that they also have to deal with stressors to do with life relentlessly moving on, whether we like it or not. Examples of the latter are the demands that everyday life places on us, such as having to go to work or doing the household, looking after the children or elderly relatives etc.

The authors of the DPM propose that a healthy adaptation to a loss experience is an ‘oscillation’ process between these two orientations; at times, we need to focus on our loss and, at other times, on the tasks of everyday living. This acknowledges the benefits of avoidance as well as confrontation of bereavement-related or life stressors. Getting stuck in either one of them is seen as a sign of problems in the grieving process that may require professional assistance. In contrast, ‘grief work’ only focuses on the loss orientation and the benefits of confrontation over avoidance.

Grief can be a taxing and confusing experience for many people. Most people get through it with the help of family and friends. There isn’t a timeline with regard to how long you should be grieving. However, it is to be expected that the first year after the death will be hard for many people who lost someone close to them. Having said this, not experiencing any pain is not necessarily a problem, depending on your personality and the nature of your relationship with the deceased.

If you’re experiencing the following after a significant loss, it might be worthwhile consulting a professional:

• You’re unable to function, go about the activities of daily living, such as run your household, go to work, look after your children, engage with your partner etc.

• You’re consumed by overwhelming feelings of loss most of the time.

• You have suicidal thoughts and feel that life is not worth living without the deceased.

• You have a history of living with a mental illness and feel that, since the death, you’ve been getting worse.

• You experienced childhood trauma and now feel abandoned by the deceased and are unable to shake this feeling.

• 15 months after the death, you feel like nothing’s changed for you, or everything has changed for the worse.

Check yourself first, though: We can sometimes feel that nothing has changed when things actually have changed. Other people are often a better judge of that, so speak with someone that you trust and who you feel will be honest with you.

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References:

Avis K. A., Stroebe M., Shut H. (2021). Stages of Grief portrayed on the Internet: A systematic Analysis and Critical Appraisal. Frontiers in Psychology Vol. 12, article 772696

Freud S. (1917/1959). Mourning and Melancholia. The Standard Edition of the Complete Psychological Works of Sigmund Freud. Volume XIV

Freud S. (1929/1960). Letter to Binswanger (letter 239). In E.L. Freud (Ed.). Letters of Sigmund Freud. New York: Basic

Klass Dennis, Silverman Phyllis, Nickman Steven (eds.,1996): Continuing Bonds. New Understandings of Grief. Philadelphia: Taylor and Francis

Kübler-Ross E. (1969). On Death and dying. New York: Macmillan

Martin Terry & Doka Ken (2000): Men don’t cry… Women do. Transcending gender stereotypes of grief. Philadelphia: Brunner/Mazel

Stroebe M. & Shut H. (1999). The Dual Process Model of Coping with Bereavement: Rationale and description. Death Studies 23, 197-224

Wortman Camille & Silver Roxane Cohen (1989). The Myths of coping with Loss. Journal of Consulting and Clinical Psychology 57 (3)