Introduction
Grief can be termed as the intense natural emotion that completes our humanity and is very fundamental and a universal experience. People experience grief after the deprivation of loved ones or a sense of loss is very deep within them. Grief is interrelated to loss; the loss of a child, parent, or spouse greatly affects the inner identities of a person. This is the way they carry themselves, their personalities and all that around them (Keegan, Kilmartin & Hickey 2010, 25). In addition to this, grief stems out of a fear of the unknown, a fear of not knowing what the future holds after experiencing the loss.
Freeman (2010, 100) in his book, ‘Grief and loss: understanding the journey’, states that one can deduce that grief is an aspect of the response to loss that contains many different aspects, features, or qualities especially when loss of someone or something that had a tight bond to the person suffering the loss (Rubin 1999, 707). It does not only concentrate its effort and/or attention, particularly on the emotional aspect of humanity but also on the physical, cognitive, behavioral, social, and philosophical dimensions (Balk 1996, 367). Bereavement is often in reference to loss while the reaction to this loss is referred to as grief. This paper is going to look into grief and loss and the results of these. It will also look into how one can cope with bereavement (loss).
When experiencing grief, persons are well in their right to cry. This is a very natural and normal occurrence, in most cases healthy part of showing grief and coming to terms with the state of loss. It has therapeutic effects on the person suffering bereavement or loss. The study of mourning developed and initiated by Sigmund Freud opened up further and intensive research that led to its gaining recognition and prominence thirty years after it was first done. Researchers have carried out consequent studies that are now more than ever helpful to persons that are affected by loss (bereavement). One of the more important results of the upwelling of research on bereavement in recent decades has been the development of criteria for complicated grief, a disorder whose coherence, correlates and consequences have been subjected to increasing scrutiny (Geller, Rushton, Francomano, Kolodner & Bernhardt, 2010, 421).
This article will look at the stages in grieving, how to cope with bereavement and grief, the science behind bereavement and will also try to highlight legislation, policy documents, inquiry reports, some practical assistance guidelines and agency materials that may shed light on the full understanding of grief and loss/bereavement
Background to the study
As noted above, grief is experienced often as a result of the loss of a loved one or something very dear that had a close bond to the person(s) suffering the loss. In most cases, it is both exhausting and stressful as it is made evident through being shown and demonstrated very clearly on people’s emotions. At various points in our lives, people will all experience loss and grief – such as the death of a loved one, a divorce, or a family breakdown.
This paper focuses on how to identify the various stages of bereavement and suggests ways of coping with a range of experiences involving loss and coming to terms with the bereavement (Center for the Advancement of Health 2004, 490; Balk 1996, 56). To understand and know more about the subject, this article looks into and outlines the theoretical context for understanding loss, grief and bereavement and summarizes some of the recent questions related to the merits of bereavement intervention. This is done through understanding the seven stages into which grief is divided 1) shock and denial; 2) pain and guilt; 3) anger and bargaining; 4) “depression”, reflection, loneliness; 5) the upward turn; 6) reconstruction and working through; and finally, 7) acceptance and hope (Kubler-Ross 1973, 36).
Challenging issues interconnected to the above-mentioned concepts in the perspective of soothing anxieties or other intense emotions and provision of care are important to fully grasp the complexity or simplicity of grief and loss (Rando 1984, 102; Stroebe & Schut 1995, 69). These consist of how to assess the needs and provide support to families suffering bereavement, how much bereavement support to provide, ways to deal with the needs of patients and families from non-dominant cultural groups, and how to deal with concerns about bereavement, grief and bereavement in the context of dementia (Schut, Stroebe, Boelen & Zijerveld 2006, 764).
Shear, Frank, Houch and Reynolds (2005, 2605) in their work, ‘Treatment of complicated grief: A randomized controlled trial’ published in the Journal of the American Medical Association, state that it should be noted and a very vital aspect of understanding grief, is that it is not an illness in any way. Although, according to studies carried out it may be the route or direction that causes or brings illness symptoms such as stomach upsets and very difficult to endure headaches (Balk 1996, 76). Another physical effect would be loss of appetite and disrupted sleeping patterns which leads to weakening of the immune system all this is due to persons being in grief and trying hard to cope with and come to terms with the loss suffered (Neimeyer 2004, 488 ).
The type of loss and intensity of a loss determines the grieving period of a person and greatly varies from one individual to another. Therefore we can confidently note that no given time frame is fixed or set for someone to grieve and be okay by the end of the set period (Gillies & Neimeyer 2006, 41). Kubler-Ross (1973, 50-90) introduced the seven stages of grief widely known as the “Kubler-Ross model of the 7 stages of grief” in her book, ‘On Death and Dying’ and described the stages an individual goes through while grieving. It is in the background of this that grieving periods differ from one individual to another. “Those who have the strength and the love to sit with a dying patient in the silence that goes beyond words will know that this moment is neither frightening nor painful, but a peaceful cessation of the functioning of the body” (Kubler-Ross 1973, 245).
The Kubler-Ross Model- The 7 stages of grief
Kubler-Ross initially used this application on individuals suffering terminal illnesses, but later administered it to patients suffering disastrous personal loss (loss of a job, income, freedoms, the death of a loved one, divorce, drug addiction, the onset of a disease or chronic illness, and infertility diagnosis and so forth) and later developed it into a seven stage process that is significant in coming to terms with grief and loss. It does not necessarily follow a specific order nor do all individuals experience all the stages but they are able to go through more than two stages (Bailley, Kral, & Dunham 1999, 261). Kubler-Ross (1973, 39) states that “often, people will experience several stages in a “roller coaster” effect switching between two or more stages returning to one or more several times before working through” the whole process.
The stages of grief according to Bowlby’s theory on attachment would seem to underpin the basis for understanding bereavement (Bowlby 1961, 327). Bowlby (1961, 318 ) further presents a case where he puts forward an explanation for the common human tendency to develop strong affectional bonds. He views attachment as a reciprocal relationship that occurs as a result of long-term interactions, starting in infancy between a child and its caregivers. He suggests that grief is an instinctive universal response to separation.
Shock and denial: the initial reaction to the sudden loss of something an individual holds dear and has created a very tight bond with is “numbed disbelief”. This is followed by a denial of actual reality. Denial in a human being is more often than not a momentary defense mechanism to try and shut out reality. It later is replaced by shock and a heightening of unconscious awareness of those left behind to deal with the bereavement. Kristjanson and Lobb (2004, 60) in their research paper found out that it is very common to hear an individual saying “I feel fine,”; “this can’t be happening, not to me”. But in a real sense, they are not and are trying to lock out the reality from registering within them.
At this stage, shock is experienced as a self-defense mechanism that tries to ease the mind from the pain being experienced from loss (Datson & Marwit 1997, 131). An individual that is grieving more often than not, thinks that they are dreaming and do not usually want to accept or rather they refuse to believe reality (the circumstances that has brought grief to them). Determining the actual duration for this stage is not possible as different people respond differently to grief and simple tasks/decisions are no longer simple but rather very difficult to accomplish. Denial is most cases does not last long but passes on to shock which is indeterminable (Kubler-Ross 1973, 63).
Pain and guilt: when the shock starts to pass, an individual is beset with immense pain. It is considered the most completely disordered and out-of-control stage of grief. At this stage individuals easily give in to alcohol and drugs due to the strong feelings of guilt they accept to weigh them down. Individuals are over and over again overpowered by intense guilty feelings and feelings of shame and regret over certain actions they may have done that led to the situation. They may end up blaming themselves for being responsible for the loss (Center for the Advancement of Health 2004, 525). This is an important stage for an individual undergoing a period of grief to pass through. Usually, it is excruciating and almost difficult, unpleasant, and impossible to bear or tolerate, it is best advised that people undergoing periods of grief should let it come out and not try to avoid, hide or escape through alcohol or drugs. An individual constantly feels like their life is muddled, daunting and has no meaning at this stage (Kubler-Ross 1973, 97).
Anger and bargaining: anger comes in as a result of the injustice an individual feels has happened to him/her or they may pass on the anger to those around them that they feel are responsible for the bereavement. In addition to frustrations of not being able to counter the circumstances that led to the loss. It is necessary for individuals undergoing anger at this stage to seek anger management counseling (Lehman, Wortman, & Williams 1987, 224; Gillies & Neimeyer 2006, 61). On the other hand, the occurrence of anger is an indication that an individual is coming out of the grieving process/period. The previous stages are all inward but anger is expressed outwardly (Currier, Holland, & Neimeyer 2006, 411; Neimeyer, 2005, 25). Anger is compounded with bargaining which is more or less a situation where an individual blames others for the circumstances surrounding the loss. It is not always correct but the individual is in no state to accept reality and tries all they can to find solutions to the loss. Bargaining is almost close to guilt and is quite natural during the grieving period (Kubler-Ross 1973, 127).
“Depression”, reflection, loneliness: this is the stage where a period of extended sadness takes over an individual and is very normal during the grief process. Therefore one should be left to endure it and not talked out of it. Kubler-Ross (1973, 141) asserts that encouragement at this stage from outside forces is very detrimental to an individual trying to come to terms with a loss (Neimeyer 2004, 25). Despite it having a tendency to recur during the grieving process, this stage helps an individual to reflect on the times shared with the loved one lost. It becomes less as the anger stage passes (Kubler-Ross 1973, 174).
The upward turn: the stage at which an individual suffering loss and going through the grief period starts to adjust to life without their loved one. Their life is much more peaceful and more controlled as they have gone through a period of grief and are now coming to terms with the reality’s impact on their lives. The stage is characterized by lessening of the physical symptoms seen in the earlier stages of grief and lifting from depression.
Reconstruction and working through: the mind is now more responsive and alert and is now more or less back to its normal functioning state. This heralds a situation where an individual tries to seek practical and realistic solutions to tackle the life ahead without their loved one (McIntosh, Silver, & Wortman 1993, 818). An individual at this stage will be in the process of planning now for life on their own minus their loved one.
Acceptance and hope: Kubler-Ross (1973, p.45) in her book, ‘On Death and Dying’, explains that this is the final stage of the grieving process although Kubler-Ross states that the stages do not occur in any particular order. An individual after reconstructing and trying to find practical solutions is now ready to accept reality. It does not automatically bring about instant happiness or the state before experiencing the loss (Neimeyer 2005, 77). “Given the pain and turmoil you have experienced, you can never return to the carefree, untroubled YOU that existed before this tragedy” (Kubler-Ross 1973, 145). All the same, the person(s) are able to look forward to the future and plan for it. They now remember their loved ones, but not with pain and might even be able to experience newfound happiness and joy.
Grief symptoms
Grief comes laden with physical, and emotional in addition to the spiritual tumult. Things such as low energy levels within the grieving person; fatigue; headaches and upset stomachs excessive sleeping or pushing oneself at work make up the physical aspect of the symptoms (Bailley, Kral & Dunham 1999, 268). “Personality traits such as trait anxiety, depression, neuroticism, satisfaction with life and being emotionally fragile have been associated with the perception of the emotional burden. Females have also been shown to have significantly more psychological distress following bereavement than males” (Shear, Frank, Houch & Reynolds 2005, 2605).
These in most cases lead to illnesses. Emotional symptoms may consist of memory gaps; depression; euphoria; distraction or preoccupation; wailing; passive resignation and so forth. Whilst, when it comes to spirituality, most people in the grieving stages express their anger toward God. It is very important for persons undergoing grief to take good care of themselves (proper diet, exercise and rest) (Barry, Kasl, & Prigerson 2002, 449). Stroebe and Schut (1999, 200) show that each and every bereaved person is unique and will deal with a significant death in their own way; therefore there is no one right or wrong way to grieve. The challenge that faces practitioners each time we meet a bereaved person is to find what helps them best. This is so because it helps heal the body and brings about faster acceptance of reality (Baker, et al. 1997, 3).
The science of bereavement and Coping with grief and loss
George Bonanno, a renowned professor of clinical psychology, has conducted numerous and extensive studies on grief spanning two decades and his findings have been widely published in journals such as ‘Psychological Science and The Journal of Abnormal Psychology (Gillies & Neimeyer 2006, 48). His studies have cut across various dynamics and show subjects suffering from bereavement across cultures and not in the US only but also across the globe (Klass, Silverman, & Nickman 1996, 79). “Bereavement maladjustment has also been associated with baseline personality traits and the perception of caregiver problems” (Joanna Briggs Collaborating Centre for Evidence-based Multi-professional Practice 2006).
The subjects were widely spread in Israel, Bosnia-Herzegovina, and China and they showed the suffering of a myriad of causes such as terrorism, wars, and deaths of loved ones especially children, sexual abuse and so forth (Gamino, Sewell, & Easterling 1998, 345). “In bereavement research, the notion of ‘‘continuing bonds’’ is generally understood to denote the presence of an ongoing inner relationship with the deceased person by the bereaved individual” (Schut, Stroebe, Boelen & Zijerveld 2006, 765). “Low levels of social support have been shown to be predictive of short term bereavement distress contend that the nature of family support and functioning are key aspects of social support in influencing bereavement outcome and suggest that family units rather than individuals should be assessed for the risk of psychological morbidity after bereavement (Joanna Briggs Collaborating Centre for Evidence-based Multi-professional Practice, 2006).
The Centre for Advancement of Health (2004, 15) also indicates that social and emotional support may help to buffer bereavement distress. It is also widespread the perception that individuals’ outlook towards bereavement and coping with it is seen as a predictor of the outcome of bereavement “with those who rate their own abilities higher experiencing less emotional distress and improved psychological, physical and spiritual well-being” (Joanna Briggs Collaborating Centre for Evidence-based Multi-professional Practice, 2006).
Relevant materials to the study
Legislation
There is no specific reference to particular legislation that addresses grief and loss. But rather bereavement leave and benefits are usually discussed either between employers and their employees or between employers and labor unions representing employees. For example, the US does not have particular Federal employment or labor laws set down that are mandatory for an employer to provide bereaved employees with leave whether paid or not. It is all at the discretion of the employer to do what they deem right. According to the Family and Medical Leave Act (FMLA), one might be allowed about 12 weeks of unpaid leave to cater to a dying family member, but it falls short of actually granting bereavement leave. But although leave is not a requirement of law, most employers grant it plus benefits “one to three days off from work”.
Policy documents
There are numerous documents that are meant to provide reference to the understanding of grief and how to cope with it. They are particularly relevant to counselors, family members, colleagues and friends who are coping with persons undergoing grief. These policy papers are both relevant to service providers and people working or studying areas related to the well-being of coming to terms with grief.
An example of such is Donna Schuurman’s paper titled ‘The Club No One Wants to Join: A Dozen Lessons I’ve Learned from Grieving Children and Adolescents’ published in the Grief Matters: The Australian Journal of Grief and Bereavement, which talks extensively on how to go about tackling grief among adolescent children (Schuurman 2002, 5). Other examples of documents could include: the ‘Literature Review on Bereavement and Bereavement Care by the Joanna Briggs Collaborating Centre for Evidence-based Multi-professional Practice of the Robert Gordon University, Aberdeen Faculty of Health and Social Care (Joanna Briggs Collaborating Centre for Evidence-based Multi-professional Practice, 2006).
Practical assistance guidelines
Below is a guideline of how counselors, family members, friends, colleagues and others can follow or utilize to offer support to bereaved persons. This can be categorized in actions one can do without asking and those that a person has to ask first before doing them.
Neimeyer (1999, 70) suggests that actions that can be done without asking may include: sending cards or flowers, mowing a grieving person’s lawn, donating blood in case of emergencies, listening without giving advice, donating time/cash to causes that have an important effect to the person in grief, be available and offer support in an unobtrusive but persistent manner and so forth (Klass, Silverman, & Nickman 1996, 108).
Actions that should first get permission before being carried out could include: offering to stay with the grieving person in their home to help in receiving guests, taking phone calls or making food; offering to babysit; offering to be their personal driver.
Healey (2010, 58) suggests other actions may include: allowing an individual in their grieving period to express anger and bitterness as it helps them to come to terms with the situation; do not try to bring up stories of your own as this reduces them to a much lower status in a humiliating way; be patient, kind and understanding without being patronizing in addition to not claiming to “know” what they are going through; be able to realize that the loss is irreplaceable and undoable and that the process has to take place so as healing can be achieved; and do not force an individual to share what they are going through if they are not ready.
Continuing bonds
Continuing bonds are experienced where the bereaved still maintain bonds, ties, or connections with the departed. “Drawing primarily on qualitative research and cultural studies, advocates of the perspective of this continuing bond have focused attention on the frequency with which bereaved persons report an ongoing engagement with the memories and images of the deceased many months or years after the loss, and the apparently salutary function of maintaining this attachment” (Neimeyer, Gillies, and Baldwin 2006, 729).
Continuing bonds up to about the twentieth century was generally considered a normal part of the grieving process. On the contrary, after the twentieth century, the view proved to be stronger and in the position of greater influence and power that mourning held over the bereavement process (Derrida 2001, 72). It brought about the perception that the bereaved persons had to emotionally detach themselves from the departed. Sigmund Freud’s studies and work have greatly contributed to this later development in the perception of continuing bonds. This is evident from the 1917 paper Mourning and Melancholia by Freud (Freud 1917, 247).
Freud is of the opinion that, “from early childhood, most people have a need to be artistic” (Freud 1917, 255). He states that a “sense of loss enables an artist to see things differently” (Nigel, Gal-Oza & Bonannob 2003, 115). He further in his essay articulates the fact that “in the death process, the dead may or may not find a permanent rebirth, but one loses self-awareness and so achieves a temporary rebirth at least. In the mourning process, one must find rebirth. If they do not succeed, Freud states they enter a cycle of melancholia instead” (Freud 1917, 56; Klass, Silverman & Nickman 1996, 127).
According to Freud (1917, 56), the bereaved person is freed “from his or her attachments to the deceased”, and this made it possible for the bereaved to move on when the mourning period was through. They are now able to forge new relationships. Looking at Freud’s works that touched on personal losses in his life, one is able to deduce that he agreed, assumed, or implied, especially without being openly or officially expressed that the grief period was not a process that which old relationships were severed. On the other hand, his theory evolved on its own and took up its own shape and perception of the grief period. It stressed encouraging people grieving to leave the past behind and it is still widely observed in the twenty-first century (Derrida 2001, 45).
Further important development in grief theory has been provided by the work of Klass, Silverman, & Nickman, (1996, 107), where they have disputed conventional thinking that the purpose of grieving was the reconstitution of an autonomous individual who could leave the deceased behind and form new attachments, in other words, ’break the bonds with the deceased. Klass and his colleagues suggest that the purpose of grieving is instead to maintain a continuing bond with the deceased, compatible with other, new and continuing relationships (Klass, Silverman, & Nickman, 1996, 108; Rubin 1999, 700 ). Although the nature of the attachment bond between the bereaved and the deceased has been a focus of scientific theory for nearly a century, Klass, Silverman, & Nickman (1996, 111), argue that serious empirical attention to its role in bereavement adaptation is of recent advent. And that, service providers, families, colleagues and any person(s) that deal with people undergoing grieving should be aware of these.
Conclusion to the Results
Going through grief is hard and very excruciating to any individual who has gone through a loss of a loved one. The seven-stage process as seen is not necessarily followed in the order given but is a very vital and integral part of coming to terms with bereavement and grief. It is a process/mechanism of healing and an individual has to undergo it so as to become strong and deal with the reality at hand. It is a guideline for working and taking an individual from shock to eventual hope. People are different so the grief would be experienced differently across people and the stages might not all be experienced. Most models of grief suggest that the bereaved need to engage with their loss and work through it, so that life can be reordered and meaningful again.
Understanding Grief and loss are very important for service providers, students, workers, family members, friends and colleagues so that they know how to approach persons going through grief. It is also important for the grieving person themselves be able to have a clear understanding of how to cope with the grief and loss. Numerous studies in the interdisciplinary field of death, dying and bereavement studies have been carried out and their findings published in many publications over the last two decades or so.
This has led to more insight into the ever-deepening and widening phenomena of grief and loss and now people know more about how to cope with it. It has also resulted in the creation of a much better understanding and grasp of bereavement and grief as new methods, models, policy papers, legislations and practical assistance guidelines have opened up the world of dealing with bereavement and grief. Most practitioners will be familiar with the stage/phase theories in identifying cognitive, social and emotional factors.
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