What is grief?

    Grief refers to the psychological reaction to the loss or bereavement. Grief is a complex process of de-attachment, and not simply an emotion. Over many years of a close relationship, our self-concept can become partially or sometimes fully defined by a relationship. Death of a long-term partner can force on us a sudden need to redefine ourselves. This is not an easy task.

    Grief is normal and occurs in stages. An initial reaction of shock and numbness is often followed by a period of yearning and searching for the loved one. As the death is gradually more accepted, this initially results in despair, disorganization, and withdrawal. Finally, a gradual reorganization emerges and a return to social activities. Unfortunately, society often assumes that grief should be brief and intense, resolving quickly with a return to normal activity. This is misleading. Grief research points to 1 to 4 years as being a more typical grief period. Some aspects of grief are life long, and reflect a positive continuing attachment to the deceased.

When is grief a problem?

    There is no clear line between normal and problematic grief. Problematic grief may be indicated by:

• A lasting loss of interest in social interactions, activities and work
• Furious hostility against specific persons
• Poor judgment (such as in finances)
• Agitated depressive symptoms (overactive behaviour combined with sadness) with bitter self-accusation (e.g., "Its all my fault". "I can’t do anything right").
• Upsetting memories and yearnings for the dead person on a daily basis over a long period of time.
• Difficulty acknowledging the person is dead
• Long-term efforts to avoid reminders of the deceased (e.g. avoiding certain rooms, buildings, people or activities.)
• Becoming overly active without a sense of loss regarding the dead person.
• Developing physical symptoms similar to the medical illness of the deceased.
• Developing psychosomatic symptoms such as headaches or aches and pains that are not related to actual physical problems or illnesses.

    Grief is different from depression, although there may be some overlap. Grief may consist of a longing for the person, a lack of acceptance of the death, memories that just "come out of nowhere" at any time or any place (intrusive memories), frequently thinking about the person (preoccupation), tearfulness, and sensing the presence of the dead spouse (50% continue to hear the voice of the spouse after one year). Depression is indicated by prolonged physical lethargy and fatigue (feeling tired all the time, no energy), or emotional distress for reasons other than the death. Anxiety and worry also accompany bereavement. For example, bereaved elderly may fear that their children or friends may abandon them. Loss of a spouse can create a serious crisis in self-confidence. Some are so used to doing daily activities as a couple, that they are unsure of themselves on their own.

    Grief can develop as a problem in one of two ways. Firstly, death of a loved one can be traumatic. Unexpected sudden death, a painful illness, and other aspects of the death can be extremely upsetting (traumatizing) to the bereaved. Intrusive memories may occur with a dramatic loss in the meaning of life, security or trust.

    Secondly, people can get stuck. This is referred to as complicated grief. They stop making progress in recovering from the death. Other life factors may contribute to the development of a complicated grief, such as a lack of support from family and friends or the personality style of the grieving person For example, if the individual is somewhat insecure or has been quite dependent on the now-deceased spouse, the grief process may be more difficult or prolonged.

When and how is grief treated?

    Treatment of traumatic or complicated grief should be approached with caution. Research shows that early preventative interventions such as bereavement groups appear to have only a temporary positive effect and little evidence of long- lasting benefit. Indeed they can be harmful if they convey to the individual that their grief is wrong and something to be treated and removed. Keep in mind that grief is a normal response. Grief reflects the individual’s healthy long-term attachment to another person. Thus, it is not necessarily desirable to eliminate the pain of grief. Nevertheless, bereavement groups can provide a useful reassurance if conducted carefully.

    Psychological interventions for longer-term difficulties related to traumatic or complicated grief have a moderate but lasting benefit. Various psychological treatment approaches exist. Cognitive therapy strategies are used to help the person think about and understand the impact of the loss. These strategies are often first directed to helping the person understand that grief is normal. Many individuals need reassurance that they are not weak or not going crazy because they break down in tears or hear their dead partner’s voice. Therapy helps them to make accurate interpretations of the grief experience.

    For some individuals, a specific cognitive focus on counterfactual thinking may be required. Counterfactual thinking is illustrated by upsetting thoughts that try to undo what has happened (e.g.,"If only I had got him to go to a doctor early"). Counterfactual thinking needs to be changed before the person can accept the loss.

    Behavioural interventions are used to help people gradually get back to their daily routines and to prevent depression. This often involves a gradual increase in exercise and activities. Psychologists work with the bereaved elderly to rebuild their self-confidence in managing on their own.

    For instances of severe grief trauma, a psychotherapeutic approach that guides the individual through repeated emotional re-experiencing of the death can be of benefit. This type of intervention is aimed at helping the individual accept the death and loss, and work through the trauma and resulting panic.

    A classic book about bereavement is Colin Murray Parkes’ Bereavement, published by Routledge.

    Other Internet information is available, such as the British United Provident Association: www.bupa.co.uk/health_information/