Grief and loss and how to deal with them

In this blog post the focus is on grief and loss and how to deal with them. 

Grief is a deep or intense sorrow or distress, especially at the death of someone or something that causes suffering. Elisabeth Kubler-Ross was a Swiss-American psychiatrist and a researcher in near-death studies, with people who were dying, not people who had experienced a loss. In 1969, she published a book entitled On Death and Dying, where she discussed her theory on the five stages of grief. It became known as an acronym called DABDA, denial, anger, bargaining, depression and acceptance. 

Denial is the idea that when people first find out that they are going to die (maybe if they have a difficult diagnosis, or a terminal diagnosis), they may deny it. In terms of people who have had a bereavement, it might be that they deny that the person has died. They don’t accept the truth that the person’s not going to be there anymore.

Anger is the emotion that emerges when people are angry at the loss. They may really be angry at the person who has died. It’s quite a normal situation. Also, people who have a terminal diagnosis may be angry at themselves. 

Bargaining is a state of mind where people say “Well, if I do this, am I going to get better?” However, the medical facts are that they won’t. People have bargaining

behaviours and might try to alter their lifestyles in the hope that their lives will be extended. For people who’ve experienced someone dying, it’s common for them to say, “Well, I’m sure that it should’ve been me”. 

Depression is about low mood, feeling sad, and generally very low about the whole situation of either having a very difficult diagnosis or losing someone. And finally, there is acceptance. 

The problem with this model is that it’s linear. People may experience all five stages, but they might not be in that order. One of the reasons that this model has found popularity in other areas of medicine, is that it’s an easy model to teach effectively to healthcare professionals and it’s also easy to share with people who might be bereaved.

Dr. Collin Murray Parkes told the British Medical Journal that, “It’s no longer considered a linear progression, one size fits all approach”. By the middle of the 1970s, people were moving away from the Kubler-Ross model and thinking that unlike the DABDA model, people grieve in different ways.

Parkes and Bowlby founded their own attachment model. It talked about numbness (a sense of unreality and disbelief) and yearning (severe feelings, including panic, crying, and physical pain). This yearning phase includes severe feelings including panic, crying, and physical pain. Next is disorganisation and despair (depression, despair and apathy). Apathy is when people can’t be bothered to do anything or are not motivated to do anything. Finally, there’s reorganisation (identity revised, ready to move on). The identity revised is where people start to identify themselves in the world as no longer being connected or moving away from the connection to the person who has died. They re-establish their identity. Bowlby also talked a lot about how attachment can impact on how people grieve. 

In 1990, the American psychologist William Worden conceived the four tasks of mourning. They move away from a more viscerally felt process to a more cognitive process. The four tasks of mourning is not linear, so that people can go back to the tasks as they need them.

Task one is to accept the reality of the loss, which means accepting that the person is no longer physically there, and won’t be coming back. Some people of faith positions may think that the person is in another place, has gone to heaven or something else. 

The second task is to work through the pain and the grief. People who are bereaved have to go through the process of feeling terrible about it and to try and find a way through that.

The third one is to adjust to the new environment. For instance, someone dies and their partner has to change their lives. They may do things after the bereavement they didn’t do before when the person was alive, such as find new friends, new activities or new hobbies and move on.

Task four is to find an enduring connection with the deceased while moving forward with life. This isn’t putting pictures of them away and never talking about the person who has died, but rather very much about finding a way that the person can still exist in conversations, pictures, remembering them, while at the same time, accepting loss and moving forward.

The Norwegian researchers, Strobe and Schut, devised the dual process model. As a result of their research, they found that people oscillated between the emotional aspects of grief (loss-orientated) and a more restorative approach (restoration-orientated). People have two processes, the cognitive and the affective domain. The cognitive domain is how we think. The affective domain is how we feel. People move between those two processes. The restorative approach is about restoring someone back to an equilibrium where they can move on with their life. They recommend that the bereaved can be supported in doing this and is a big step from the emotional process model by Kubler-Ross.

In other words, in the loss-orientated approach the grief breaks through, people feel very sad and tearful, bonds and ties are broken, they experience the reality of loss and realise that actually that person isn’t coming back. They experience denial and avoidance of restoration changes; there is a resistance to move on.

The restoration-orientated approach means attending to life’s changes, the practical things like changing people’s names on bills, bank accounts and the kinds of administrative things which happen when someone has died. It also involves doing new things and finding distractions from grief, so that they don’t get completely lost in the process and instead have a cognitive view of it. There can now be a denial and avoidance of grief, but also new roles, a new identity and new relationships.

The dual process model of coping by Strobe and Schut, is loss-orientated (intrusion, breaking bonds, denial, and avoidance, or experiencing grief) on one hand. And on the other hand, restoration-orientated (attending to life’s challenges, doing new things, distraction, denial and avoiding grief). People might say, “I’ll put some time aside to be upset, but really I have to get on with the practical things, like getting the kids to school, or getting on with my job”. The dual process model is similar to a coaching model as there’s a lot of encouragement for people to work with the restoration-orientated model while acknowledging the loss-orientated model, with people oscillating between the two.

There are different types of grief and loss. The most common ones are: normal (uncomplicated) grief, anticipatory grief, complicated grief, secondary losses in grief, traumatic grief and collective grief.

Normal grief is the ability for people to move on with their lives. There’s a gradual lessening of intense emotions with individuals being able to engage with their daily lives. A person may talk about the deceased, process a lot of what is going on for them, talk about feeling guilty, about not having given up their job, about having had to put someone into care, or maybe even about if they had just done things differently, but generally after about two or three sessions, they find out it is quite normal for people to have these feelings, and so they end therapy, because they want to get on with their life and to engage in the more restorative side. It’s difficult, uncomfortable and sad, but they can engage and have the internal resources to move on.

Anticipatory grief refers to things like terminal illness, a loss of role or function, separation, or loss of a future. It appears often in therapy. Terminal illness is an illness that is going to end in the end of a life. But loss of a role or function, separation and the loss of a future can come up with people who have not actually lost someone. It could be

someone whose children are going off to university for the first time and suddenly they have an empty house, they’ve lost their role as a parent and they’re wondering what their life is going to be like.

Another example is divorce or separation, where people are moving away from each other, and is also a form of loss. Not all separations are acrimonious and sometimes, they’re a necessity. Also, the loss of a future could involve a large industry closing down in a small town and the people who worked there feeling they no longer have a future as there is no work for them. It’s a powerful loss and links into our identity, self-structure and self concept, how we feel about ourselves and our community. Anticipatory grief can be very powerful. Even the idea that these things could happen can be very powerful for us.

Complicated grief is a combination of a traumatic and prolonged yearning for the deceased person. There’s no one indicator for complicated grief, but sometimes people don’t admit the person has died. Regardless of the evidence (the person went to the funeral service), yet they think they’re still not dead. It is difficult to work with in therapy as people can sometimes stay in the middle of the restorative model and the grief model in the dual process. They don’t engage with moving on with their lives, but neither do they invest in the feelings of loss. They are in limbo. Many people with complicated grief may not go to see a therapist, because they may not be in a position to engage with the process of letting go of that person.

Symptoms can include an extreme focus on the death of a loved one. It’s normal to be preoccupied with their death, but in this case the focus is extreme and it will be over a long period of time. Problems accepting death can occur in many ways; it can be that someone just either doesn’t believe someone’s dead or alternatively, that they have interesting theories of why they died. Numbness and detachment is a key element of complicated grief where people are completely detached from what’s going on. In some cases they’re completely disconnected from the world around them. Other symptoms can be feeling that life has no purpose or extreme anger. Mummification is a strong indicator that someone may have complicated grief. This is when their symptoms are still intense six months or more after the death and they haven’t moved on. This can sometimes be the indication that they’ve got a difficulty that might need more specialist help. There is no time limit on grieving. However, in a normal situation, over a period of time, the feelings lessen as people re-engage into their life. 

Looking at complex grief viewed in the dual process model (an oscillation between the loss-orientated model and the restorative-orientated model) a person is stuck and suspended between the two models. It can be so bad that people become psychotic and a different form of help is needed (medication or maybe a more directive approach). Thinking of complex grief as being stuck (not processing the loss, nor thinking about moving on, just suspended in pain) is a key element of complex loss.

William Worden, a psychiatrist, looks at a loss and observes that: “Denying the facts of the loss can vary in degree from a slight distortion to a full-blown delusion. Bizarre examples of denial through delusion are the rare cases in which the bereaved keeps the deceased’s body in the house for a number of days before notifying anyone of their death”. Not notifying anybody about the death avoids admitting that the person has died, that something needs to happen. Clearly, by not notifying anyone there is the sense that they’re suspended between grieving and dealing with it. 

Grief in itself is not a process that starts at the point where someone dies. It’s informed by how the person is within themselves before that happens, and whether they were already either manifestly psychotic, eccentric or reclusive. What’s more likely to happen is that a person will go through what Geoffrey Gorer, in 1965, calls mummification. That could be retaining possessions of the deceased or keeping rooms intact ready for use when he or she returns, such as in the novel Great Expectations by Charles Dickens, when Miss Havisham lives for years in a house with the wedding breakfast laid out, never taking off her wedding dress after being stood up at her wedding. 

A contemporary example of mummification is the grief displayed by Mohammed Fayed, the father of Dodi Fayed, the boyfriend of Princess Diana,who was killed along with her in Paris in 1997. After his death, Mohammed Fayed kept his son’s apartments (in Paris and London) unchanged as shrines. They were cleaned but the staff had to put everything back as it was, showing that he’d never got over his son’s death. In addition, he had his son’s body reinterred in a private mausoleum in the grounds of his home, which he visited every day. Mohammed Fayed also came up with interesting ideas of why his son died, accusing the Duke of Edinburgh, the Queen’s husband, of planning his assassination. He didn’t move on at all and fitted the description of someone who was suffering from complex grief.

Secondary grief is when someone dies, and the wreckage that’s left behind after their death can be emotional, financial, or structural, cluttering up the process of grieving. There’s so much that gets in the way, so people may be experiencing secondary loss or grief when they talk about things that may not be connected at all with the grief or the loss or the person who has died, but rather practical things. This comes after primary grief. They’ve accepted that the person has died. However, they have also lost their relationship with that person, as maybe they had a unique relationship with them, for instance, a business relationship, and they now have the trauma of having to figure out what work that person did and how they’re going to deal with that. This can filter down into how people stand in society. Imagine a woman whose husband has died and thereafter they are no longer invited round to their married friends’ because they’re no longer in a couple. People feel uncomfortable with their new situation so the invitations stop. It could also be the loss of material things, for instance, a house. Let’s imagine the deceased husband has indebted their business to such an extent that shortly after they die their partner is about to be evicted. There’s no money in the bank and their business has collapsed. Consequently, the partner has lost the person and her lifestyle within a month. Loss of your role can be when people have a role in life to look after someone or fulfill a responsibility and suddenly that disappears when someone dies. For instance, if someone receives a carer’s allowance as they’ve been caring for someone, and that person suddenly dies, the carer loses the person, the role of being a carer and the financial support of being a paid carer, so they have to get by the best they can, losing their old lifestyle. The loss of support is, for instance, when someone is in a team or a group and someone from the group suddenly dies, so the others no longer have their support. The loss of the future is, for instance, when someone has paid into a good pension in order to be able to enjoy their retirement, but then discovers that they won’t be able to due to bad health, and that their future plans are no longer valid. All of it can disappear. Secondary grief can be the focus of their grief, working through it first before coming to their primary grief, as these are the things that they have to function with in order to get by in the world. Sometimes grieving the person who is gone is a luxury because they have to do more practical things first such as find somewhere to live, and it might feel odd for them to talk about or be angry with the person who has died and instead talk about something practical. 

Some considerations when dealing with secondary grief and loss are:

• Being aware that crying and feeling the pain may seem a luxury when other issues such as loss of home, finances, or explaining what happened to the children take priority.
• Losing a partner can be a loss of identity and future. So when someone dies, people need to explore what they want to do with their lives now.
• Dealing with what the person needs to focus on first is important, rather than forcing them to look at the primary loss. 
• The primary loss will present itself when the secondary losses are dealt with. This is because the person is remapping their life and part of that is getting support (which can be from a therapist) so that they start to talk about the person who has died. 

Traumatic grief is sudden and unexpected, and often results in horrific or frightening circumstances. These can be things like natural disasters, terrorist attacks, suicide, losing your child, or anything which is out of sequence. As children, we attend funerals, relatives die, and we realise that there is a natural order to life, but if people die out of the natural order, it can cause trauma. With traumatic grief you have to work with the trauma first, even if a person feels that they need help for different issue, and that might not be therapy. It might be very practical support, like finding someone who can sit with you, for instance you may need to see a doctor before you can even get to the grief. 

There’s also a strong link between post-traumatic stress disorder and complicated grief. It’s necessary to avoid triggers and flashbacks, so that people don’t disassociate (a mental process of disconnecting from one’s thoughts, feelings, memories or a sense of identity).

A toolkit for dealing with trauma includes working with triage (or whatever a person says they need to focus on) to get a sense of what’s going on with them. Another part of the kit is mapping support, which means asking, “Have you got anybody else you can speak to?” or even signposting them out to other support services, because if someone’s in trauma, they’re unable to go through the process of therapy. Being referred to external support, such as social support, can help. It’s also important to work with the initial impact of the trauma. It’s common for people to forget what they have told someone as they block out what is happening to them as a defense mechanism. Someone going through trauma needs empathy, support and to be listened to actively. 

Collective grief is where a large number of people mourn the loss of someone or a group, such as when there is a terrorist attack or when Princess Diana died in 1997. Someone could show their connection to her by saying, “Do you know I’m just like Diana?” showing that they are experiencing collective grief as it triggers their unresolved grief or grief that they have from their own losses. It can suddenly re-appear, as they identify with the victims and re-experience or awaken their own grief.

Emotional investment, or how much we invest in the other, has a direct correlation to how much we grief, whether it’s for a pop star whose songs form the backdrop of our lives, a politician who has changed the way we live our lives through the work they’ve done, or someone close to us. It’s all to do with investment and attachment.

Attachment styles are very useful to understand in relation to grief. That is, how people interact with others and how that can play out into grief. The cultural aspects of grief are also important because people grieve in different ways and the culture we live in will inform how we grieve to some extent and give us a sense of belonging and connection. 

John Bowlby is considered the father of attachment theory. He’s the psychiatrist who was invited by the World Health Organisation in the 1970s to look at children who had been orphaned and how it had affected them. From that, he wrote a report for the World Health Organisation called Maternal Deprivation Studies, which gave a very strong link to the fact that when a child is separated from their caregivers, the child may very well have difficulties in later life connecting with others or forming relationships. The theory implies a cause and effect relationship between early attachment patterns. So when we’re looking at grief, what we’re really looking at is attachments. Bowlby argued that how we form attachments affects later reactions to bereavements. He notes, “Whether an individual exhibits a healthy or problematic pattern of grief following separation depends on the way his or her attachment system has become organised over the course of development”.

Dr. Collin Murray Parkes observed that the role that the deceased had in the life of the bereaved impacted on how they process grief. The more investment you have, the more you’re likely to grief. Bowlby believed there are full distinguishing characteristics of attachments, proximity maintenance, a safe haven, a secure base and separation distress.

Proximity maintenance is the desire to be near people we are attracted to. For example, if you’re out with your partner or out with your children and you get separated, you feel a desire to find them again and you think, “I’ve got to go and find them”. And when you find them, if you’ve got a good relationship and you feel complete, you feel better.

A safe haven is when we turn to the attachment figure for comfort and safety in the face of fear or threat. For instance, if something happens, small children run back to their parents and hide behind their legs. A significant part of this attachment is in adults, for instance, when something happens to someone, the first person they go to is their partner and say, “You’ll never guess what’s happened!”. Attachment moves throughout our lives.

A secure base is when the attachment figure acts as a base of security from which a child can explore the surrounding environment. Translated to adult lives an example would be that there are many couples who go on holiday together because they feel supported, whereas, they wouldn’t go on their own.

Separation distress is a feeling of anxiety in the absence of the attachment figure. It’s that feeling you get when you are at an event with your partner and you get separated. Then you stand on your tiptoes looking around hoping to find them, calling them on your mobile phone to arrange to meet up. These experiences in children carry on into our adult lives.

Patricia Barkway observed in the book, Psychology for Health Professionals, that, “Theorists and researchers, for some time, have explored factors that contribute to complicated grief. Is it due to the griever’s personality, previous life experiences, lack of social support, or the nature of the loss? Interestingly, recent work proposed that complicated grief can be viewed as an attachment disorder.” People with complex grief may have an attachment disorder, which might need a bigger intervention than just counselling, as, at some level, they have a real problem in either making a connection with someone or separating away from someone (far greater than if someone has healthy attachments).

She also observes that Bowlby “conceptualised grief as a response to separation and argued that difficulties grieving as an adult were related to disruptions in a person’s childhood attachments with parents or other significant carers. Three pathological attachment patterns were identified.” This is crucial in Bowlby’s work because he is saying that complex or complicated grief has a strong link to the person’s childhood history.

An anxious attachment to parents would result in an insecure attachment to significant others in adulthood. People think a child develops a set pattern of behaviour in isolation. Whereas, anxious attachment is a child mirroring the attachment style of the parent. If a child has an anxious parent, then they are likely to see that in the parent and mirror it in themselves and carry that into adulthood. An anxious attachment is effectively one where we get overly frightened and overly dependent on others to regulate us. We can’t regulate ourselves. And if that other person dies, that leaves us in a difficult place because we’ve got no way to regulate ourselves. It’s as if the deceased has taken their internal thermostat with them and the person doesn’t know how to set their own emotional temperature.

Overdependence and chronic grief following a major loss go hand in hand with attachment. A person might substitute the person who has died for their therapist and want to see them more, despite their not being able to replace the person who has died.

A child who is reluctant to accept care and is highly self-sufficient is described as compulsively self-reliant and is therefore likely to deny any loss and experience delayed grief. So people with avoidant attachment styles (who’ve learned very early on in childhood that part of their survival strategy was to be reliant on themselves and not rely on anyone else) will have quite a lot of difficulty when someone dies, because they don’t exist emotionally for them as they weren’t there in the first place so the person is reliant on themselves. A difficulty with delayed grief is that it can go on for many years until, suddenly, somebody goes to a funeral (and not necessarily for someone related to them) and they collapse into a deep pit of grief. It’s like lighting a fuse. They’ve held it in without addressing it, and suddenly something can light it. It could even be the loss of a favourite famous person, despite never having met them, but they’re really grieving for something in their history. 

Barkway also observes that “chronic grief was also likely to be experienced by a compulsive caregiver, someone whose role as a child was one of a giver rather than the receiver of care.” Linking this to attachment it’s as if the person’s childhood dies and the grief is just as intense. If someone’s had an unbalanced relationship in childhood, it may be that the grief itself becomes unbalanced, which is what chronic or complex grief is, unbalanced grief.

Ray and Prigerson suggest that attachment-related risk factors for complicated grief include:

• Weak parental bonding: when children don’t bond with their caregivers.
• A damaged sense of security due to childhood abuse or severe neglect.
• Childhood separation anxiety: for example, if a child spends a long time in hospital, their caregivers have spent a lot of time in hospital, their caregivers have been separated because of war or they’ve had to go away on business, this can create separation anxiety in children.
• People who are generally averse to change of any kind: some people seem
• to be fixed in their ways from a very early age, for instance, some people who are autistic.

Two other risk factors are:

• The griever’s perception of being unsupported.
• The lack of preparation for death, which makes suicidal deaths particularly difficult to deal with. Loss through suicide has been identified as a specific risk factor for complicated grief. When people can prepare for death, after a difficult diagnosis or when somebody has been talking about suicide for a long time, there’s a part of a person which is prepared for it. 

When complicated grief occurs, the person may need to see a therapist who can best match their needs and has the necessary experience of working with it. However, if they have lost touch with reality and, for example, have visions of the deceased person, a good option is to consult a medical professional. 

An indicator for complex grief can be linked with early attachment, childhood, and family dynamics. It could be that this person needs to do more than working through their feelings around their grief, as they come to understand that they have had a very difficult relationship with the person who has died or difficult family dynamics, then they can work on that. Sometimes people think that the most dysfunctional relationships they had as children were normal because they have nothing to compare them to. It’s only when they work in therapy that they come to the opinion that what they experienced wasn’t a healthy upbringing. Sometimes people want to know why they’re feeling as they’re feeling. So attachment is sometimes a useful tool for people to work through their complex grief.

There is a model called complicated grief therapy, which includes techniques similar to prolonged exposure (repeatedly telling the story of the death and in vivo exposure activities), and also involves focusing on personal goals and relationships.

It’s not unusual for a bereaved person to have sudden and unexpected pain after the loss of a loved one. Sometimes this pain directly reflects the illness that the bereaved person had. For example, a person who gets migraines says that their partner died of a brain tumour. Somatic symptoms can be projected onto people as a form of transference and it can help some people to know this.

There are some untruths about grief:

• ‘The pain of loss will go faster if you ignore it.’ It’s the opposite; if it’s not processed, it just builds up and will come out eventually. It might not come out as grief, but as anger, drug or alcohol abuse, or even self-harm, which can link back to unexplored and unresolved grief.
• ‘It’s important to be strong in the face of loss.’ It’s all right to cry, get upset and feel the pain of it, because it’s the pain that is the process of moving on. If we don’t engage with that, then we store it up.
• ‘If you don’t cry, it means you aren’t sorry about the loss.’ There isn’t a measure for how much you cry. Some people don’t cry, which is fine. 
• ‘Grief should last about a year.’ There’s no statute of limitations. It’s not unusual for somebody who suffered a bereavement many years ago to suddenly get a feeling of loss as if it happened yesterday with all the feelings attached to that. However, if it’s still very intense after about six months, it may be an indication that someone might need a different form of help, especially if they don’t acknowledge it and they’re stuck in limbo.

References:

Hughes, N. (2022). Preparing to work with loss and bereavement [lecture]. Counsellor CPD. Counselling Tutor. [29/05/2024].