Grief

Grief is how one reacts to a loss. Losses can range from loss of employment, pets, status, a sense of safety, order, possessions, to the loss of the people nearest to us, and even to symbolic loss.  All loss involves the absence of someone loved or something that fulfills a significant need in one’s life.

Our grief response to loss is varied and includes a wide variety of responses that are influenced by personality, family, culture, and spiritual and religious beliefs and practices.  Grief may be experienced in the combination of mental/emotional, physical, or social reactions. Mental/emotional reactions can include anger, guilt, anxiety, sadness, depression and despair. Physical reactions can include sleeping problems, changes in appetite, physical problems, or illness. Social reactions can include feelings about taking care of others in the family, role changes in the family, returning to work, or differences in social situations.

There is no right or wrong way to grieve after a significant loss. Most discover how to eventually move on with life, even though the grief experience is a difficult and trying time.  Coping styles depend on one’s personality and their relationship with the person who has died. This experience can also be affected by one’s cultural and religious background, coping skills, mental history, and their support system. Although everyone experiences grief when they lose someone, grieving affects people in different ways. How it affects you partly depends on your situation and relationship with the person who died.

The circumstances under which a person dies can influence grief feelings. For example, if someone has been sick for a long time or is very old, you may have expected that person's death. Although it doesn't necessarily make it any easier to accept (and the feelings of grief will still be there), some people find that knowing someone is going to die gives them time to prepare. And if a loved one suffered a lot before dying, a person might even feel a sense of relief when the death occurs. If the person who has died is very young, though, you may feel a sense of how terribly unfair it seems.

Losing someone suddenly can be extremely traumatic, for example as a result of violence, heart attack, or an accident.  It can take a long time to overcome a sudden loss because you may feel caught off guard by the event and the intense feelings that are associated with it.  Losing someone because he or she committed suicide can be especially difficult to deal with. People who lose friends or family members to suicide may feel intense despair and sadness because they feel unable to understand what could have led to such an extreme action. They may even feel angry at the person - a completely normal emotion. Or they could feel guilty and wonder if there was something they might have done to prevent the suicide.

Bereavement is the period after a loss during which grief is experienced. The time spent in a period of bereavement depends on how attached the person was to the person who died, and how much time was spent anticipating the loss. Bereavement, while a normal part of life for us all, carries high risk factors when no support is available. Severe reactions to loss may carry over into familial relations and cause trauma for children and spouses: 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 covered by many years and circumstances this often goes unnoticed. Issues of personal faith and beliefs also come under severe attack as persons reassess personal definitions in the face of great pain. Probably the best resource to avoid problems are early intervention and caring support, and understanding of the experience.

Some view the process of bereavement as having several phases:

Shock and numbness: Usually occurring soon after a death, this is evident when the person finds it difficult to believe the death has occurred.  the person is stunned and numb. They may have feelings of unreality, depersonalization, withdrawal, and an anesthetizing of affect. These feelings often occur early in grief, and may be a self-protective way of getting through the facts of the death. Persons often remark on how someone appears stoic or strong when they are actually in shock.

Yearning and searching: As shock and numbness recede, there remains the tendency to “forget” the person has died. Perhaps one catches a glimpse of somebody who reminds them of the deceased, or you expect them to be there when you first arrive home. This process has also been referred to as 'pining.' Common reactions include feelings and even cognitions of 'seeing' the deceased for fleeting moments, hearing the door at the time they used to come home, or even incorrectly 'finding' the person, for example in a crowd, although intellectually realizing this is not so. This process appears to be an attempt of the person to cognitively and emotionally begin to let go, by coming to terms with the reality of the loss.

Disorganization, despair, and suffering: As the reality of the absence of the person who died settles in, it is common to feel depressed and find it difficult to think about the future. You may be easily distracted, or have difficulty concentrating and focusing on any one task. There are no easy answers to assuage this difficult experience: it must simply be endured, although it may take years of all of the above experiences overlapping, waxing and waning before the last process takes place. The suffering process typically involves a wide range of feelings, thoughts, and behaviors, as well as an overall sense of life seeming chaotic and disorganized. The duration of the suffering process differs with each person, partly depending on the nature of the loss experienced. Some common features of suffering include:

•Sadness. Sadness is perhaps the most common feeling found in grief. It is often but not necessarily manifested in crying. Sadness is often triggered by reminders of the loss and its permanence. Sadness may become quite intense and be experienced as emptiness or despair.

•Anger. Anger can be one of the most confusing feelings for the grieving person. Anger is a frequent response to feeling powerless, frustrated, or even abandoned. Anger is also a common response to feeling threatened; a significant loss can threaten a person's basic beliefs about self and about life in general. Consequently, anger may be directed at self, at God, at life in general for the injustice of the loss, for others involved, or, in the case of death, at the deceased for dying.

•Guilt. Guilt and less extreme self-reproach are common reactions to things the griever did or failed to do before the loss. For example, a griever may reproach him/herself for hurtful things said, loving things left unsaid, not having been kind enough when the chance was available, actions not taken that might have prevented the loss, etc.

•Anxiety. Anxiety can range from mild insecurity to strong panic attacks; it can also be fleeting or persistent. Often, grievers become anxious about their ability to take care of themselves following a loss. Also they may become concerned about the well-being of other loved ones.

•Physical, behavioral and cognitive symptoms. Often, grief is accompanied by periods of fatigue, loss of motivation or desire for things that were once enjoyable, changes in sleeping and eating patterns, confusion, preoccupation, and loss of concentration.

Suffering is often the most painful and protracted stage for the griever, but it is still necessary. For most people, these many emotional and physical reactions are common symptoms that will stabilize and diminish with time as the person moves through the grieving process. If these symptoms persist, it may be important to seek professional help.

Reorganization and recovery: As one slowly makes the adjustment to all the ways in his or her life that have changed as a result of the loss, a sense of reorganization and renewal begins to evolve. Life is forever changed after a significant loss, but you slowly learn how the different aspects of your life become reprioritized as you “pick up the pieces” and begin to move on. As recovery takes place, the individual is better able to accept the loss, resume a "normal" life, and to reinvest time, attention, energy and emotion into other parts of his/her life. The loss is still felt, but the loss has become part of the griever's more typical feelings and experiences.  Many times, in widowhood, one is so much a part of their spouse, that new definitions of identity must take place for healing. For the elderly after a lifetime of defining themselves in terms of their marriage relationships, this may take the rest of their lives.

The grieving process is very personal and individual - each person goes through his or her grief differently. Some people reach out for support from others and find comfort in good memories. Others become very busy to take their minds off the loss. Some people become depressed and withdraw from their peers or go out of the way to avoid the places or situations that remind them of the person who has died. Just as people feel grief in many different ways, they handle it differently, too.

For some people, it may help to talk about the loss with others. Some do this naturally and easily with friends and family, others talk to a professional therapist. Some people may not feel like talking about it much at all because it's hard to find the words to express such deep and personal emotion or they wonder whether talking will make them feel the hurt more.

A few people may act out their sorrow by engaging in dangerous or self-destructive activities. Doing things like drinking, drugs, or cutting yourself to escape from the reality of a loss may seem to numb the pain, but the feeling is only temporary. The person isn't really dealing with the pain, only masking it, which makes all those feelings build up inside and only prolongs the grief.

Grief puts a great stress on the physical body as well as on the psyche, resulting in wear and tear beyond what is normal. Further, grief is often accompanied by crying, lack of sleep, loss of appetite, and ceasing to care for one's physical and emotional well being. All these can contribute to a predisposition for illness in bereavement. 

Many studies have looked at the bereaved in terms of increased risks for stress-related illnesses such as colitis and breathing difficulties, and so forth in the first six months following a death. Others have noted increased mortality rates  a greater risk of suicide in teens following the death of a parent. Children may exhibit signs of delinquency, rage, introversion or other problems. Further, grief can insidiously work in family relationships as individual members sort or act through their feelings about the death.

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.

Child death

Death of a child can take the form of a loss in infancy such as stillbirth or neonatal death, SIDS, or the death of an older child. In all cases, parents find the grief devastating and while persons may rate the death of a spouse as first in traumatic life events, the death of a child holds greater risk factors. This loss also bears a lifelong process; one does not get 'over' the loss but instead learns to 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. 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. This, coupled with normal experiences of grief, can be overwhelming.

Spouse death

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.

Other losses

Many other losses predispose persons to physical and emotional risk. Loss reactions may occur after the loss of a parent, sibling, friend, romantic relationship, a vocation, a pet a home, children leaving home (empty nest), a favored appointment or desire, etc. While the reaction may not be as intense as the loss of a child or spouse, experiences of loss may still show in these forms of bereavement.

Loss as experienced by a child:  This section is adapted from the AACAP: Children and Grief website and specially deals with some issue of children and grief.  If this section is not relevant to you, please scroll through the next 4 (four) paragraphs.

When a family member dies, children react differently from adults. Preschool children usually see death as temporary and reversible, a belief reinforced by cartoon characters who die and come to life again. Children between five and nine begin to think more like adults about death, yet they still believe it will never happen to them or anyone they know.  Adding to a child's shock and confusion at the death of a brother, sister, or parent is the unavailability of other family members, who may be so shaken by grief that they are not able to cope with the normal responsibility of childcare.

Parents should be aware of normal childhood responses to a death in the family, as well as signs when a child is having difficulty coping with grief. It is normal during the weeks following the death for some children to feel immediate grief or persist in the belief that the family member is still alive. However, long-term denial of the death or avoidance of grief can be emotionally unhealthy and can later lead to more severe problems.  Once children accept the death, they are likely to display their feelings of sadness on and off over a long period of time, and often at unexpected moments. The surviving relatives should spend as much time as possible with the child, making it clear that the child has permission to show his or her feelings openly or freely.

The person who has died was essential to the stability of the child's world, and anger is a natural reaction. The anger may be revealed in boisterous play, nightmares, irritability, or a variety of other behaviors. Often the child will show anger towards the surviving family members.  After a parent dies, many children will act younger than they are. The child may temporarily become more infantile; demand food, attention and cuddling; and talk baby talk. Younger children frequently believe they are the cause of what happens around them. A young child may believe a parent, grandparent, brother, or sister died because he or she had once wished the person dead when they were angry. The child feels guilty or blames him or herself because the wish came true.

A child who is frightened about attending a funeral should not be forced to go; however, honoring or remembering the person in some way, such as lighting a candle, saying a prayer, making a scrapbook, reviewing photographs, or telling a story may be helpful. Children should be allowed to express feelings about their loss and grief in their own way.

The following has been adapted from the kidshealth website.

The loss of someone close to you can be stressful. It can help you to cope if you take care of yourself in certain small but important ways. Here are some that might help:

Remember that grief is a normal emotion. Know that you can (and will) heal from your grief.
Participate in rituals. Memorial services, funerals, and other traditions help people get through the first few days and honor the person who died.
Be with others. Even informal gatherings of family and friends bring a sense of support and help people not to feel so isolated in the first days and weeks of their grief.
Talk about it when you can. Some people find it helpful to tell the story of their loss or talk about their feelings. Sometimes a person doesn't feel like talking, and that's OK, too. No one should feel pressured to talk.
Express yourself. Even if you don't feel like talking, find ways to express your emotions and thoughts. Start writing in a journal about the memories you have of the person you lost and how you're feeling since the loss. Or write a song, poem, or tribute about the person who died. You can do this privately or share it with others.
Exercise. Exercise can help your mood. It may be hard to get motivated, so modify your usual routine if you need to.
Eat right. You may feel like skipping meals or you may not feel hungry - but your body still needs nutritious foods.
Join a support group. If you think you may be interested in attending a support group, ask an adult or school counselor about how to become involved. The thing to remember is that you don't have to be alone with your feelings or your pain.
Let your emotions be expressed and released. Don't stop yourself from having a good cry if you feel one coming on. Don't worry if listening to particular songs or doing other activities is painful because it brings back memories of the person that you lost; this is common. After a while, it becomes less painful.
Create a memorial or tribute. Plant a tree or garden, or memorialize the person in some fitting way, such as running in a charity run or walk (a breast cancer race, for example) in honor of the lost loved one.
Getting Help for Intense Grief
If your grief isn't letting up for a while after the death of your loved one, you may want to reach out for help. If grief has turned into depression, it's very important to tell someone.

How do you know if your grief has been going on too long? Here are some signs:

You've been grieving for 4 months or more and you aren't feeling any better.
You feel depressed.
Your grief is so intense that you feel you can't go on with your normal activities.
Your grief is affecting your ability to concentrate, sleep, eat, or socialize as you normally do.
You feel you can't go on living after the loss or you think about suicide, dying, or hurting yourself.
It's natural for loss to cause people to think about death to some degree. But if a loss has caused you to think about suicide or hurting yourself in some way, or if you feel that you can't go on living after your loss, it's important that you tell someone right away.

Grief is a normal and natural, though often deeply painful, response to loss. The death of a loved one is the most common way we think of loss, but many other significant changes in one's life can involve loss and therefore grief. Everyone experiences loss and grief at some time. The more significant the loss, the more intense the grief is likely to be.

Each individual experiences and expresses grief differently. For example, one person may withdraw and feel helpless, while another might be angry and want to take some action. No matter what the reaction, the grieving person needs the support of others. A helper needs to anticipate the possibility of a wide range of emotions and behaviors, accept the grieving person's reactions, and respond accordingly.

Grieving and responses to loss can be helped by psychotherapy. A wide variety of therapeutic approaches used by psychologists and other mental health professionals have been shown to be very effective.

If you really want help dealing with your feelings and emotions, changing your behavior, and improving your life and the approach and office hours of typical therapists and counselors do not fit your life style or personal needs, I may have a solution.

By using very flexible office appointments, telephone consultations, email, teleconferences, and the willingness to travel and meet with you personally in your home, office, or other location,  I can be available to help you anytime and anywhere.

Feel free to contact me now for your free initial consultation. Once you become an existing client, you will be given a  pager  number where you can reach me whenever you need.

Glossary of terms about end-of-life decision-making:

Advance directive - A general term that describes two kinds of legal documents, living wills and medical powers of attorney. These documents allow a person to give instructions about future medical care should he or she be unable to participate in medical decisions due to serious illness or incapacity. Each state regulates the use of advance directives differently.

Artificial nutrition and hydration - Artificial nutrition and hydration (or tube feeding) supplements or replaces ordinary eating and drinking by giving a chemically balanced mix of nutrients and fluids through a tube placed directly into the stomach, the upper intestine or a vein.

Assisted suicide - Providing someone the means to commit suicide, such as a supply of drugs or a weapon, knowing the person will use these to end his or her life.

Benefits and burdens - A commonly used guideline for deciding whether or not to withhold or withdraw medical treatments. A benefit can refer to the successful outcome of a medical procedure or treatment. Outcomes can be medical (e.g. the heart beats again) or functional (e.g. the person is able to walk to the bathroom after being incapacitated by a stroke), or it supports the patient’s values (for example, the patient is able to die at home as he wished). However, a benefit from one point of view can be experienced as a burden from another and might be viewed differently by doctors, patients and families. For example, if a patient is resuscitated and the heart starts beating again, this is a successful outcome from a medical point of view and a doctor may consider it a benefit. To the patient who is dying from a serious illness or disease, resuscitation may cause further injury and only contribute to the overall experience of suffering. This success, from the doctor’s point of view, might actually be experienced as an additional burden by the patient. Discussions of the benefits and burdens of medical treatments should occur within the framework of the patient’s overall goals for care.

Bereavement - The period after a loss during which grief is experienced. The time spent in a period of bereavement depends on how attached the person was to the person who died, and how much time was spent anticipating the loss.

Best interest - In the context of refusal of medical treatment or end-of-life court opinions, a standard for making health care decisions based on what others believe to be "best" for a patient by weighing the benefits and the burdens of continuing, withholding or withdrawing treatment. (Contrast with "substituted judgment.")

Brain death - The irreversible loss of all brain function. Most states legally define death to include brain death.

Capacity - In relation to end-of-life decision-making, a patient has medical decision making capacity if he or she has the ability to understand the medical problem and the risks and benefits of the available treatment options. The patient’s ability to understand other unrelated concepts is not relevant. The term is frequently used interchangeably with competency but is not the same. Competency is a legal status imposed by the court.

Cardiopulmonary resuscitation - Cardiopulmonary resuscitation (CPR) is a group of treatments used when someone’s heart and/or breathing stops. CPR is used in an attempt to restart the heart and breathing. It may consist only of mouth-to-mouth breathing or it can include pressing on the chest to mimic the heart’s function and cause blood to circulate. Electric shock and drugs also are used frequently to stimulate the heart.

Clear and convincing evidence - A high measure or degree of proof that may be required legally to prove a patient’s wishes. A few states require clear and convincing evidence that an incompetent patient would want to refuse life-support before treatment may be stopped unless the patient has completed an advance directive authorized by the state's law.

Do-Not-Resuscitate (DNR) order - A DNR order is a physician’s written order instructing health care providers not to attempt cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest. A person with a valid DNR order will not be given CPR under these circumstances. Although the DNR order is written at the request of a person or his or her family, it must be signed by a physician to be valid. A non-hospital DNR order is written for individuals who are at home and do not want to receive CPR.

Emergency Medical Services (EMS) - A group of governmental and private agencies that provide emergency care, usually to persons outside of health care facilities; EMS personnel generally include paramedics, first responders and other ambulance crew.

Euthanasia - The term traditionally has been used to refer to the hastening of a suffering person's death or "mercy killing". Voluntary active euthanasia involves an intervention requested by a competent individual that is administered to that person to cause death, for example, if a physician gives a lethal injection with the patient’s full informed consent. Involuntary or non-voluntary active euthanasia involves a physician engaging in an act to end a patient’s life without that patient’s full informed consent. See also Physician-hastened Death (sometimes referred to as Physician-assisted Suicide).

Grief - Grief is how one reacts to a loss. Grief reactions may be experienced in response to physical losses, such as death or in response to social losses such as divorce or loss of a job. All loss involves the absence of someone loved or something that fulfills a significant need in one’s life.

Guardian ad litem - Someone appointed by the court to represent the interests of a minor or incompetent person in a legal proceeding.

Incompetent - See "Capacity."

Healthcare agent - The person named in an advance directive or as permitted under state law to make healthcare decisions on behalf of a person who is no longer able to make medical decisions.

Hospice care - A program model for delivering palliative care to individuals who are in the final stages of terminal illness. In addition to providing palliative care and personal support to the patient, hospice includes support for the patient’s family while the patient is dying, as well as support to the family during their bereavement.

Intubation - Refers to "endotracheal intubation" the insertion of a tube through the mouth or nose into the trachea (windpipe) to create and maintain an open airway to assist breathing.

Legislation - Laws enacted by state or federal representatives.

Life-sustaining treatment - Treatments (medical procedures) that replace or support an essential bodily function (may also be called life support treatments). Life-sustaining treatments include cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition and hydration, dialysis, and certain other treatments.

Living will - A type of advance directive in which an individual documents his or her wishes about medical treatment should he or she be at the end of life and unable to communicate. It may also be called a “directive to physicians”, “health care declaration,” or “medical directive.” The purpose of a living will is to guide family members and doctors in deciding how aggressively to use medical treatments to delay death.

Mechanical ventilation - Mechanical ventilation is used to support or replace the function of the lungs. A machine called a ventilator (or respirator) forces air into the lungs. The ventilator is attached to a tube inserted in the nose or mouth and down into the windpipe (or trachea). Mechanical ventilation often is used to assist a person through a short-term problem or for prolonged periods in which irreversible respiratory failure exists due to injuries to the upper spinal cord or a progressive neurological disease.

Medical power of attorney - A document that allows an individual to appoint someone else to make decisions about his or her medical care if he or she is unable to communicate. This type of advance directive may also be called a health care proxy, durable power of attorney for health care or appointment of a health care agent. The person appointed may be called a health care agent, surrogate, attorney-in-fact or proxy.

Palliative care - A comprehensive approach to treating serious illness that focuses on the physical, psychological, spiritual, and existential needs of the patient. Its goal is to achieve the best quality of life available to the patient by relieving suffering, by controlling pain and symptoms, and by enabling the patient to achieve maximum functional capacity. Respect for the patient’s culture, beliefs, and values are an essential component. Palliative care is sometimes called “comfort care” or “hospice type care.”

Respiratory arrest - The cessation of breathing - an event in which an individual stops breathing. If breathing is not restored, an individual's heart eventually will stop beating, resulting in cardiac arrest.

Surrogate decision-making - Surrogate decision-making laws allow an individual or group of individuals (usually family members) to make decisions about medical treatments for a patient who has lost decision-making capacity and did not prepare an advance directive. A majority of states have passed statutes that permit surrogate decision making for patients without advance directives.

Withholding or withdrawing treatment - Forgoing life-sustaining measures or discontinuing them after they have been used for a certain period of time.

If you really want help dealing with your feelings and emotions, changing your behavior, and improving your life and the approach and office hours of typical therapists and counselors do not fit your life style or personal needs, I may have a solution.

By using very flexible office appointments, telephone consultations, email, teleconferences, and the willingness to travel and meet with you personally in your home, office, or other location,  I can be available to help you anytime and anywhere.

Feel free to contact me now for your free initial consultation. Once you become an existing client, you will be given a  pager  number where you can reach me whenever you need.