Grief Counseling: The Grief Process, Models of Grief, and Grief Therapy

Grief, Loss, and Bereavement


A bouquet of white flowers sits atop a closed coffin.Most people will experience loss at some point in their lives. Grief is a reaction to any form of loss. Bereavement is a type of grief involving the death of a loved one. 

Bereavement and grief encompass a range of feelings from deep sadness to anger. The process of adapting to a significant loss can vary dramatically from one person to another. It often depends on a person’s background, beliefs, and relationship to what was lost.

Grieving Thoughts and Behaviors

Grief is not limited to feelings of sadness. It can also involve guilt, yearning, anger, and regret. Emotions are often surprising in their strength or mildness. They can also be confusing. One person may find themselves grieving a painful relationship. Another may mourn a loved one who died from cancer and yet feel relief that the person is no longer suffering.

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People in grief can bounce between different thoughts as they make sense of their loss. Thoughts can range from soothing (“She had a good life.”) to troubling (“It wasn’t her time.”). People may assign themselves varying levels of responsibility, from “There was nothing I could have done,” to “It’s all my fault.” 

Grieving behaviors also have a wide range. Some people find comfort in sharing their feelings among company. Other people may prefer to be alone with their feelings, engaging in silent activities like exercising or writing.

The different feelings, thoughts, and behaviors people express during grief can be categorized into two main styles: instrumental and intuitive. Most people display a blend of these two styles of grieving:

  • Instrumental grieving has a focus primarily on problem-solving tasks. This style involves controlling or minimizing emotional expression.
  • Intuitive grieving is based on a heightened emotional experience. This style involves sharing feelings, exploring the lost relationship, and considering mortality.

No one way of grieving is better than any other. Some people are more emotional and dive into their feelings. Others are stoic and may seek distraction from dwelling on an unchangeable fact of living. Every individual has unique needs when coping with loss.

Models of Grief

Grief can vary between individuals. However, there are still global trends in how people cope with loss. Psychologists and researchers have outlined various models of grief. Some of the most familiar models include the five stages of grief, the four tasks of mourning, and the dual process model. 

Five Stages of Grief

In 1969, Elisabeth Kubler-Ross identified five linear stages of grief:

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance

Kubler-Ross originally developed this model to illustrate the process of bereavement. Yet she eventually adapted the model to account for any type of grief. Kubler-Ross noted that everyone experiences at least two of the five stages of grief. She acknowledged that some people may revisit certain stages over many years or throughout life.

Four Tasks of Mourning

Psychologist J. W. Worden also created a stage-based model for coping with the death of a loved one. He divided the bereavement process into four tasks: 

  1. To accept the reality of the loss
  2. To work through the pain of grief
  3. To adjust to life without the deceased
  4. To maintain a connection to the deceased while moving on with life

Dual Process Model

As an alternative to the linear stage-based model, Margaret Stroebe and Hank Schut developed a dual process model of bereavement. They identified two processes associated with bereavement:

Loss-oriented activities and stressors are those directly related to the death. These include:

  • Crying
  • Yearning
  • Experiencing sadness, denial, or anger
  • Dwelling on the circumstances of the death
  • Avoiding restoration activities

Restoration-oriented activities and stressors are associated with secondary losses. They may involve lifestyle, routine, and relationships. Restoration-oriented processes include: 

  • Adapting to a new role
  • Managing changes in routine
  • Developing new ways of connecting with family and friends
  • Cultivating a new way of life.

Stroebe and Schut suggest most people will move back and forth between loss-oriented and restoration-oriented activities.

The Process of Recovering from Grief

Everyone grieves in their own way and in their own time. Some people recover from grief and resume normal activities within six months, though they continue to feel moments of sadness. Others may feel better after about a year. 

A young woman swings alone, looking at the empty swing beside her.Sometimes people grieve for years without seeming to find even temporary relief. Grief can be complicated by other conditions, most notably depression. The person’s level of dependency on the departed can also cause complications.

The grieving process often involves many difficult and complicated emotions. Yet joy, contentment, and humor do not have to be absent during this difficult time. Self-care, recreation, and social support can be vital to the recovery. Feeling occasional happiness does not mean a person is done mourning.

Grieving the loss of a loved one be a difficult process, whether the loss is due to death, a breakup, or other circumstance. One of the hardest challenges is adjusting to the new reality of living in the absence of the loved one. Adjusting may require a person to develop a new daily routine or to rethink their plans for the future. While creating a new life, a person may adopt a new sense of identity

Complicated Grief

The experience of grief is not something a person ever recovers from completely. However, time typically tempers its intensity. Yet an estimated 15% of people who have lost a loved one will experience “complicated grief.” This term refers to a persistent form of bereavement, lasting for one year or more. 

Again, the length of time it takes for a person to grieve is highly variable and dependent on context. But when symptoms persist without improvement for an extended period, they may qualify as complicated grief. In addition, the symptoms of complicated grief to be more severe. Complicated grief often dominates a person’s life, interfering with their daily functioning.

Prolonged symptoms may include:

  • Intense sadness and emotional pain
  • Feelings of emptiness and hopelessness
  • Yearning to be reunited with the deceased
  • Preoccupation with the deceased or with the circumstances of the death
  • Difficulty engaging in happy memories of the lost person
  • Avoidance of reminders of the deceased
  • A reduced sense of identity
  • Detachment and isolation from surviving friends and family
  • Lack of desire to pursue personal interests or plans

The Diagnostic and Statistical Manual (DSM-5) does not classify complicated grief as a clinical condition. Yet it does include diagnostic criteria for “persistent complex bereavement disorder” in the section of conditions requiring further study.

Broken Heart Syndrome

Generally speaking, grief cannot kill a person. That said, there are cases in which severe stress could harm an otherwise healthy person’s heart. 

A man in a gray sweater grips his chest in pain.When a person experiences a shocking event, their body fills with stress hormones. These hormones can cause part of a person’s heart to briefly swell and stop pumping. The rest of the heart continues beating, causing blood to flow unevenly. A person may feel intense chest pain, similar to a heart attack (but unlike a heart attack, the arteries are not blocked). This temporary malfunction is called “broken heart syndrome.”

As the name suggests, the broken heart syndrome often follows news of loss, such as a divorce or death of a loved one. Yet symptoms can also appear after a good shock, such as winning the lottery. Women are more likely than men to develop the condition.

Most people who experience broken heart syndrome recover within weeks. Deaths from the condition are rare. Since the syndrome is prompted by a shocking event, people have a low risk of experiencing it twice.

Depression and Grief

The DSM-5 does not define bereavement as a disorder. Yet typical signs of grief, such as social withdrawal, can mimic those of depression.

So how can one tell the difference between grief and depression?

  • Grief is typically preceded by loss. Depression can develop at any time.
  • The sadness present in grief is typically related to the loss or death. Depression is characterized by a general sense of worthlessness, despair, and lack of joy
  • Symptoms of grief may improve on their own with time. Someone with depression often needs treatment to recover.

Despite their differences, depression and grief are not mutually exclusive. If someone is vulnerable to depression, grief has the potential to trigger a depressive episode. If someone already has depression, their condition may prolong or worsen the grieving process. A therapist can help a person in mourning recognize and manage any depressive symptoms.

Bereavement and Culture 

Certain aspects of grief are virtually universal. Most cultures have rituals of mourning after a death. Crying is common, regardless of a person’s origins. However, the bereavement process can vary dramatically depending on one’s culture. Cultural values may affect a person’s:

  • Attitude toward death: Many Western cultures display death-denying traits. Death is often depicted as something to fight or resist. Eastern cultures, meanwhile, tend to characterize death to be a part of life. Death is often considered more of a transition than an end. Research suggests people in death-denying cultures tend to have more anxiety around death than people in death-accepting cultures.
  • Remembrance of the deceased: Some cultures, such as the Hopi or Achuar peoples, grieve by attempting to forget as much of the deceased as possible. It may be taboo for loved ones to say the person’s name or to touch their belongings. Rituals are done to sever connections with the dead. Other cultures mourn by sharing memories of the deceased. People in the Akan region of Ghana often hold elaborate funerals which may cost a full year’s income. The deceased are typically placed in “fantasy coffins” personalized with symbols of their life. 
  • Emotional DisplaysSocial norms can differ regarding how much emotion is “appropriate” to show. A 1990 study compared bereavement norms in two Muslim societies. Mourners in Egypt may be encouraged to grieve for an extended period of time. A person might display their love for the deceased through displays of unrestrained emotion. Meanwhile, Balinese culture tends to pathologize overt sorrow. People are encouraged to put on a happy face in front of others and to cut ties with the deceased.

When analyzing grieving behaviors, context matters as much as the symptoms themselves. Bereavement trends which are typical in one culture may be stigmatized in another. When working with individuals in grief, therapists may need to keep cultural influences in mind.

Disenfranchised Grief

Disenfranchised grief occurs when a person’s mourning is restricted in some way. Society may stigmatize a person’s mourning process or refuse to acknowledge their loss. Grief may be disenfranchised for several reasons:

  • Society devalues the loss. The loss of a pet often garners less sympathy than the loss of a human relative. Others may say “it was just an animal” and accuse the person of being too emotional. Yet research shows the mourning period for a pet is about the same length as for a human family member.
  • The loss is ambiguous. An adopted child may grieve the loss of their birth parents, even if said adults are alive. If a loved one has late-stage dementia, family members may feel as if the person they knew is gone.
  • Society stigmatizes the circumstances of the loss. Pregnancy-related loss is often considered taboo. Women who undergo a miscarriage may feel guilt and shame. They may avoid telling others about the loss to avoid being blamed. 
  • Society doesn’t recognize the person’s relationship to the deceased. A co-worker or friend may mourn a person, but they will likely receive less support than a family member. The same is true for ex-spouses, even though they used to be family. In societies with systemic homophobia, same-sex partners may also have disenfranchised grief.
  • Others do not consider the person capable of grief. When young children experience loss, adults may misinterpret signs of bereavement. They may believe the child is not capable of understanding the loss or have prolonged feelings about it. People who have cognitive impairments or intellecutal disabilities may also have disenfranchised grief.

Disenfranchised grief can interfere with the bereavement process. If society does not recognize a loss, the person may have trouble accepting it themselves. They may try to repress or deny their emotions. Shame and secrecy can make the symptoms of grief more severe.

Social support is often vital to recovery. A community can provide emotional and financial aid when people are vulnerable. Mourning rituals can offer closure. If a person is forced to grieve alone, they may have a delayed recovery.  

If you have lost someone or something precious, you may wish to find a therapist. Therapy can help with any sort of loss, whether society validates the grief or not. Therapy is an opportunity to explore your feelings and memories without judgment. No loss is too big or too small to warrant support. You do not have to endure your grief alone.

References:

  1. Doka, K. (2002). Disenfranchised Grief. In K. J. Doka (Ed.), Living with Grief: Loss in Later Life (pp. 159-168). Washington, D.C.: The Hospice Foundation of America.
  2. Gilbert, K. (2007, August 26). HPER F460/F450: Ambiguous Loss and Disenfranchised Grief, unit 9 notes. Retrieved from http://www.indiana.edu/~famlygrf/units/ambiguous.html
  3. Gire, J. (2014). How Death Imitates Life: Cultural Influences on Conceptions of Death and Dying. Online Readings in Psychology and Culture, 6(2). Retrieved from https://scholarworks.gvsu.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1120&context=orpc
  4. Is broken heart syndrome real? (2017, December 12). American Heart Association. Retrieved from http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Is-Broken-Heart-Syndrome-Real_UCM_448547_Article.jsp#.Ww3GkUgvyM8
  5. Kersting, K. (2004, November). A New Approach to Complicated Grief. Monitor on Psychology, 35(10). Retrieved from https://www.apa.org/monitor/nov04/grief.aspx
  6. Klass, D., Silverman, P. R., & Nickman, S. L. (1996). Continuing bonds: New understandings of grief. Philadelphia, PA: Taylor & Francis.
  7. Major Depressive Disorder and the “Bereavement Exclusion”. (n.d.) American Psychiatric Association. Retrieved from http://www.dsm5.org/Documents/Bereavement%20Exclusion%20Fact%20Sheet.pdf
  8. Wakefield, J. C. (2013). DSM-5 grief scorecard: Assessment and outcomes of proposals to pathologize grief. World Psychiatry. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683270
  9. Why we need to take pet loss seriously. (2018, May 22). Scientific American. Retrieved from Dishttps://www.scientificamerican.com/article/why-we-need-to-take-pet-loss-seriously

 

Last updated: 06-21-2018

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