Grief is a natural and universal response to the loss of a loved one. The grief experience is not a state but a process. Most individuals recover adequately within a year after the loss; however, some individuals experience an extension of the grieving process. This condition, identified as prolonged grief disorder, results from a failure to transition from acute to integrated grief. Symptoms of acute grief include sadness, tearfulness, and possibly insomnia, and typically require no treatment. Prolonged grief disorder involves intense, painful emotions associated with a lack of adaptation to the loss of a loved one that persists for more than 1 year in adults and more than 6 months in adolescents or children. This condition is estimated to affect as many as 7% of bereaved individuals.
The terms grief, mourning, and bereavement have slightly different meanings:
Grief is a person's emotional response to loss. Loss can commonly include the death of a loved one. Alternatively it can be in the form of receiving a terminal diagnosis resulting in the anticipatory knowledge of impending loss of life.
Mourning is an outward expression of that grief, including cultural and religious customs surrounding the death. Mourning is also the process of adapting to life after loss.
Bereavement is a time period of grief and mourning after a loss.
Anticipatory grief is a response to an expected loss that affects the person diagnosed with a terminal illness as well as their families. Healthcare professionals can experience anticipatory grief as they work with patients approaching the end of life.
Disenfranchised grief, as defined by Kenneth Doka (1989), is "grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported." Some examples could include grief related to the loss of a pet, perinatal losses, and loss of a body part. Healthcare professionals may experience disenfranchised grief in the workplace with patient deaths or complicated patient outcomes.
There have been many theories on grief processing. One of the most notable and historic theories was presented by Dr Elizabeth Kubler-Ross in her 1969 book, On Death and Dying. The book explored the experience of dying through interviews with terminally ill individuals and outlined the 5 stages of dying: denial, anger, bargaining, depression, and acceptance. This work is historically significant as it marked a cultural shift in the approach to conversations regarding death and dying. Before her work, the subject of death was somewhat taboo. Patients at the end of their life were not always given a voice or choices in their care plan. Some were not even explicitly told about their terminal diagnosis. Her work was popular in medical and lay cultures and shifted the nature of conversations around death and dying by emphasizing the experience of the dying patient.
Kubler-Ross's 5 Stages of Dying
Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. While persistent denial may be deleterious, a period of denial is quite normal and could be important for processing difficult information.
Anger is commonly experienced and expressed by patients as they concede the reality of their loss. The anger may be directed at blaming cllinicians for inadequately preventing a terminal illness, family members for contributing to risks or not being sufficiently supportive, or spiritual providers or higher powers with a sense of injustice.
Bargaining typically manifests as patients seeking some measure of control over their illness or loss. The negotiation could be verbalized internally, as well as medical, social, or religious applications. Bargaining can appear rational, such as committing to treatment recommendations, or it could also represent more magical thinking, such as efforts to appease misattributed guilt they may feel is responsible for their diagnosis.
Depression is perhaps the most immediately understandable of Kubler-Ross's stages, and patients experience it with symptoms such as sadness, fatigue, and anhedonia. Spending time in the first 3 stages is potentially an unconscious effort to protect oneself from this emotional pain.
Acceptance describes recognizing the reality of a difficult diagnosis while no longer protesting or struggling against it. Patients may focus on enjoying the time they have left and reflecting on their memories. They may begin to prepare for death practically by planning their funeral or helping to provide financially or emotionally for their loved ones.
Understanding the stages has less to do with promoting a linear progression and more to do with anticipating patients' experiences to allow more empathy and support for whatever they go through.[
Dual Process Model of Coping with Bereavement: Stroebe and Schut: Dual process 1999
In 1999, Margaret Stroebe and Henk Schut published the dual process model of coping with bereavement. In this model, the bereaved intermittently confronts and avoids the stressors of grieving. The stressors are divided into 2 categories: those oriented towards restoration, for example trying new things, and adjusting to their changing reality, and those oriented towards their recent loss, such as the intrusion of grief into daily life, or breaking relational bonds as a result of the loss. Attending to work in both categories can be burdensome, so oscillating between them, as well as doing the work in tolerable increments, is important.
Neimeyer's Narrative and Constructivist Model
Robert Neimeyer views grieving as a process of meaning-making. He has published many works ranging from the 1990's through 2024. His theory acknowledges that people co-construct their understanding of reality through a narrative of their own life stories, influenced by their beliefs and world views. He describes "6 key realities influenced by death." In these 6 realities, he acknowledges that significant loss can validate or invalidate a person's framework and beliefs in life; this may require developing a new framework to heal and incorporate the loss into their worldview. Grief is simultaneously universal and unique, so the therapy for the bereaved must be tailored to each client's individual needs. The process of grieving is inherently an active rather than passive process, filled with decision-making and reconstruction both practically and existentially.
Emotions during the grieving period are useful and can serve as guides in reconstructing a sense of balance and meaning in life after the disruption caused by significant loss. Reconstructing an identity after a significant loss is an inherently social process, as the new identity is partly defined in relation to their community and social norms. Finally, adapting to loss involves finding a way to incorporate the loss into a new identity and self-narrative, giving the loss a sense of meaning and making sense of the changes. This can enable not only survival after a loss but eventually thriving. Therapists using the narrative and constructivist model may have patients re-tell the story of their loss with visual aids, exploring the thoughts and feelings accompanying it. They may also suggest writing goodbye to the deceased or exploring their feelings through metaphors.
Prolonged Grief Disorder
Most people can adequately process their grief within a year for adults or 6 months for children or adolescents. This does not mean that they have forgotten their loved one or are not still impacted by their loss, however, they are functional and are no longer severely affected by the distress of intense grief to a degree that limits their daily activities on a regular basis. They have been able to move forward in their lives and incorporate their loss into their new reality. However, there are some people who develop what is called prolonged grief disorder and continue to have severe symptoms of grief for a prolonged period of time.
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