Ananya Kowta
National Forensic Sciences University, Gandhinagar
9th December 2024
Grief is primarily an emotional/affective process of reacting to the loss of a loved one through death (Stroebe, et al. 2008). It cannot be reduced to a single emotion, rather it is an experience encompassing a multitude of thoughts and feelings which are manifested physically, mentally, emotionally, behaviourally and defined by factors ranging from broader social paradigms such as culture to individual differences such as personality. Bereavement is the state or objective reality one faces after having lost an important person via death. According to Sanders (1989), bereavement describes the vast array of changes and conditions that follow loss. It describes the existential state and experience that a person goes through after accepting that a major loss has occurred in their life. Grief is an internal experience of an external event of loss and the meaning the bereaved person usually assigns to that loss (Abi-Hashem, 1999).
Grief is a natural and indispensable response to loss. Death of a significant other is considered as an indicator of maximum distress in an individual’s life and consequently increasing the risk of serious physical and mental health disturbances including but not limited to sleep disturbances, depression, cardiovascular diseases, inflammation-related health problems and even some types of cancer. While psychological intervention is not usually required, in some cases, grieving takes a more unnatural turn. Recently, the focus of research has shifted to differentiating between normal, uncomplicated grief and complicated grief. Healthy grieving is believed to be a process of gradually letting go of emotional energy towards the deceased, while complicated or pathological grief is an inability to let go. Common reactions of grief include: sense of shock, feelings of anxiety, distress, anger, loneliness, emptiness and anguish, insomnia (difficulty falling asleep, sleeping too much or too little), persistent lack of energy, denial or disbelief, feeling numb or overwhelmed, guilt or self reproach, changes in appetite, social withdrawal, difficulty concentrating, anhedonia or lack of pleasure from usually enjoyed tasks, pessimism or apathetic towards life, and in fewer cases, depersonalisation (feeling like one is not real) and/or derealisation (feeling like the world is not real). These reactions may occur in isolation or together, but are typically experienced intensely in the initial stages following loss and gradually abate over time. Prolonged, intense reactions may indicate the need for psychological interventions.
However, it is also important to note that grief is more than often a never ending process, outlining two types- acute grief occurs immediately following loss, characterised by normative reactions such as intense sadness and crying, social withdrawal, preoccupation with thoughts of the deceased, difficulty concentrating, and denial among others and later grief or integrated where the bereaved experiences sadness and longing and gradually finds his way back to living a fulfilling life. Though grief has been integrated, it is not marked by the emotional or mental loss of the deceased; they continue to be important to the bereaved.
Theories of grief
Freud (1917) proposed the original “grief work” theory where he outlined the process of decathexis or emotional withdrawal of one’s attachment to the deceased. Freud differentiates between mourning and melancholia referring to the former as grief and the latter as depression - “In grief, the world looks empty to the person and in depression, the person experiences the self as empty.” Freud described an intrapsychic, universal process of dis-investment of libidinal (mental and emotional) energy (decathexis) from memories of the lost loved one. He postulated that a person’s grief resolves when decathexis was complete and the person could invest his emotional energy into new relationships and activities. The mourning activities are called “grief work.” He said, “when mourning is complete, the ego can become free and inhibited again.” While decathexis was considered to be a normal part of the grief process by Freud, later analysts were of the view that it was more reflective of unsuccessful or partial mourning.
Erich Lindemann (1944) distinguished between normal grief and morbid grief in his paper titled “Symptomatology and Management of Acute Grief.” Normal grief, corroborating with acute grief, occurs as the bereaved experiences and accepts the loss of loved one, navigating the various emotional responses stemming from it. On the other hand, morbid grief refers to repressed or denied grief. Such morbidity may be a result of delay or postponement of grief responses, in case of situations where the bereaved is required to remain stable and keep up the morale of others and consequent to the delay, distorted reactions, where the person’s original grief morphs into overactivity, hypochondriasis or hysteria, psychosomatic conditions or medical conditions, social withdrawal, intense anger towards specific people, apathy, and agitated depression. Lindemann identified five common symptoms of grief: somatic distress (lethargy/exhaustion, shortness of breath, lack of appetite and motivation), preoccupation with images of the deceased (positive or negative memories), guilt (feeling personal responsibility in the death of the loved one), hostile reactions to others (irritability, hostility, anger), and loss of pattern of conduct (restlessness, meaninglessness, lack of daily routine or structure). He also identified a sixth, less common symptom where the bereaved person adopts the traits of the deceased. This could include behaving or appearing to look like the deceased. Importantly, Lindemann acknowledged a physical component of grief, along with its psychological manifestation. His concept of ‘grief work’ involves three primary steps. The first step is referred to as ‘emancipation from bandage to the deceased’, that is, moving on from emotional and mental attachment to the deceased in order to grieve healthily and restore a normal routine and seek new relationships. Second, ‘readjustment to a new environment in which the deceased is absent’ involves accepting the world where a loved one ceases to exist. And lastly, forming new relationships. Success of the final step depends on the success of the first step of letting go. Expression of grief is thus an important element of the grieving process according to Lindemann, failure of which leads to morbidity, demanding psychological interventions.
John Bowlby (1980) and Colin Parkes (1972) developed the phases of mourning, outlining the trajectory of grief after the death of a loved one. They identified four stages beginning with shock and numbness, which is believed to play an adaptive role in helping the bereaved defend themselves against the pain of loss through its disregard. The second stage is characterised by yearning and searching, where the bereaved tends to deny the permanence of the loss, often resulting in feelings of hostility and anger. Thirdly, the bereaved experiences disorganisation and despair, often taking the image of existential questioning of life and its new meaning or lack thereof for the bereaved. The third phase is the most painful overcoming which the person moves on to the final phase of reorganisation wherein they are able to restore purpose and fulfilment in their lives. When the goal of attachment is motivated by the need for security, safety and affection, situations that endanger them lead to specific reactions. Bowlby pioneered the field of attachment theory and extending it to grief work, postulated that a person’s pattern of grief is a result of their attachment styles, that is secure or insecure attachment, that develops over the course of life. Bowlby rejects the Freudian consideration of attachment as a result of strictly internal processes, emphasising on the role of social and developmental factors defining patterns of attachment in children and adults alike. Parkes, like Freud, considers grief work a necessary process to overcome painful loss. This involves confronting preoccupation with thoughts of the loved one and modifying assumptions of the new world where the loved one no longer exists.
William Worden understands grief as the experience of losing a loved one to death or the reaction to bereavement composed of thoughts, feelings, behaviour, and physiological changes that differ in pattern and intensity over time (Worden, 2008). Worden strays away from the theory of stages of mourning, noting that the grieving process does not take a linear direction to adaptation. While he partially agrees with the theory of phases of grief, as developed by Parkes, Bowlby among others, his work resonates the most with Freud’s theory of tasks of grief, identifying mourning as a process. Worden outlines four tasks of grief which he considers essential in order to overcome and adapt to loss. Firstly, to accept the reality of loss, that is, against the feelings of shock and numbness that initially accompany grief, one is expected to confront and accept their realities. The second task involves processing the pain rather than rationalising or repressing it. The third task requires adjustment to a world without the deceased, which occurs at three levels - external adjustment to the environment and social relations and obligations, internal adjustment to one’s own sense of self and identity and spiritual adjustment to one’s assumption of the world they inhabit. The fourth and last task asks the bereaved to emotionally relocate the deceased and move forward in their life. This task of memorialising the deceased within oneself without compromising on living their own life is unlike the task of decathexis as proposed by Freud in that it incorporates a healthy reminder of the loss.
Stroebe and Schut (1999) criticised the earlier theories of grief and particularly grief work as imprecise, lack of dynamic representations of the grieving process and a lack of empirical evidence, cultural and historical validation of theories, with a limited focus on health outcomes. Fundamentally, the dual process of grieving differs from earlier models in identifying two kinds of stressors associated with bereavement, namely, those oriented to loss and those oriented to restoration. The former involves processing and accepting loss of the loved one and the emotional, mental, physical experience of bereavement, that is, the primary stressor, through grief work, breaking bonds and emotional relocation. Restoration orientation, on the other hand, deals with the secondary stressors associated with grief such as adopting new roles and relations, fulfilling obligations, reorienting oneself to the new environment and the world. The theory is refreshing in that it acknowledges denial, repression, and avoidance as a normal part of the grieving process, shedding it of its trajectory towards morbidity or prolonged, complicated grief. Here, the concept of oscillation is critical to the theory, as it allows a person to oscillate between confronting the loss/restoration and avoiding the loss/restoration. According to this model, bereavement is a complex process of avoidance and confrontation, and oscillation between the two types of stressors is necessary for healthy coping.
Stages of Grief
Elizebeth Kubler Ross adapted Robertson, Bowlby and Parkes’s (Bowlby & Parkes, 1970; Robertson & Bowlby, 1952) Phases of Grief to describe the Phases of Dying (Ross, 1970),11 or what has unequivocally come to be described as the Stages of Grief. Though that was ot the intent, Kubler-Ross’s theory has aided theories of grief over the last 40 years. She identifies 5 stages in coming to terms with death or loss.
1. Denial: denial is the period of grieving where the bereaved denies the reality of the death of a loved one. Denial is a common defence mechanism where a person guards themselves against anxiety-provoking situations. Accompanied by shock, numbness and disbelief, denial is a normal part of the grieving process where a person begins to acknowledge an upsetting reality. This may include refusal to accept or address the loss.
2. Anger: upon addressing the reality of loss, anger is a natural response. A person may consider the loss to be unfair, often directing the anger towards oneself, doctors, God or other family members. The bereaved turns hostile and irritable in this stage.
3. Bargaining: grief is accompanied by feelings of helplessness and loss of control. In order to restore control and overcome loss, one often resorts to irrational negotiating, usually with a higher power, in order to secure more time with the loved one. Bargaining is reflective of irrational or magical thinking. Alternatively, one may also engage in counterfactual thinking such as “if only I had..”
4. Depression: Common symptoms of sadness, lethargy, agitation or restlessness, anhedonia take over the bereaved. While the previous stages help protect oneself, this stage allows one to process the emotional pain of loss.
5. Acceptance: the fifth and last stage of Kubler-Ross’s stages of grief is a stage of grief where one comes to terms with the reality of their situation, no longer denying it or struggling against it.
Grief and culture
The primary question under this section is how the grieving process is both a personal yet social process. Grief is a universal experience, but its expression and management are profoundly influenced by cultural contexts. Different cultures have unique practices and beliefs regarding death, mourning, and the grieving process. For example, in many Western cultures, grief is often expressed openly and publicly, with a focus on individual emotional processing. In contrast, some Eastern cultures, such as those influenced by Confucianism, may emphasise a more restrained and communal approach to mourning, reflecting a broader social and familial context.
The loss of a loved one is both an individual and collective loss in how the reaction is extremely intimate yet driven by rituals deemed “appropriate” by religious factors. Every society differs in its expression of grief in terms of their rites, rituals and tradition driven by their belief system. For instance, in Hinduism, the mourning period lasts thirteen days where the grieving family holds a ceremony on the last day to help release the soul for reincarnation. This is primarily driven by the Hindu belief of a cyclical universe where a soul is reborn in a new physical form owing to his karma (good or evil actions) in the past life. On the other hand, in Christianity, the traditional mourning process lasts up to forty days. Their faith revolves around a belief in heaven, hell and purgatory depending on one’s actions in his life; the righteous go to heaven, the sinners go to hell, while those who have committed forgivable sins spend time in purgatory before going to heaven.
From a socio-cultural standpoint, in the United States, mourning typically involves a sequence of customs and observances that highlight personal introspection and public expression. The notion of finding "closure" is key, as people are urged to navigate their grief by discussing their loss, joining support groups, and taking part in memorial events. The American approach to mourning often centres on individual feelings and the emotional journey through the grief stages proposed by Kübler-Ross (1969), which include denial, anger, bargaining, depression, and acceptance. Conversely, in Japan, the experience of sorrow is closely connected to the cultural custom of honouring ancestors and the tradition of "O-bon," a festival dedicated to deceased ancestors. Families gather during the O-bon festival to conduct ceremonies guiding the spirits of the departed to their resting places, and to present prayers and food at family altars. This collective approach highlights the importance of preserving family lineage and integrating grief into ongoing cultural and familial traditions, rather than solely focusing on individual emotional coping. In Ghana and other African societies, elaborate funerals are part of traditional mourning customs, serving not only as a time for individual sorrow but also as a means of reaffirming communal connections and cultural legacy. These rituals may encompass prolonged periods of grieving, with community members engaging in ceremonies that communicate shared sadness and unity. These customs demonstrate that mourning is not solely an individual process but also a social and cultural occurrence that bolsters community bonds. While these beliefs and associated rituals have no scientific evidence, they serve as spiritual and social support for the bereaved. Hawkins and Dawson suggest that end-of-life and post-death rituals and processes represent “social control of what is, an apparently biological event.”
Difference between grief and depression
Grief and depression differ in their affective and behavioural disruptions. However, they differ in terms of the pathology in cognitive functioning. Both cause feelings of intense sadness and low mood. Emotional reactions include crying, irritability, hostility, distress, numbness or feeling overwhelmed; the experience of emotional pain is similar in both cases. However, consistent with Freud’s theory of grief work, studies have indicated the presence of distorted, negative perceptions of the self and the world while differentiating depression from normal, uncomplicated grief.
According to the American Psychological Association, major depression is a medical illness that affects the way a person thinks, feels and behaves causing persistent feelings of sadness and anhedonia or a loss of interest in previously enjoyed activities. It is a chronic illness requiring long-term treatment. The current differentiation of normal grief from major depressive disorder was originally introduced in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, the DSM-III (1980) did not acknowledge complicated grief as a separate emotional disturbance, rather diagnoses it as depression or other psychiatric condition. This was potentially harmful in that it could lead to unwarranted treatment and intervention techniques causing more harm than good. With the DSM-IV (1994), bereavement was classified under the V code identifying it under ‘Other conditions that may be a focus of clinical attention.’ Additionally, the exclusion criteria advised clinicians to refrain from diagnosing major depression within the first two months following the death of a loved one as it would be incorrect to label a normal process of life as a disorder. While the rationale behind such exclusion was to prevent misdiagnosis of bereavement as major depression, it ran the risk of underestimating the progression of depression in a bereaved person.
While grief and depression are common in their emotional reactions, they also differ on certain aspects. One, painful memories of the deceased are intermixed with their positive memories in grief, while depression involves consistently negative thought and and affect. Two, the grieving process preserves one’s self esteem, while on the other hand, depression is accompanied by morbid preoccupation with worthlessness and self loathing. However, depression may more readily develop with bereavement, especially among those who are more vulnerable (genetic, biological, social or psychological vulnerability).
Types of grief
As discussed earlier, research differentiates between two major grief responses - normal, uncomplicated grief and complicated grief. In this section, we reiterate our understanding of normal grief and explore the specifying types of complicated grief. Anticipatory grief refers to a grief reaction in response to an anticipatory loss. It is defined as “the total set of cognitive, affective, cultural, and social reactions to expected death felt by the patient and family.” This type of grief is common in families of terminally ill or dying patients, although it is also common for patients themselves to experience the same.
Symptoms of such grief fluctuate unexpectedly and include intense sadness, loneliness, isolation, fear, anxiety, hostility, guilt, excessive preoccupation with the dying person and often, rehearsal of death. The trajectory of anticipatory grief may overlap with that of the traditional stages of dying. Distinctly, it may begin with acceptance of the inevitable loss of the loved one, reflection wherein the caregiver assesses their feelings such as anger, guilt, fear, sadness towards the dying person, rehearsal of death, that is, anticipating the feelings during and after death, and finally imagining the future and mapping a road to healthily letting go and moving forward in life. Also known as preparatory grief, it helps people cope with the impending loss and allows them to be less negatively affected at the end of life. However, studies also suggest that in cases of unrelenting loss, anticipatory grief may be a risk factor to the development of prolonged grief disorder.
Normal grief follows a natural trajectory characterised by gradual acceptance of the loss. Many theoretical models of normal grief have been postulated over the years, such as Kubler-Ross’s stages of dying outlining the process of mourning beginning with denial, anger, bargaining, depression and eventually acceptance. Other models include Worden’s four tasks of grief, Stroebe and Schut’s dual processing model of grief and Bowlby and Parkes’s stages of grief.
Acute grief occurs immediately after loss and is marked by a separation response. The bereaved experience confusion and uncertainty over their identity or their social role without the deceased during this moment of severe bereavement. As a result of shock and disbelief, they may withdraw from previously enjoyed or routine activities.
Complicated grief refers to an inability to emotionally and mentally let go of the deceased. Sudden or traumatic death, suicide, homicide, dependent relationship with the deceased, long-term illness, child death, multiple losses, unresolved grief from previous losses, simultaneous stressors, witnessing a difficult dying process such as pain and suffering, absence of support systems, and absence of a faith system are risk factors for developing complicated grief. Depending on the severity, complicated grief could require professional assistance. Lack of a support system, experiencing losses simultaneously, having inadequate coping mechanisms, and loneliness are all factors that lead to complicated grief in older persons. According to the End-Of-Life Nursing Education Consortium (2021), there are four types of complicated grief - chronic grief, exaggerated grief, delayed grief and masked grief.
Chronic grief refers to normal grief reactions that do not gradually subside but continue for longer than normal periods of time. Exaggerated grief is an intense reaction to grief including nightmares, phobias, delinquent behaviour and suicidal ideation apart from the normal grief reactions in the bereaved. Delayed grief involves the suppression or repression of grief responses by the person either consciously or unconsciously in order to protect oneself from the severity of the painful loss experience. Masked grief is more common in societies that dictate appropriate reactions of grief and refers to when the bereaved does not acknowledge their grief despite experiencing it.
Other types of grief include traumatic grief, usually in response to sudden unexpected loss, which along with normal grief reactions triggers intense anxiety or trauma in the bereaved about the event, disenfranchised grief which involves a lack of societal support and recognition of loss, and absent grief wherein the bereaved shows no signs of grief reaction, typically occurring after anticipatory grief.
DSM-5 Prolonged Grief Disorder
Prolonged grief disorder is characterised by an intense and persistent grief that causes functional and social impairment. A person suffering from prolonged grief disorder may experience intense yearning for the deceased or become obsessed with their memories. The person could also have severe distress or difficulty going about their daily life at work, home, or in other crucial areas. Disabling and impairing daily functioning, the prolonged grief differs from normal grief.
DSM-5-TR diagnostic criteria for Prolonged Grief Disorder requires that at least 12 months have passed since the loss in the case of adults, and 6 months for children and adolescents. Additionally, the person must report either intense yearning or preoccupation with memories of the deceased. The bereaved is also required to experience at least 3 symptoms in terms of their cognitive, emotional and behavioural functioning, such as identity disruption, avoidance of reminders of the deceased, intense emotional pain, emotional numbness and social withdrawal. The symptoms must cause functional impairment or clinically significant distress and cannot be explained by cultural factors or other medical and mental conditions.
Epidemiology: Prolonged grief disorder is comorbid with PTSD, anxiety or depression. Additionally, 80% of patients report chronically poor sleep. An estimated 7%-10% of bereaved adults will experience the persistent symptoms of prolonged grief disorder (Szuhany et al., 2021). Among children and adolescents who have lost a loved one, approximately 5%-10% will experience depression, posttraumatic stress disorder (PTSD), and/or prolonged grief disorder following bereavement (Melhem et al., 2013).
Risk factors: People with a history of depression or bipolar illness, as well as older persons, may be more susceptible to developing extended grieving disorder. Additionally at risk are caregivers, particularly if they were caring for a spouse or had dealt with depression before death. There is also an increased likelihood of extended sorrow in cases when a loved one passes away abruptly or in a traumatic way (Szuhany et al. 2021).
Conclusion
The experience of grief and mourning encompasses a wide range of influences from historical, theoretical, cultural, and clinical perspectives. Throughout history, the understanding of grief has evolved from early interpretations rooted in religion and philosophy to more modern psychological theories, such as Kübler-Ross’s stages and models of complicated grief. Culturally, mourning practices exhibit significant variation, reflecting diverse societal norms and values that shape how individuals express and manage their sorrow. Recognizing different types of grief - acute, chronic, and complicated - can improve the effectiveness of therapeutic interventions in a clinical setting. The DSM-5 incorporates these perspectives into a diagnostic framework, addressing grief-related disorders within a global context. This comprehensive approach, which merges scientific understanding with cultural sensitivity, emphasises the intricate nature of grief as both a personal and universal experience.
Ananya Kowta is part of the Global Internship Research Program (GIRP) under IJNGP.
TAGS GRIEF | LOSS | PSYCHOTHERAPY | CULTURE
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