The five domains of the Kübler-Ross grief cycle (denial, anger, bargaining, depression, acceptance) is commonly quoted in the conversation about grief.
However, research has noted that while there may be different domains of grief, not everyone experiences all domains. Furthermore, grief is not a linear process and individuals often move back and forth among the domains before resolution.
There are various forms of grief and it is not always experienced immediately after the death of a person.
Content
What is grief?
Grief is an intense emotional response to loss. This can include (but is not limited to) the loss of a loved one, the ending of an important relationship, and/or loss of independence from a debilitating illness.
Difference between Grieving and Mourning
Grief is a highly personalised process of experiencing reactions to perceived loss. Mourning is the behavioural manifestations of grief and is often influenced by social, cultural or religious norms.
In some circumstances, mourning can facilitate grieving e.g. attending the funeral of a loved one and being able to use the time to say a meaningful final goodbye. In other circumstances, mourning may make it more difficult for an individual to grieve. For example, an individual may prefer to grieve in solitude but the societal and cultural norm may requires the person to interact with many people, perform certain rituals or carry out certain duties.
Manifestations of Grief
There are many possible physical manifestations of grief:
Crying
Loss of appetite (anorexia)
Loss of interest (anhedonia)
Insomnia
Fatigue
Chest tightness
Abdominal discomfort
Heightened sensitivity to noise
Shortness of breath
Weakness
Grief can also be accompanied by other emotional states and thought patterns:
Sadness
Anger
Guilt
Anxiety
Confusion
Depersonalisation
Recurrent dreams of the deceased
Lack of emotions
Disorganisation in daily routine
People who are grieving can also experience "grief pangs" which are highly intense, short bursts (e.g. 20-30 minutes) of distress. There does not necessarily need to be clear trigger for such episodes to occur.
Types of grief
There is no universal classification of the types of grief. Grief is a subject that is continuously being studied and the definitions of the types of grief are constantly being revised in order to guide diagnosis and management.
Being able to correctly identify the type of grief a person is experiencing can help in determining the type of support that they need.
Normal grief (common grief)
Normal grief is a normal response to loss. The intense feeling of sorrow may make it difficult to continue with daily activities although it should not incapacitate a person. Much of the emotional distress arises from the awareness of being permanent separated from the deceased.
As time passes, there is gradual transition towards integrated or abiding grief. There may never be complete resolution of grief, but it will no longer be intensely painful.
Anticipatory grief
In the past, grief was primarily considered a post-death reaction. However, in present times, anticipatory grief is increasingly being recognised as a significant and unique form of grief that requires attention.
Anticipatory grief is the grief reaction that occurs pre-death - upon receiving knowledge of imminent death, grieving begins in response to multiple losses:
The loss of normalcy e.g. stability, certainty
The loss of opportunities e.g. to get married, see their children grow up, meet their grandchildren
The loss of independence in terms of physical function or cognitive ability
Complicated Grief (Pathological Grief)
According to the American Psychological Association (APA), complicated grief is a response to loss that deviates significantly from normal expectations. It is usually last longer than than normal grief and can cause functional impairment i.e. inability to work, look after one's health, and/or inability to function socially.
People experiencing complicated grief require more specialised attention and may benefit from grief counselling and medications.
There are different types of complicated grief:
Chronic Grief
Chronic grief is the failure of transition from acute grief to integrated grief. As a result, the individual experiences the intense emotions for a prolonged period of time (6 months is the ballpark figure).
Delayed Grief
Delayed grief describes a reaction whereby the symptoms of grief are only experienced after a long time - it could be weeks to years - after the death has occured. The grief may be triggered by a seemingly unrelated event and may result in an out of proportion emotional response to the severity of that incident.
Inhibited Grief
Inhibited grief occurs when the individual avoids confronting the reality of the loss. They may distract themselves with other activities and do not manifest any of the symptoms of grief.
Distorted Grief
Distorted grief manifests as an intense reaction to a loss that often includes a change in behaviour. It often involves hostility to others and self-destructive behaviour.
Difference in response to an unexpected and expected death
Unexpected death
In an unexpected death, intense shock often precedes the normal grief reaction. There may be initial strong sense of disbelief ("This is just a bad dream, right?") and numbness to the situation. When gradual acceptance of the situation occurs, the normal grief reaction often kicks in all at once.
Confusion may be a prominent feature. There will be many questions about how the death happened and why did it happen especially if the deceased was very yong.
There may also be guilt if the last interaction with the deceased was not a favourable one e.g. if the last thing that you said or felt about that person was not pleasant. There may be self-blame and revisiting of the recent past with regret ("if only I had did that instead, things may have turned out differently.")
There may also be a lot of uncertainty if the individual had passed on without leaving behind instructions on what to do after his/her death (which is common if the individual is young and if the death is unexpected).
It may be difficult to achieve proper closure as there may not have been a proper goodbye.
Expected death (such as death from a terminal illness)
Prior to the death, anticipatory grief may be a prominent feature and it can be stretched out over a period of months to years.
Anticipatory grief can sometimes be more complex than normal grief because of:
Guilt: family members and friends of a terminally ill person may feel guilty for having thoughts about the person dying while they are still alive or wishing that the person will pass on sooner
Frustration and fatigue: the loved ones of a terminally ill person often have to taken on additional roles (i.e. caregiver role) as the person loses independence. They may feel frustrated at having to give up their personal freedom or because of the extra demands placed on them ("my life is already so difficult; why must you ask me to do this task this specific way?")
Uncertainty and anxiety: anticipatory grief is often accompanied by thoughts of 'what is going to happen in the near future?' and 'how will the death happen?'
Anticipatory grief is under-recognised: loved ones of people with terminal illnesses may feel that the people around them do not understand why they are grieving when death has not happened yet; these unacknowledged and unvalidated emotions can lead to 'disenfranchised grief' which makes it difficult for them to process and recover from
However, in contrast to sudden death, being diagnosed with a terminal illness grants one the opportunity to say proper goodbyes and this can help achieve better closure for the surviving loved ones. It also allows one to prepare instructions on how they want their assets distributed after death which can lead to less post-death uncertainty for their loved ones.
Occasionally, death from a terminal illness can bring about relief for their loved ones. This relief can come from knowing that the sufferings of their loved one has finally come to an end. It can also come from the release of their responsibilities as a caregiver.
End outcome of grief
For most people, the grieving process is never fully completed but is no longer intensely painful. Acute grief evolves into integrated grief whereby the deceased is called to mind with sadness and longing but may reawaken during significant anniversaries or stressful periods.
There is no consensus to what working through grief entails but the process consists of at least three fundamental segments:
Acknowledging the death
Acknowledging the death involves coming to terms with the finality of the death. Young children may face difficulty with grasping the irreversibility of the death and understanding the cause of the death.
Working through the pain
Working through the pain entails recognising the emotional and physical manifestations of grief, making sense of it and resolving it.
Accommodating the death
Accommodating the death - also known as "reconstitution" - involves day-to-day and emotional task reassignment (i.e. taking on roles previously played by the deceased), redefinition of self, and ultimately the resumption of routine life. Successful reconstitution usually leads to a decrease in the frequency and intensity of grief.
It is important to note that that dissipating or absent sadness
Does not mean that you do not miss the person,
Does not mean you have forgotten the person, and
Does not mean that the person is no longer important to you.
Even though the actual relationship with the person has ended in the physical terms, there are still ways to find new and meaningful ways of continuing the relationship with the deceased. (More about this in another upcoming article!)
Conclusion
"What is grief, if not love persevering?" -- Vision, WandaVision
We grieve because we love. Although grieving is a painful and challenging process, it often leads to significant personal growth.
Terminal illnesses tend to bring about a protracted period of anticipatory grief but with proper planning and guidance, loved ones can achieve better closure and gain more certainty on the post-death events.
If you find that you, or someone you know, is not coping well with grief, do reach out for help.
References
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Tomarken, A., Holland, J., Schachter, S., Vanderwerker, L., Zuckerman, E., Nelson, C., Coups, E., Ramirez, P. M., & Prigerson, H. (2008). Factors of complicated grief pre-death in caregivers of cancer patients. Psycho-oncology, 17(2), 105–111. https://doi.org/10.1002/pon.1188
Zisook, S., & Shear, K. (2009). Grief and bereavement: what psychiatrists need to know. World psychiatry : official journal of the World Psychiatric Association (WPA), 8(2), 67–74. https://doi.org/10.1002/j.2051-5545.2009.tb00217.x
Borins M. (1995). Grief counseling. Canadian family physician Medecin de famille canadien, 41, 1207–1211. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2146191/pdf/canfamphys00089-0077.pdf
Devan G. S. (1993). Management of giref. Singapore medical journal, 34, 445-448. http://www.smj.org.sg/sites/default/files/3405/3405ia1.pdf
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