Grief, Loss & Bereavement

What Are Grief, Loss, And Bereavement?

Signs and Symptoms of Grief, Loss, and Bereavement

People respond to loss in an enormous variety of ways. Emotional and behavioral responses to loss might include: sadness, preoccupation, yearning, depression, anxiety, or numbness. A grieving patient might oscillate between strong feelings and no feelings. Diagnostic systems are beginning to draw distinctions between normal and ‘pathological’ grief. DSM-5 identified persistent complex bereavement disorder, previously referred to as complicated grief, as a diagnostic category for further research.

Signs and symptoms of persistent complex bereavement disorder are listed below. To meet diagnostic criteria for persistent complex bereavement disorder particular symptoms must have been present: to a clinically significant degree; on more days than not; in a manner which is out of proportion to or inconsistent with cultural, religious, or age-appropriate norms; and must have persisted for at least 12 months following the death:

• persistent yearning or longing for the deceased
• intense sorrow and emotion pain in response to the death
• preoccupation with the deceased
• preoccupation with the circumstances of the death
• marked difficulty accepting the death
• experiencing disbelief or emotional numbness over the loss
• difficulty with positive reminiscing about the deceased
• bitterness or anger related to the loss
• maladaptive appraisals about oneself in relation to the deceased or death (e.g., self-blame)
• excessive avoidance of reminders of the loss
• a desire to die in order to be with the deceased
• difficulty trusting other individuals since the death
• feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased
• confusion about one’s role in life, or a diminished sense of one’s identity
• difficulty or reluctance to pursue interests since the loss or to plan for the future

Psychological Models and Theory of Grief, Loss, and Bereavement

There are a wide range of models and metaphors to help clinicians and their patients to conceptualize the grief process. A number of models draw upon Bowlby’s attachment theory to understand grief as a rupture in the attachment relationship.

• Elizabeth Kübler-Ross published a stage model of grief in her 1969 book On Death and Dying. Originally designed to understand emotional states experienced by terminally ill patients, it has been used more widely. It postulates that grieving individuals may go through stages of denial, anger, bargaining, depression, and acceptance.
• Margaret Stroebe and Henk Schut published their dual-process model of coping with bereavement in 1999. They propose that effective ways of coping with bereavement include both loss-oriented and restoration-oriented process, and that bereaved individuals will oscillate between both processes.
• Paul Boelen, Marcel van den Hout, and Jan van den Bout published a cognitive behavioral model of complicated grief in 2006. Bearing some similarities to the cognitive model of PTSD, this model identifies mechanisms that may serve to maintain and prolong the grieving process. These maintenance mechanisms include poor integration of the separation (loss) with existing autobiographical knowledge, negative global beliefs and misinterpretations of grief reactions, and anxious and depressive avoidance strategies.

Evidence-Based Approaches for Working with Grief, Loss, and Bereavement

Techniques that specialists in grief therapy have found helpful when working with grieving patients include:

• encouraging the patient to narrate their story of the loss, the events leading up to it, and subsequent events;
• exploring the meaning of the loss for that individual;
• engaging in mourning tasks;
• using imagery to ‘talk’ to the deceased.

Resources for Working with Grief, Loss, and Bereavement

Psychology Tools resources available for working therapeutically with grief, loss, and bereavement may include:

• psychological models of grief, loss, and bereavement
• information handouts for grief, loss, and bereavement
• exercises for grief, loss, and bereavement including mourning tasks
• grief and loss worksheets: CBT worksheets for grief, loss, and bereavement
• self-help programs for grief, loss, and bereavement

References

• Boelen, P. A., van den Hout, M. A., & van den Bout, J. (2006). A cognitive-behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13(2), 109–128.
• Kübler-Ross, E. (1969). On death and dying: What the dying have to teach doctors, nurses, clergy and their own families. New York: Scribner.
• Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197–224.