Does the grieving process differ when dealing with the loss of a family member due to a terminal disease, compared to a sudden death (e.g. car accident)? Does knowing in advance that a family member is dying soon make things easier or harder?
The grieving process is different for the same person across differing circumstances. In other words, many factors may impact how a sudden loss or an expected loss is experienced by an individual – to list a few, factors such as one’s ability to accept the inevitable, one’s views on life and death, the impact on one’s self-identity and sense of security, and one’s capacities to cope with the loss and separation of a significant other.
Knowing that a cherished family member is dying soon may very well change our own responses toward that person. For better or worse, it may evoke proximity-seeking and increased efforts to be emotionally closer to that family member. However, for others, dealing with the eventual loss may be coped with by distancing oneself physically and emotionally from the family or family members, which may assist with lessening the perceived emotional pain to come.
It is said that people grieve in different ways. Is that true? Or is there a grieving process that is broadly similar for all?
Yes, certainly. People do grieve in different ways, and some more adaptively, and some more maladaptive. However, we must respect how each person grieves. Maladaptive ways of grieving (see Question 9), albeit unhelpful, still serve a specific purpose in regulating our emotions.
It is good to start with a broad understanding that grief (in the context of losing a significant other) is an emotionally painful process, dealt with in one’s own way, and one’s own time.
Please take us through the various stages of grief. What are the common symptoms for each stage? How long should each stage last?
Contrary to popular writings and homage to the Kübler-Ross’ (1969) Five Stages of Normal Grief (namely, denial, anger, bargaining, depression and acceptance), the original Four Phases of Grief may address the oversimplification of the Five Stages, and perhaps provide a more relatable context.
John Bowlby (1907 – 1990), a British psychologist and psychiatrist, who was a pioneer of attachment theory in children, tested theories that attachment was a survival mechanism in human evolution, and that children mourned separations from their primary caregivers.
By applying the theory of attachment and separation to grief and bereavement, Bowlby suggested that grief was a normal adaptive response when a loss occurs. Once our “affectional bonds” are threatened or broken, it follows with a grief response to separation and loss. The Four Phases of Grief (Bowlby and Parkes) are:
- Shock and numbness - This is the phase where there is a sense the loss is not real and seems impossible to accept. There is physical distress during this phase, which can result in somatic symptoms such as bodily tension in the form of aches and pains, nausea, or vomiting. If we do not progress through this phase, we will struggle to accept and understand our emotions and communicate them. We will shut-down emotionally, and not progress through the phases of grief.
- Yearning and searching - In this phase, we are acutely aware of the void left in our life from the loss. The future we imagined is no longer a possibility. We search for the comfort we used to have from the person we have lost and we try to fill the void of their absence. We may appear preoccupied with the person. We continue identifying with the person who has died, looking for constant reminders of them and ways to be close to them. If we cannot progress through this phase, Bowlby and Parkes feel we will spend our life trying to fill the void of the loss and remain preoccupied with the person we have lost.
- Despair and disorganisation - In this stage, we have accepted that everything has changed and will not go back to the way it was or the way we imagined. There is a hopelessness and despair that comes with this, as well as anger and questioning. Life feels as though it will never improve or make sense again without the presence of the person who died. We may withdraw from others. Bowlby and Parkes suggest that if we do not progress through this phase, we will continue to be consumed by anger, depression, and that our attitude toward life will remain negative and hopeless.
- Re-organisation and recovery - In this phase, your faith in life starts to be restored. You establish new goals and patterns of day-to-day life. Slowly, you start to rebuild and you come to realise that your life can still be positive, even after the loss. Your trust is slowly restored. In this phase your grief does not go away nor is it fully resolved, but for Bowlby the loss recedes and shifts to a hidden section of the brain, where it continues to influence us but is not at the forefront of the mind.
Each stage lasts as long as it needs to and this differs from person to person. If the person begins to regress into a space where their psychosocial daily functioning is unduly impacted by their emotional pain, it may be time to seek professional help to address the underlying issues that prevent psychological resolution of the loss.
Will the pain of losing a family member go away faster if you ignore it? Does the “fake it ‘til you make it” response work?
As introduced earlier, the pain of losing a family member may be experienced differently. Many may choose to ignore its impact, or face it head-on. Either way, there will be psychological consequences to our management of the emotional stress.
Our Emotional Competence is made up of our actual capacity to cope with the loss, but also our perceived capacity to tolerate its impact on us. In this way, sometimes “faking it till we make it” may work, but only temporarily, as it provides a space where someone can psychologically process the shock and numbness in a secure way. On the flipside, ignoring the pain may be the only way one knows how to cope, so confronting head-on is viewed as unhelpful but inconceivable.
If you don’t cry, does that mean you are less sad about the loss?
Of course not – from my personal clinical experience, it can be more concerning when individuals don’t cry when it is appropriate to. Crying is the behavioural manifestation of a felt emotion, and often the individual will display their emotional “behaviours” in ways that are consistent with what they have experienced with close others in their lives.
For instance, one may feel extremely sad, but hide their overt emotions, as it may be pointless or unsafe for one to display emotional vulnerability. In fact, for these individuals, they may have not received sufficient care and support from close others, which has then rendered them more prone to self-reliance and emotional shut-downs in times of stress.
How important is it to put on a strong front in the face of loss?
The decision to mount a behaviour (i.e., putting on a strong front in the face of loss) in place of emotional insecurity must be considered carefully. To some, this behaviour represents strength and leadership, such as in the context of being a parent so that one may be a figure of security to their children. Whilst to others, it helps them feel less vulnerable and more able to stay present in the process of mourning. Therefore, before we become judgmental about others or ourselves in the way and reason behind what is done in times of grief, it is useful to consider one’s emotional style of relating to others, and the context.
How can we tell the difference between someone who is coping with grief well and someone who isn’t? At what point does grief become a serious issue that warrants professional help?
Sometimes observation can give us a clue into what is consistent or inconsistent with one’s behaviour, as it may help us tell if someone might require professional advice. We might need to remember that grief is a normal response to loss, and this creates uncomfortable emotions that may be daunting to anyone. Whilst we are concerned and may likely enquire with the person in kind ways, sometimes it is wise to just be accessible to the person such that they may approach you when needed.
The process of grief must be respected like how we would like our privacy to be respected. Hence, one tip is to provide tangible help like offering assistance and tissue paper, without being overly intrusive. Sometimes asking the person what they need might suffice, allowing them the space to come forth with what’s on their minds. For all we know, it may not always be about the loss itself – so it’s worth keeping this in mind.
Is it common for people mourning the death of a family member to fall into clinical depression or other mental health disorder? How do psychologists/psychiatrists typically treat such patients?
I wouldn’t say it is common, but there is always a possibility that anyone may fall into clinical depression based on the accumulation of certain factors like sudden and unexplainable loss, an experience of loss as being traumatic, betrayal, attributing responsibility for another’s death etc.
Typically, anxiety and depression is experienced in aggregate levels and is a normal response to painful events, so as professionals, we do not assume anything about how painful or not painful an event may be. The assumption is that there is a possibility that one may suffer from a specific experience of loss, but before we go down the lane of assuming that that was the case, we always enquire about how they experienced the loss and what emotions followed. One common mistake for novice practitioners is that we first assume that it was tough and difficult for our patients – we may be sorely mistaken!
What is the best advice you can give to those who have suffered a death in the family? Can you share any healthy coping tips or strategies?
Embrace your emotions, they are what makes you, you! Give yourself permission to experience them for what they are, but do so in the comfort and safety of those you trust. If this is not for you, give yourself individual space and adequate time to feel more in control before evaluating if you’d like to join in with others. Go for a walk and take some time off away from distractions. The idea is to remove what gets in the way so we can allow ourselves the opportunity to come to terms with what we’re experiencing, even if it was severely difficult.
If you become tough on yourself for the death in the family, perhaps taking a break from criticising yourself may be useful. Take a break from work and where necessary, tell someone who cares about what you’re going through. You do not need to tell many others about your problems if that scares you, but the value of being cared for cannot be underestimated. We know that emotional support in times of stress is a strong protective factor from mental illness.
Common maladaptive ways of coping that make it difficult for us to come to terms with our experience is drugs/ alcohol, lashing out at others, and seeking gratification from food, sex and material goods. More adaptive ways of coping include getting involved in things that provide meaning for us in our lives and which remind us that we are valued. Seek others who are caring and really do bother about how we feel. Try not to change your life too much so that it introduces unwanted stress to yourself – the loss is stressful enough. Lastly, give yourself time and allow yourself the experience of painful emotions.