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Grief is our natural human response to bereavement

When we're badly physically injured, there may be horrible pain and loss of ability to function normally. Then though there is typically a gradual recovery.  Scars may be left; there may be some persisting vulnerability, but basically our bodies are wonderful at self-healing.  There are parallels between wounds due to physical injury and wounds due to emotional injury.  For example, when we are bereaved, there may be horrible pain and loss of ability to function normally.  Gradually, over time, our minds & hearts can heal.  Of course, if we have lost someone important to us, we will never be quite the same.  We may always miss them, and remember them with sadness, gratitude and love.  The grief resolves though and we can move on with our lives, even though we continue to carry our loved ones in our hearts ... and this resolution is what they would have wanted for us.

As Professor Kathy Shear has written in her article "Getting straight about grief" - "Acute grief is emotionally intense, cognitively preoccupying, and disruptive, but grief is not an illness; major depression and anxiety are. Grief and mourning have a purpose.  They provide an intense, focused opportunity to reregulate emotion and to engage in a learning process that is aimed at reconfiguring life without the deceased - both the internal life of the mind, and ongoing life in the world.  A bereaved person needs to figure out how to find meaning, purpose, joy, and satisfaction in life without someone who has previously been central to these feelings.  This reconfiguration is a very natural process that tends to occur in fits and starts as bereaved people move forward and deal with everyday life.  Nevertheless, a knowledgeable, empathic and supportive clinician can foster good adjustment." 

It's a truism to say that people grieve in a whole variety of ways.  There does however seem to be validity to the idea that there are often "stages of grief".  Maciejewski & colleagues followed 233 bereaved people for two years after the death of a loved one and wrote in their 2007 paper "An empirical examination of the stage theory of grief" - "Five rater-administered items assessing disbelief, yearning, anger, depression, and acceptance of the death from 1 to 24 months postloss. Results: Counter to stage theory, disbelief was not the initial, dominant grief indicator. Acceptance was the most frequently endorsed item and yearning was the dominant negative grief indicator from 1 to 24 months postloss. In models that take into account the rise and fall of psychological responses, once rescaled, disbelief decreased from an initial high at 1 month postloss, yearning peaked at 4 months postloss, anger peaked at 5 months postloss, and depression peaked at 6 months postloss. Acceptance increased throughout the study observation period. The 5 grief indicators achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the stage theory of grief. Conclusions: Identification of the normal stages of grief following a death from natural causes enhances understanding of how the average person cognitively and emotionally processes the loss of a family member. Given that the negative grief indicators all peak within approximately 6 months postloss, those who score high on these indicators beyond 6 months postloss might benefit from further evaluation."

It does make sense to review at about 6 months postloss to check that grief is easing.  In their 2011 article "The prevention and treatment of complicated grief: A meta-analysis", Wittouck et al commented "Bereaved individuals are at increased risk of mental and physical disorders, and prevention and treatment of complicated grief is indicated. Earlier quantitative reviews have not focused on the effect of bereavement interventions on (complicated) grief. Therefore the main objective of this meta-analysis was to determine the short-term and long-term effect of both preventive and treatment interventions on complicated grief ... Fourteen randomized controlled trials met the inclusion criteria ... Contrary to preventive interventions, treatment interventions yielded significant pooled standardized mean differences in favor of the (specific) grief intervention at post-test and follow-up. During the follow-up period, the positive effect of treatment interventions for complicated grief even increased. Conclusions Treatment interventions can effectively diminish complicated grief symptoms. Preventive interventions, on the other hand, do not appear to be effective."  So at that stage (in 2011), carefully designed treatments for established complicated grief seemed helpful, but effective prevention had lagged behind.  More recently preventive interventions have begun to show promise.  Litz & colleagues in their 2014 paper "A randomized controlled trial of an internet-based therapist-assisted indicated preventive intervention for prolonged grief disorder" reported encouraging outcomes for a CBT-based preventive approach aiming to promote reengagement (self-care activities) and reconnection with supports for those who, prior to six months post-bereavement, were suffering from high levels of symptoms & impairment - more detail is available on the web.

So our current understanding is that the great majority of people who have lost a loved one will grieve and over several months their grief will gradually ease.  The process has parallels with recovery after physical injury. Mourning may well involve powerful feelings of yearning, disbelief, anger & depression.  When we have lost someone who has been very important to us, of course we need time to learn to live without them. Reconfiguring our inner emotional lives and our outer activities can be such a challenge.  Mostly though people manage.  It may be hard, but like the body healing after injury, emotional pain also resolves as we hold our loved ones in our hearts but engage more fully again in our lives.  Sometimes though after physical injury, wounds don't heal adequately.  Maybe there is infection or non-union of fractures.  In these situations the healing process may need skilled help.  In the same way, grief may sometimes not resolve naturally as it should.  If the yearning, anxiety, pain & deep sadness are very severe or are not showing signs of lessening by about six months after bereave-ment, then it's wise to consider seeking additional skilled help.  In the next post I look at how often this non-resolution happens.    


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