The terms grief, bereavement, and mourning are often used interchangeably, however, they have different meanings. Grief is the normal process of reacting to a loss. Grief can be in response to a physical loss, such as a death, or a social loss including a relationship or job. Bereavement is the period after a loss during which grief and mourning occurs. The time spent in bereavement for the loss of a loved one depends on the circumstances of the loss and the level of attachment to the person who died. Mourning is the process by which people adapt to a loss. Mourning is greatly influenced by cultural beliefs, practices, and rituals (Casarett et al., 2001).

The Process of Grieving

Typical grief reactions involve emotional, mental, physical, and social responses. These reactions can include feelings of numbness, anger, guilt, anxiety, sadness, and despair. The individual can experience difficulty concentrating, sleep and eating problems, loss of interest in formerly pleasurable activities, physical problems, and even illness. Research has demonstrated that the immune systems of individuals grieving is suppressed and their healthy cells behave more sluggishly, resulting in greater susceptibility to illnesses (Parkes & Prigerson, 2010). However, the intensity and duration of typical grief symptoms do not match those seen in severe grief reactions, and symptoms typically diminish within 6-10 weeks (Youdin, 2016).

Prolonged and Complicated Grief

After the loss of a loved one, however, some individuals experience complicated grief, which includes atypical grief reactions (Newson, Boelen, Hek, Hofman, & Tiemeier, 2011). Symptoms of complicated grief include: Feelings of disbelief, a preoccupation with the dead loved one, distressful memories, feeling unable to move on with one’s life, and a yearning for the deceased. Additionally, these symptoms may last six months or longer and mirror those seen in major depressive disorder (Youdin, 2016).

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013), distinguishing between major depressive disorder and complicated grief requires clinical judgment. The psychologist needs to evaluate the client’s individual history and determine whether the symptoms are focused entirely on the loss of the loved one and represent the individual’s cultural norms for grieving, which would be appropriate. Those who seek assistance for complicated grief usually have experienced traumatic forms of bereavement, such as unexpected, multiple and violent deaths, or those due to murders or suicides (Parkes & Prigerson, 2010).

Anticipatory Grief

Grief that occurs when a death is expected, and survivors have time to prepare to some extent before the loss is referred to as anticipatory grief. Such anticipation can make adjustment after a loss somewhat easier (Kübler-Ross & Kessler, 2005). Anticipatory grief can include the same denial, anger, bargaining, depression, and acceptance experienced in loss one might experience after a death; this can make adjustment after a loss somewhat easier, although a person may then go through the stages of loss again after the death. A death after a long-term, painful illness may bring family members a sense of relief that the suffering is over or the exhausting process of caring for someone who is ill is over. At the same time, when a person has organized all their waking hours around the care of a dying loved one, upon their death the caregiver may experience feelings of emptiness and disorientation in addition to relief.

Survivor’s Guilt

Survivor’s guilt (also called survivor’s syndrome) is a mental condition that occurs when a person blames themselves for surviving a traumatic event when others did not. It may be found among survivors of combat, natural disasters, epidemics, among the friends and family of those who have died by suicide, and in non-mortal situations such as among those whose colleagues are laid off.

Disenfranchised Grief

Social support from others plays an important role in processes of grieving. However, grief that is not socially recognized is referred to as disenfranchised grief (Doka, 1989). Examples of disenfranchised grief include death due to AIDS, the suicide of a loved one, perinatal deaths, abortions, the death of a pet, lover, or ex-spouse, and psychological losses, such as divorce or a partner developing Alzheimer’s disease. Due to the type of loss, there is no formal mourning practices or recognition by others that would comfort the grieving individual. Consequently, individuals experiencing disenfranchised grief may suffer intensified symptoms due to the lack of social support (Parkes & Prigerson, 2010).

Patterns of Grief

It has been said that intense grief lasts about two years or less, but grief is felt throughout life. One loss triggers the feelings that surround another. People grieve with varied intensity throughout the remainder of their lives. It does not end. But it eventually becomes something that a person has learned to live with. As long as we experience loss, we experience grief. Over time, grief becomes interlaced with gratitude for the presence of the loved one in our lives and the cherished memories that remain.

There are layers of grief. Initial denial, marked by shock and disbelief in the weeks following a loss may become an expectation that the loved one will walk in the door. And anger directed toward those who could not save our loved one’s life, may become resentment and bitterness that life did not turn out as we expected. There is no right way to grieve. A bereavement counselor expressed it well by saying that grief touches all of us on the shoulder from time to time throughout life.

Grief and mixed emotions go hand in hand. A sense of relief is accompanied by regrets, and periods of reminiscing about our loved ones are interspersed with feeling haunted by them in death. Our outward expressions of loss are also sometimes contradictory. We want to move on but at the same time are saddened by going through a loved one’s possessions and giving them away. We may no longer feel sexual arousal or we may want sex to feel connected and alive. We need others to befriend us but may get angry at their attempts to console us. These contradictions are normal and we need to allow ourselves and others to grieve in their own time and in their own ways.

The “death-denying, grief-dismissing world” is often the approach to grief in our modern society. We are asked to grieve privately, quickly, and to medicate our suffering. Employers grant us 3 to 5 days for bereavement, if our loss is that of an immediate family member. And such leaves are sometimes limited to no more than one per year. Yet grief takes much longer and the bereaved are seldom ready to perform well on the job. It becomes a clash between life having to continue, and the individual being unready for it to do so. One coping mechanism that can help smooth out this conflict is called the fading affect bias. Based on a collection of similar findings, the fading affect bias suggests that negative events, such as the death of a loved one, tend to lose their emotional intensity at a faster rate than pleasant events (Walker et al., 2003). This is believed to help enhance pleasant experiences and avoid the negative emotions associated with unpleasant ones, thus helping the individual return to his or her normal daily routines following a loss.

Factors that Affect Grief and Bereavement

Grief reactions vary depending on whether a loss was anticipated or unexpected (e.g., parents do not expect to lose their children), and whether or not it occurred suddenly or after a long illness, and whether or not the survivor feels responsible for the death. Struggling with the question of responsibility is particularly felt by those who lose a loved one to suicide or overdose (Gibbons et al., 2018). These survivors may torment themselves with endless “what ifs,” even if they know cognitively that there was nothing more that could have been done.

And family members may also hold one another responsible for the loss. The same may be true for any sudden or unexpected death, making conflict an added complication to the grieving process. Much of this laying of blame is an effort to think that we have some control over these losses; the assumption being that if we do not repeat the same mistakes, we can control what happens in our life and prevent such losses in the future. While grief describes the response to loss, bereavement describes the state of being following the death of someone.

As we’ve already learned in terms of attitudes toward death, individuals’ own lifespan developmental stage and cognitive level can influence their emotional and behavioral reactions to the death of someone they know. But what about the impact of the type of death or age of the deceased or relationship to the deceased upon bereavement?

Death of a Child

Death of a child can take the form of a loss in infancy such as miscarriage or stillbirth or neonatal death, SIDS. Alternatively,  death can take an older child, adolescent, or adult child. In most cases, parents find the grief almost unbearably devastating, and the death of a child tends to hold greater risk for negative psychical and psychological outcomes than any other loss. This loss also begins a lifelong process: One does not “get over” the death but instead must bear, assimilate, and live with it. Intervention and comforting support can make a big difference to the survival of a parent in this type of grief but, the risk for negative outcomes is great and may include family breakup, depression, or suicide. Feelings of guilt, whether legitimate or not, are pervasive, and the dependent nature of the relationship predisposes parents to feelings of responsibility, and hence to a variety of problems as they seek to cope with this great loss. Parents who suffer miscarriage or a regretful or coerced abortion may experience resentment towards others who experience successful pregnancies. And seeing other children who are the age that the child would have been had they lived can be painful and triggering.

Suicide and Drug Overdoses

Suicide rates are growing worldwide and over the last thirty years there has been international research to gather knowledge about who is “at-risk” and to find out how to successfully intervene to curb this phenomenon. When a parent loses their child through suicide (and suicide is the second leading cause of death during adolescence), it is traumatic, sudden, and impacts all those who loved this child. Suicide leaves many unanswered questions and leaves most parents feeling hurt, angry, and deeply saddened by such a loss. Parents may feel they can’t openly discuss their grief and feel their emotions because of how their child died and how the people around them may perceive the situation. Parents, family members and service providers have all confirmed the unique nature of suicide-related bereavement following the loss of a child. They report that “a wall of silence” goes up around them that shapes how people interact with them. One of the best ways to grieve and move on from this type of loss is to find a support group of other parents who have suffered a similar loss, and to find ways to keep that child as an active part of their lives. It might be privately at first but as parents move away from the silence they can move into a more proactive healing time.

When adolescents or other family members die from a drug overdose, the grieving process can also be prolonged and complicated, with patterns similar to grieving someone who committed suicide. Survivors may experience feelings of guilt, anger, resentment, and helplessness; and may not receive the sympathy and social support from others that they otherwise would. Survivors may worry about the person’s reputation and the value placed on them by society because they committed suicide or died from an accidental overdose, and so may feel defensive, inhibited, or worried about sharing their experience of loss.

Death of a Spouse

The death of a spouse is usually a particularly powerful loss. A spouse often becomes part of the self in unique ways. Many widows and widowers describe losing “half of themselves” and losing their past selves as well. The days, months, and years after the loss of a spouse can echo with emptiness, and learning to live without them may be harder than the survivor expects. The grief experience is unique to each person. Sharing and building a life with another human being, then learning to live alone, can be an adjustment that is more complex than those providing support may realize. Depression and loneliness are very common. Feeling bitter and resentful are also normal feelings for the spouse who is “left behind.” Oftentimes, the widow/widower may feel it necessary to seek professional help in dealing with their new life.

After a long marriage, at older ages, the elderly may find it a very difficult transition to begin anew; but at younger ages as well, the death of a spouse is unexpected and off-time. A marriage relationship is often a profound anchor around which one’s life is organized, and the loss can completely disrupt the life of the survivor. Furthermore, most couples have a division of ‘tasks’ or ‘labor’, (e.g., the husband mows the yard, the wife pays the bills, etc.) which, in addition to dealing with great grief and life changes, means added responsibilities for the bereaved. Immediately after the death of a spouse, there are tasks that must be completed. Planning and financing a funeral can be very difficult if pre-planning was not completed. Changes in insurance, bank accounts, claiming of life insurance, securing childcare are just some of the issues that can be intimidating to someone who is grieving. If there are children still at home, the survivor must take care of them, support them in their grieving processes, and still find time to take care of themselves as well. Social isolation may also become an issue, as many groups composed of couples find it difficult to adjust to the new identity of the bereaved, and the bereaved themselves have great challenges in reconnecting with others. In fact, seeing other couples still together may be intensely painful. Widows in many cultures, for instance, wear black for the rest of their lives to signify the loss of their spouse and their ongoing grief. Only in more recent decades has this tradition been reduced to shorter periods of time.

Death of a Parent

When an adult child loses a parent in later adulthood, it is considered to be “timely” and so a normative life course event. This allows the adult children to feel a permitted level of grief. However, research shows that the death of a parent in an adult’s midlife is not experienced as a simple “normative life event” by any measure, but instead represents a major life transition that can trigger an evaluation of one’s own life or mortality. Others may shut out friends and family in processing the loss of someone with whom they have had the longest relationship (Marshall, 2004). And the grieving process can be especially challenging if the parent-child relationship was contentious or difficult, and many issues were unresolved.

Death of a Sibling

The loss of a sibling can be a devastating life event. Despite this, sibling grief is often the most disenfranchised or overlooked of the four main forms of grief, especially with regard to adult siblings. Grieving siblings are often referred to as the ‘forgotten mourners’ who are made to feel as if their grief is not as severe as their parents’ grief. However, the sibling relationship tends to be the longest significant relationship since it can last for the lifespan, and siblings who have been part of each other’s lives since birth, such as twins, help form and sustain each other’s identities. With the death of one sibling comes the loss of that part of the survivor’s identity because “your identity is based on having them there.”

The sibling relationship is a unique one, as they share a special bond and a common history from birth, have a certain role and place in the family, often complement each other, and share genetic traits. Siblings who enjoy a close relationship participate in each other’s daily lives and special events, confide in each other, share joys, spend leisure time together (whether they are children or adults), and have a relationship that not only exists in the present but often looks toward a future together (even into retirement). Surviving siblings lose this “companionship and a future” with their deceased siblings (White, 2006).