Understanding Grief: A Journey of Adaptation

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Grief is a natural process that occurs after the death of a loved one and involves emotional reactions. During the mourning period, a person may feel shock or disbelief at the death or loss of a loved one. Feelings of loss, pain, sadness, grief, sorrow, longing, longing, anger, guilt, regret, anxiety, fear, alienation, loneliness, and emptiness are natural emotions felt after loss. Each person’s journey through grief is unique, and the emotions they experience can vary widely. The intensity of natural grief symptoms and distressing emotions are expected to change and decrease over time. According to Kübler-Ross, grief has stages. Let’s dive into these stages to understand the essence of the grieving process.

Stage 1 (Denial): The first stage can vary between a few hours and a few weeks; the person who is in the grief process might have difficulty grasping the reality of death—the first phase after receiving news of the loss, learning about or experiencing the painful event. The first reaction is to deny the situation. There may be feelings and thoughts that such a loss is unfair or that the news is mistaken or inaccurate.
Stage 2 (Anger): In the second stage, the person feels the pain of loss more and more and experiences intense sadness and longing. In addition to these feelings, a person might start to feel other negative emotions ranging from anger, restlessness, fear, and hopelessness. Since the experience is unique to each person, feelings that are experienced significantly vary. Also, it is common to struggle to concentrate and feel hesitant about engaging in activities the person enjoys before. The mind is preoccupied with the deceased and death. At this stage, the reasons for the experience of losing someone are questioned. Questions like “Why did this happen to us?” can be asked. Following that, anger can be directed toward the people we think caused this situation or the person themselves. This phase may last for days or weeks.
Stage 3 (Bargaining): In the third stage, feelings of hopelessness and helplessness increase with the realization that the lost one will not return. This causes a realization and also internalization of the process. The pain and sadness are acknowledged at this stage. On the other hand, the possibilities begin to be questioned with what-if questions. This kind of questioning and the events that have happened start to revolve in the mind. As a result, different possibilities are considered and lead to the depression phase.
Stage 4 (Depression): In this stage, the person accepts that it has become meaningless to think about the possibilities, and the anger is replaced by feelings of depression. This stage can be considered as the stage of exhaustion. Physical difficulties may occur, such as crying, eating, or sleep disturbances. Depressive symptoms such as anhedonia may arise. At this stage, the grief begins to be confronted, and gradually, adaptation to the loss starts.
Stage 5 (Acceptance): In the last stage of grief, the intensity of longing and sadness diminishes as acceptance of death and its effects grow over time. Although the memories of those who have passed persist, the person slowly returns to their former condition, restructures their life, and revives aspirations and intentions for the future (Kübler-Ross & Kessler, 2005).

The Kübler-Ross model does not necessarily apply to everyone in every bereavement. However, George Bonanno, a professor of clinical psychology at Columbia University’s Loss, Trauma, and Emotion lab, says the model can be seen as “a roadmap.” As can seen in the stages, there is a stage related to depression. Eventhough the stages of grief have a resemblance of a depressive episode, grief should not be mixed with any other mental disorder. Grief differs from depression in multiple aspects. Grief is related to a response to loss. The focus of the grieving process is to lose one or the deceased. On the other hand, in depression, the focus is on self-worth. In the grieving process, emotions like sadness and yearning center around the loss of one, while a person often maintains self-esteem. Having difficulties keeping activities physical, sleep, and routine might disturb and low mood every day in both grief and depression, but the underlying processes are significantly different (Parker et al., 2015). The adaptation process after losing someone can sometimes be prolonged and affect the person’s functionality for long periods. In this case, grief can turn into a prolonged grief disorder.

What is Prolonged Grief Disorder?

Prolonged grief is defined as the progression of the natural symptoms of the grief process after loss and the derailing of the natural grief process when complications accompany it. According to the World Health Organization’s (WHO) and ICD-11, prolonged grief disorder includes persistent and pervasive grief reactions that occur after the loss of a parent, spouse/partner, child, or close loved one. Even after a year for adults and six months for children and adolescents following the death of a loved one, individuals may still feel that they have lost a part of themselves with that loss. In addition, there are symptoms such as disbelief in the reality of death, avoidance of reminders of death, difficulties in establishing friendships, pursuing meaningful activities, or planning for the future after the death of a loved one, and emotional numbing. When we look at the risk factors that lead to prolonged grief, the duration and intensity of grief are influenced by how the loss occurred, the level of closeness with the deceased, and the characteristics of the deceased (WHO, 2018). Let’s look at a case study of Ms. D, published in the Journal of Clinical Psychiatry, to understand prolonged grief disorder.

Ms. D, aged 60, unexpectedly lost her 55-year-old brother 18 months ago. They have a close relationship, and Ms. D cared for him during her teenage years. One evening, her brother suddenly collapsed while watching television. Ms. D promptly called emergency services and attempted CPR, but unfortunately, he passed away. This event profoundly affected her emotionally. In the grieving process, Ms. D experienced intense guilt as she hadn’t done enough to save him, and she felt anger towards doctors who were unable to bring him back. She experienced “numbing out” and started avoiding places they had often visited. At the end of the 18 months, she felt depressed and sought therapy. By the end of her treatment, Ms. D had become more accepting of her brother’s death and felt comfort in knowing she had been there for him. She could experience joy when thinking about their shared moments and started re-engaging with social activities (Harkness et al., 2002).

As indicated in the case above, the grief process can be dysfunctional and prolonged due to several factors. One of the factors that affect the grief process is that some losses might be sudden and unexpected, especially due to bombings, war, or violence. When a person witnesses these events, the grief process can become more complex, and the grief symptoms can be more severe and last longer. In the literature, this is called traumatic grief. Let’s examine what traumatic grief is.

What is traumatic grief?

Traumatic grief is maladaptive symptoms and reactions to loss as a result of the sudden and violent death of a loved one. The grief process after every loss is considered a natural reaction. However, in traumatic grief, the unexpected and violent nature of the loss affects this natural process. In traumatic grief or traumatic bereavement, it is considered the emergence of the symptoms of post-traumatic stress disorder (PTSD) with grieving that occurs under traumatic conditions. PTSD includes symptoms such as reliving the traumatic situation, avoiding stimuli that remind of the traumatic situation, and feeling under constant threat for more than 2 weeks. The simultaneous dual effects of trauma and loss severely damage the way the individual perceives the world and coping mechanisms (Boelen et al., 2003).

The connection between grief and trauma is complex. Eventhough grief itself is seen as a traumatic experience, normal bereavement is a process that usually allows individuals to accept the loss and return to their daily lives gradually. On the other hand, a person who has lost a loved one in a traumatic experience suffers from both shock and fear of the experience. In a study conducted 2-3 years after the 9/11 attacks, researchers contacted 280 people who had lost loved ones in the attacks. They conducted structural interviews and psychological tests to asses grief, PTSD, and other psychological disorders such as depression and anxiety. %43 of the participants were found to have complicated grief alongside PTSD (Rubin et al., 2020).

What is the difference between prolonged grief disorder and traumatic grief?

The question here is, what is the difference between prolonged grief disorder and traumatic grief if they both affect functionality drastically and extend the bereavement process? Fear is the main emotion in traumatic grief, but longing and sadness are more common in prolonged grief disorder. Thoughts are related to the traumatic event in traumatic grief; on the other hand, thoughts are usually associated with the circumstances of the death in prolonged grief disorder. Avoidance behaviors are often related to safety concerns or a need to avoid threats in traumatic grief. On the other hand, avoidance is associated with a need to avoid painful reminders of the loss and the persistence of that loss in prolonged grief disorder. In addition, hyperarousal and excessive alertness are more commonly associated with traumatic grief. In contrast, difficulties in moving on without the deceased (e.g., feelings of meaninglessness, wanting to be with the person who died, loneliness) are more common in prolonged bereavement disorder (Szuhany et al., 2021).

How does our Brain perceive The Grief?

In their book The Grieving Brain, Neuroscientist Mary Frances O’Connell explains that grief is the natural emotional response to a loss and that grieving adapts to this new reality. Grieving is framed as an adaptation process because our brain must remap this new reality of life without our loved ones. According to O’Connell, our brain helps us make sense of the world by drawing from past experiences and memories. This mental “map” helps us navigate day to day. When we form an attachment to someone we love, our brain processes that they will always be there for us, and the memories of loved ones create an internal desire to know where they are and when they will return. The posterior cingulate cortex (PCC) plays a role in retrieving emotional memories about the loved one, while the anterior cingulate cortex (ACC) directs attention to significant events, such as losing a loved one. This attachment element is centered around a bond of closeness, where we can predict where and when to reach our loved one. When we are to lose someone that we love, our attachment to this person is threatened. This triggers our brain to send signals to find them, although we may know we cannot get to them. These two streams of conflicting information are complex for our brains to process right away. We may know that we cannot find them, but our attachment to these people makes us yearn for their return.

In navigating this new reality, grief sparks strong emotions like panic, depression, and yearning for their return. Yearning can be defined as an unsatisfied, intense, and future-oriented appetitive desire toward a lost person. Yearning can arise from intrusive thoughts or voluntary memories as our brain attempts to understand where our loved one went. These thoughts can occur in “what ifs” scenarios, which can be a mental block from accepting the reality of the loss, as we cannot relive what happened in the past. Our brain goes through these scenarios in an attempt to remap what occurred. This can make it challenging to feel like we can be “present” as we may find comfort in daydreaming of memories of our deceased loved one. The Dual Process Model highlights how grief involves shifting between loss-oriented stressors (focused on pain and longing) and restoration-oriented stressors (adjusting to new roles and realities). Although it may feel uncomfortable, being aware of where our mind is (even in deep, sad thoughts) is more helpful in our healing process than attempting to avoid these painful emotions.

How can we move on from grief?

Although losing our loved ones changes our lives, it does not mean that we cannot move on. As Dr. O’Connel outlines in the book, we will oscillate from feeling consumed by the loss to finding more restoration. This process of envisioning, adapting, and living a new life takes patience to reach a place of acceptance. By building support networks, navigating triggering memories, and discovering peace in carrying their memories, we start to reimagine our purpose, giving us the strength to keep going forward.

The common narrative of “it gets better with time” holds some truth, but it is more about learning to work through the emotions of grief to discover a new purpose. The critical question to be asking ourselves when drowning in grief is “How to restore a meaningful life?” versus “How can I get over this loss?”. We may never “get over” the loss, but we can find a way to navigate better the emotions that come with it. Our brain must remap this new living reality by forming new memories and social bonds to help us not be consumed by the loss. With intention, grace, and a strong support network, we slowly start to heal and learn to live with this loss. This helps restore some hope in the journey of feeling lost.

Mental health professionals play a vital role in offering emotional support to those navigating the grieving process. Through therapy, these experiences can guide individuals who have faced loss on their healing journey. Additionally, support groups allow individuals to connect with others who share similar experiences. Platforms like online forums and social media groups enable grieving people to express their feelings, honor their loved ones, and receive much-needed social support. Such supportive environments can help reduce isolation during this challenging time and encourage emotional healing. It’s also important to remember that seeking guidance from a specialist can be beneficial if the healing process is prolonged.

References:

Kübler-Ross E., Kessler D. (2005). On grief and grieving: Finding the meaning of grief through the five stages of loss. New York, NY: Scribner.
Parker, G., McCraw, S., & Paterson, A. (2015). Clinical features distinguishing grief from depressive episodes: A qualitative analysis. Journal of Affective Disorders, 176, 43–47. https://doi.org/10.1016/j.jad.2015.01.063
World Health Organization (2018). ICD-11 International Classification of Diseases 11th Revision. for Mortality and Morbidity Statistics. 6B42 Prolonged grief disorder. http://id.who.int/icd/entity/1183832314.
Harkness, K. L., Shear, M. K., Frank, E., & Silberman, R. A. (2002). Traumatic grief treatment: Case histories of 4 patients. Journal of Clinical Psychiatry, 63(12), 1113-1120.
Boelen, P. A., van den Bout, J., & de Keijser, J. (2003). Traumatic grief is a disorder distinct from bereavement-related depression and anxiety. The American Journal of Psychiatry, 160(7), 1339–1341.
O’Connor, M. (2022). The grieving brain: the surprising science of how we learn from love and loss.
Rubin, S. S., Malkinson, R., & Witztum, E. (2020). Traumatic bereavements: Rebalancing the relationship to the deceased and the death story using the two-track model of bereavement. Frontiers in Psychiatry, 11, 537596.
Szuhany, K. L., Malgaroli, M., Miron, C. D., & Simon, N. M. (2021). Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment. Focus (American Psychiatric Publishing), 19(2), 161–172. https://doi.org/10.1176/appi.focus.20200052

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This page is also part of the Roamers Therapy Glossary; a collection of mental-health related definitions that are written by our therapists.

While our offices are currently located at the South Loop neighborhood of Downtown Chicago, Illinois, we also welcome and serve clients for online therapy from anywhere in Illinois and Washington, D.C. Clients from the Chicagoland area may choose in-office or online therapy and usually commute from surrounding areas such as River North, West Loop, Gold Coast, Old Town, Lincoln Park, Lake View, Rogers Park, Logan Square, Pilsen, Bridgeport, Little Village, Bronzeville, South Shore, Hyde Park, Back of the Yards, Wicker Park, Bucktown and many more. You can visit our contact page to access detailed information on our office location.