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The Complex Necessity of Grief

I was working at the funeral home for a year when I met Mrs. Jones. She was a quiet, sweet-spirited woman with bright and welcoming eyes. She came in with her two adult children to make funeral arrangements for her beloved husband, Johnny, of forty-eight years. I wasn’t responsible for making arrangements with her, but gathered the information needed for the obituary. She spoke of Mr. Jones in the most endearing and respectful way. She spoke of the struggles, disappointments and shortcomings of their marriage but was careful to cover their covenant with a love that seemed unshakeable. He was, as she described, her “everything.” Over the next few days Mrs. Jones and I would develop a lasting bond that we would both come to appreciate over the next two years. When she had questions about anything she called and our conversations would last an hour or more. She encouraged me to keep up the good work; I encouraged her to keep her head up. It was on the second anniversary of Mr. Jones’ death that Mrs. Jones came in with a handwritten memorial tribute she wanted to run in the local newspaper—the same as she did the year before. After we exchanged pleasantries she sat down and said, “Tori, I just can’t seem to get myself together. I miss Johnny so much. It’s as though he died yesterday. The other day someone called the house and the phone just rang and rang. In the forty-eight years of our marriage, I never answered the phone. After the fourth ring I yelled to the other room for Johnny to answer. I called for him the second time and it hit me all of a sudden. He’s gone and I’m responsible for answering the phone now. All I could do was cry.”

What is Grief?

Whether it be the loss of a child, parent, spouse, close friend, that special someone or pet, everyone will experience loss by means of death in their lifetime. By definition, grief is the normal process of reacting to a loss. Many studies suggest grieving is a necessary process in creating a new normal after a loss. Although experienced by many in some form or another, there is evidence to suggest a lack of knowledge as to the increased effect of grief on the bereaved. What is known however is:

  1. Grief unattended is associated with a seven-fold increase in mortality.
  2. Unattended grief leads to “complicated grief” and a Prolonged Grief Diagnosis (PGD).

Grief is considered the universal emotion that connects all of humanity. Though experienced by all, it is expressed differently by each individual. Grief expression can have both physical and emotional effects on the bereaved. It is the variation and duration of grief expression for each individual that contributes to the complexity of its understanding and treatment. The grieving process is as unique as ones DNA and the varying degrees of loss accounts for the intricacy of its expression. Experiencing the loss of a parent, for example, will yield different expresses for each child.

Studies suggest that primary care physicians are the first line of treatment for suffers of complicated grief. The differing expressions of grief symptoms may result in a misdiagnosis by medical professionals as these expressions are in most cases in the form physical ailments. The challenge for mental health professionals is that neither the Diagnostic Statistical Manual (DSM-V) nor the International Statistical Classification of Disease and Related Health Problems (ICD-10) have a named and classified diagnosis for grief. As a result, like medical professionals, mental health professionals are left treating co-occurring symptoms of grief and are not successful in targeting the root cause of the presenting symptoms.

A Closer Look

Elizabeth Kübler-Ross is accredited for providing a better way of understanding and conceptualizing the grief process. Though not a “perfect” categorization of the grief process, Kübler-Ross’ model provides the best current understanding of this complex process. She classified grief into five stages: denial, anger, bargaining, depression and acceptance. The term “stages” can be misleading as it implies that an individual will experience grief in a fluid, step-by-step progression. To the contrary, Kübler-Ross contends that individuals experiencing grief fluctuate between stages, and will often experience more than one stage at a time. The “stage” dynamic contribute to the difficulties associated with developing effective treatments for grief. Implying that a person must complete one stage of the process before experiencing another is a harmful methodology that ultimately impedes the grieving process for the bereaved and the treatment process for practitioners. However, Kübler-Ross’ process has been effective in process recognition and provides a framework from which to study grief.

What has proven helpful in understanding the grieving process is an awareness of the barriers to treatment. There has long since been differing opinions from medical professionals and mental health practitioners on how long a person should grieve. Earlier studies suggested one year is the average time a person should grieve. However, more recent research encourage practitioners to not limit grief evaluation on a time scale alone, but rather examine the progression of coexisting conditions that accompany grief and the effect those conditions have on the quality of life of the bereaved.

Women and Grief

While the study of grief has proven difficult for medical and mental health professionals, the symptoms that accompany grief have been well documented and are the focus of much of the current research and treatment development planning. Studies suggest that women who suffer a loss have a higher occurrence of prolonged grief among different bereaved individuals. These women are more likely to be diagnosed with complicated grief symptoms such as depression, anxiety, eating disorders and PTSD. A Prolonged Grief Diagnosis (PGD) for many women is as a consequence of the exasperation of these coexisting symptoms and is responsible for a decrease in the quality of life.

Research has shown there a strong association between health and bereavement. For older women, bereavement is the cause for higher hospitalization rates and perceived and actual changes in health conditions. This is as a result of the unmet needs of grief treatment and addressing bereavement concerns. Treatment studies show on average the time between the actual loss and the start of treatment is several years. The length of time between loss and treatment present a significant barrier to diagnosis and treatment and are contributing factors to possible prolonged grief diagnosis.

In addition to health decline, there are reported social and economic consequences of widowhood and bereavement on older women. The loss of a spouse often leads to living alone. The negative outcomes of living alone are loneliness, social isolation, economic strain and inadequate support to help facilitate grief. The economic hardships due to the loss of income in and the increased expenses create stress that attribute to the decline of physical and mental health.

Signs and Treatments

Funeral Directors, medical and mental health practitioners have in common the certainty of encountering someone in any of the many stages of grief. Leaning on your rapport building skills and your knowledge of community resources are best in helping families that you feel are experiencing grief. Having an extensive knowledge base of the resources in your area is critical in bridging the gap from grief to treatment. The unique relationship you have based on the services you provide will help you be a better advocate for bereaved families.

Here are some signs that a person may be experiencing complicated grief:

  1. An obsession with the death of the loved one
  2. Isolation or detachment
  3. Intense and persistent longing or pining for the loved one
  4. Extreme focus on reminders of loved one
  5. Excess avoidance of reminders of the loved one
  6. A loss of meaning for life
  7. Inability to enjoy life and have positive experiences

Grief treatment is as unique as the individual experiencing the loss. Qualified and licensed medical and mental health practitioners are encouraged to use the following techniques to gain a better understanding of the needs of the individual and develop therapeutic goals and interventions to meet those specific goals.

  1. Build rapport
  2. Find ways to enhance motivation for treatment
  3. Confront the painful aspects of the loss
  4. Allow a safe place for reconciling the loss
  5. Discuss integration of the loss into the new life that must be lived by the bereaved

Helpful Resources

Here are some helpful resources to help navigate through the journey of grief. Sesame Street has great resources for children dealing with grief. Visit their website at There you will find age appropriate material to help children sort out the complex emotions associated with grieving. For adults, is a comprehensive website where you can find reading materials, bereavement groups; both online and in your local communities, videos and other helpful resources. It is important to remember that you are not alone no matter where you find yourself on this journey.

A Few Final Thoughts

After experiencing loss, the most difficult challenge is the journey to return to a life of normalcy. Charity Cowper said, “Grief is itself medicine.” The truth of this statement is the foundation of the complexity of the grief journey. Keep in mind that those in the thralls of grief need the support of those who remain. Making yourself available and lending a listening ear can prove impactful on the road to healing. It is often said that grief shared is grief diminished. Creating a woven community of support ensures that we not only share in the sorrow, but contribute to the eventual joy that lies ahead.


Keep Shining.

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