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by Leonard Vanderlinde, M.D.
In the 1950s, John Bowlby, a British psychiatrist, observed children
from 15 to 30 months of age who were separated from their mothers and
cared for by nurses in a hospital. From his observations, he was able
to discern distinct stages in the infants' emotional reactions as they
attempted to adapt to the temporary loss of their mothers.
Initially, the infants were disturbed and distraught--they cried loudly,
threw themselves about their cribs, and actively looked for their mothers
to return. They did not find the nurses satisfactory and rejected them.
This stage was followed by one characterized by more hopelessness, despair,
and a decrease in activity. The infants appeared listless and quiet in
the cribs, showing little active interest in those around them.
In time, their interest in the world seemed to return and they interacted
with the nurses in a friendly, sociable fashion. They accepted them as
caretakers and engaged in active play.
When their mothers returned, the infants appeared to have lost interest
in them. They remained detached and some even turned away from them initially.
Bowlby labeled these stages "protest," "despair,"
and "detachment" to highlight the predominate emotional reactions
at each stage.
Following a death, there is a brief period of numbness and shock (which
can last from a few hours to a few weeks), and grieving people feel tremendous
pain, anxiety, and anger. This is often accompanied with waves of physical
distress such as shortness of breath, dizziness, weakness, and fatigue.
They may experience uncontrollable sobbing and outbursts of tears.
Their frequent thoughts of the deceased result in intense pining and
yearning for the lost relationship. They might direct the anger that emerges
at themselves, at the person who has died, at others around them, or they
may experience it as generalized irritability.
Some theorists believe this stage results from the grief-stricken person
not yet accepting the reality and permanence of the loss. Much like the
infant who has temporarily lost its mother, the bereaved protests the
absence of one who has died and attempts--in desperate ways--to bring
about their return. The cries, the pain, the anxiety, and the anger are
emotional reactions that express their frustration at the loss and are
cries for the lost one to return. The intense thoughts and pining are
attempts to recreate in the mind what can no longer be experienced in
reality. In summary, the intense emotional reaction is both a realization
of the loss and a desperate effort to bring the lost person back.
As the reality and the permanence of the loss sets in, the emotional
reaction shifts. The anger, irritability, pain, anxiety, and intense longing
for the lost person becomes more subdued and less intense. Because protesting
the loss hasn't been successful in bringing about the return of the lost
one, people experience a growing sense of despair. Life seems meaningless,
without purpose, and disorganized. Depression, along with feelings of
hopelessness and helplessness, can all be quite intense.
Grieving people may withdraw from normal social contacts and involvements
because they are now accepting the loss and tolerating the pain that results
from that loss. It is the painful acknowledgment of a new reality that
leaves the bereaved lonely, isolated, and in despair. This stage is one
of transition--a transition from living with the lost person to living
without the lost person.
As time passes, bereaved people gradually adapt to the loss. Their emotional
energies are reinvested in the world and in both new and old relationships.
They begin to feel more active and involved again. The despair and hopelessness
fades, and life takes on a brighter cast. Memories of the deceased may
still bring sadness and pain, especially around holidays and anniversaries,
yet the memories are just as likely to be associated with more pleasant
emotions as well. Life, of course, will never be the same and the pain
of the loss does not go away, but they now have more control over when
the sadness is expressed or felt. They are able to detach themselves from
the experience.
The normal grieving process takes time, and that time can vary from individual
to individual. For purposes of description, the stages of grief and mourning
are presented as clearly separated, but in reality they overlap. In most
cases, the period of numbness and shock lasts a few hours up to a few
days, the protest phase often peaks at two to four weeks, and despair
can last up to one year and beyond.
When the grieving process is excessively prolonged, when the individual
appears stuck in one stage without apparent movement to the next stage,
or if she/he seems to miss a stage entirely (e.g. total inability to cry
or feel anger, no despair), pathologic or unresolved grief could be present.
This often requires professional intervention to help the bereaved so
they don't become incapacitated and disabled by grief.
It is sometimes hard to distinguish grief from a clinical depression.
Depression may require more active treatment or medication management.
The symptoms are often the same:
- sadness
- despair
- loss of energy, interest, and motivation
- changes in sleep or eating habits
- feeling hopeless and helpless
- irritability and anger
- tearfulness
- fatigue
In depression, the symptoms are often more intense and long-lasting and
may interfere to a greater extent in a person's normal functioning.
In grief, a person rarely loses touch with reality, whereas this may
happen in depression. It is not usual for a grieving person to have suicidal
thoughts, show markedly slowed down behavior, or feel overwhelmed by guilt,
always thinking of their many past mistakes and misdeeds. If people in
the process of grief appear severely depressed or have suicidal thoughts,
marked slowness in their thinking or behavior, or overwhelming guilt,
they should be encouraged to seek out psychiatric evaluation.
The infant's loss of its mother and the loss of a loved one to death
are two highly-charged emotional events that place the grieving process
in high relief, but there are other losses in life that can lead to grief
as well. Judith Viorst, in her book Necessary Losses, states:
...we lose not only through death, but also by leaving and being left,
by changing and letting go and moving on. And our losses include not
only our separations and departures from those we love, but our conscious
and unconscious losses of romantic dreams, impossible expectations,
illusion of freedom and power, illusions of safety--and the loss of
our own younger self, the self that thought it always would be unwrinkled
and invulnerable and immortal.
The adolescent who leaves home to attend college may gain some independence
but lose the comfort of being taken care of at home. The single person
entering a marriage gains a partner and companion, but takes on more responsibility
and loses a measure of freedom. The birth of a child results in the loss
of an exclusive relationship between partners. A promotion may bring about
changes in friendships and roles that involve some losses.
All of these, while normal and expectable in life, can be experiences
that may result in some grieving. We must acknowledge and experience our
feelings of loss to move and grow.
At Pine Rest, grieving can be a significant portion of a patient's treatment.
When hospitalized, people's images of themselves are changed--they are
no longer whole and healthy; they have an illness that not only disrupted
their life once, but may continue to in the future. This is a loss that
they must grieve before they can achieve a healthy adjustment. They must
detach from their old image of themselves and incorporate the new and
more painful aspects. Those who have been sexually abused or involved
in incestuous relationships must grieve their early loss of innocence
and the absence of a normal childhood. Many who have been abused have
a difficult time facing the reality that others who have been involved
in their pain may not change. And even if they were to change, it wouldn't
take away the pain of the past. Giving up the hope that the past can be
changed is a difficult process, a process involving much grief and despair.
Then what makes grief easier to bear? The answer to this question is
not simple, for many factors are involved. The nature and timing of the
loss is important as well as the maturity and strength of the person suffering
the loss. In general, if people have been able to develop a significant
number of attachments, if they live in a supportive, caring social environment,
and if the loss is not laden with conflict or mixed emotions, their grieving
process will proceed to a satisfactory resolution.
Religion and spirituality play an important and sustaining role in a
person's ability to grieve effectively, too. I cannot overemphasize the
importance of the ability to call on fellow Christians, friends, and God
for support through the pain, anger, grief, and despair. To know that
others are there and recognize the suffering is a crucial support.
From the very beginning, our lives involve an unavoidable series of attachments
and losses, and from the losses we experience grief and the mourning process.
For us to continue to grow and adapt, we must acknowledge and experience
this grief. We must allow ourselves to feel the pain of letting go.
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