Grief: A Human Condition

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The story of grief starts with the story of love and attachment. Human evolution has hard-wired us with a strong inherent need for connection with others. These attachments are vital to human survival and health, to meet our physical needs as well as for emotional wellness. On a basic logistical level, it takes more than one person to procure food and water, guard against predators, all while caring for helpless offspring (not to mention needing another person for procreation in the first place!). Our hard-wired need to bond with others also has vital emotional underpinnings, combatting loneliness, depression, and anxiety.

With our strong drive towards social attachments comes inevitable loss and grief, an unavoidable aspect of the human condition.

Grief is wrenching. It has been described in terms such as “anguish,” “deep and poignant distress,” and “acute pain” following the loss of someone (or something) we cherish. A signature characteristic is an intense yearning to be with the person who has been lost. 

There have been many efforts to characterize, categorize, and better understand grief. For example, in her 1969 book On Death and Dying, the psychiatrist Elisabeth Kubler-Ross described “5 stages of grief” (denial, anger, bargaining, depression, acceptance). In reality, while these emotions are common, most people do not proceed through designated stages in an orderly manner. In fact, the experience is unpredictable and very different for each person. Grief often occurs in waves, washing over at unexpected moments in unanticipated ways. In addition to sadness and deep yearning, more complicated emotions such as anger or guilt are common. After the loss of a long-term partner, one may sense the person in the room with them or even briefly hear their voice. The death of a child is especially devastating. So is violent, sudden loss.

Death of a friend or family member is not the only culprit. There is growing understanding that an intense grief reaction can also follow other kinds of losses, such as the loss of a pet, one’s home, a job, a pregnancy (such as through miscarriage), one’s health (or the health of a loved one), or a relationship. 

The first year after a loss is especially difficult, with the first anniversaries of birthdays, holidays etc. as poignant reminders.

There has long been controversy in the mental health field about categorizing some forms of grief as a disorder. This has included disagreement about whether to diagnose clinical depression (Major Depressive Disorder) in the context of a significant loss (and whether to prescribe antidepressants). On one hand, dismissing severe depression as an expected reaction to bereavement, and thus failing to offer effective treatment, may lead to needless profound suffering and incapacitation. On the other hand, we want to avoid pathologizing grief, which is a normal human reaction to significant loss. The last thing people in mourning need is to be made to feel ashamed of their feelings, that, somehow, they are abnormal.

Newer research suggests that grief is distinct from depression, although clearly many of the symptoms overlap. And therefore, the treatment approaches should differ as well. (It is important to note that, while they are different, they can occur together; grief does increase the risk of developing depression, and vice versa.)

The study of grief as different from traditional depression, and the growing understanding of broader causes, has led to a new diagnosis: Prolonged Grief Disorder (PGD). This year, PGD was added to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). The American Psychiatric Association explains, “Americans are currently facing several ongoing disasters that have caused death and suffering, such as COVID-19, the wind-down in Afghanistan, floods, fires, hurricanes and gun violence. While many Americans are mourning, some may experience prolonged grief disorder, which is characterized by incapacitating feelings of grief.” In PGD, the intense grief lasts longer than might be expected, and at least 12 months after the loss. And the symptoms are more severe, impairing and/or distressing.  Symptoms include: feeling that life is meaningless; identity disruption (e.g., feeling as though part of oneself has died); and difficulty moving on with life (e.g., problems engaging with friends, pursuing interests, planning). It is thought that a relatively small subset of people, 4 to 7%, continue to experience incapacitating levels of grief 12 months after the loss. (For more information:  https://www.webmd.com/mental-health/prolonged-grief-disorder)

As we reflect upon the last several years of national and global stressors, we can identify some of these insidious and more abstract kinds of loss, including: the loss of nature (with related climate anxiety); Covid-related losses (such as in-person connectedness and social opportunities); and a loss of social cohesiveness, kindness, and sociopolitical norms.

Pauline Boss, Ph.D., has described the concept of “ambiguous loss,” when one experiences loss without closure. Ambiguous loss is a “relational disorder caused by the lack of facts surrounding the loss of a loved one.” Examples include situations of disappearance or separation during war, immigration/deportation, and natural disasters, when you don’t know where your loved one is, or if they are still alive. Boss refers to these situations as “physical absence with psychological presence.” Other types of ambiguous loss include separation due to divorce, incarceration, adoption, or a loved one developing dementia (physically present but not mentally with us). This concept is helpful in that it recognizes types of mourning that society traditionally has not acknowledged.

The bottom line is to allow grief to unfold in its own way and at its own pace, while also watching for signs of complicated or prolonged grief. When grieving, it can be vital to reach out for support from family and friends, and to consider talking with a counselor about your feelings and struggles and/or attending a bereavement group for support and connection with others.  

If you know of someone who is grieving, spend time with them and allow them to talk openly about their sadness and other feelings. Just being present, and listening without judgement, are the most important things you can do. You can help with practical tasks and share stories about the deceased.  Avoid platitudes, and don’t worry too much about saying just the right thing to make them feel better. Continue to reach out for some time after the loss.

Some signs that it may be especially important to seek professional help include: suicidal thinking; feeling that life no longer holds any meaning; prolonged grief (see PGD above); impaired daily functioning (such as eating, bathing and sleeping); isolation and/or detachment; inability to derive pleasure or joy from things; intense self-blame and rumination; and focusing on little else apart from the loss. Your primary care physician or local hospice organization are good resources. 

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