Bereavement is the loss by death of a loved one such as a parent, child, spouse, or close friend. Bereavement can occur at any stage of life, but is a common occurrence for older adults and the rate of bereavement accelerates as we age. While many aspects of this discussion of grief can apply to younger adults, much of our understanding of grief comes from the psychological study of middle aged and elderly bereavement. Bereavement takes various forms:

Grief refers to the psychological reaction to the bereavement, the death of a loved one. When a person dies who has been a close or constant companion and with whom we have had a close attachment, many changes in our life must be assimilated. Over many years of a close relationship, our self-concept can become defined by the relationship. Death of a long-term partner can force on us a sudden need to redefine ourselves. This is not an easy task.
 

Grief is normal. Grief is something we experience and pass through. In the words of the 18^th century poet Samuel Johnson, “grief must first be digested, and only then can distractions work to alleviate the distress.” Some people experience an initial stage of shock or numbness, followed by a period of depressed mood and yearning for the loved one. However, many people do not experience an intense emotional grief and quickly resume activities. Both reactions are normal. Neither intense grief nor its absence should be seen as indicating a future problem.
 

Normal grief may last for months or even several years. Some aspects of intense normal grief can linger for many months without being problematic. For example, sensing the presence of the dead spouse, such as briefly hearing his or her voice, is common and can last for over a year. Many people find hearing the voice of a spouse or dreaming of the spouse re-assuring if they are aware that it is normal.

There is no clear line between normal and problematic grief. Problematic grief has been conceptually defined as “traumatic grief” or “complicated grief”.
 

Death of a loved one is traumatic. Unexpected, sudden or accidental death can be extremely shocking. After a very close and lengthy relationship, experiencing being alone can be a shock and feel alarming and threatening.

People can sometimes “get stuck” in grief, which is what is meant by “complicated grief” or “chronic grief.” They stop making progress in recovering from the death and remain overly focused on past memories. Life factors may contribute to the development of a complicated grief, such as a lack of support from family and friends. The personality style of the grieving person can also lead to complicated grief. For example, if the individual has been overly dependent on the now-deceased spouse or parent, the grief process may be more difficult or prolonged.

Excessive grief is seen as a problem only if it continues too long and interferes with resuming normal activities. But how long is too long? There is much debate about how long normal grief should last, and this can vary by culture, age, and circumstances of the death. One proposed diagnostic guideline is that excessive grief should be resolving by 6 months. Another expert guideline uses 14 months to differentiate normal from complicated grief, suggesting that intensive grief should only be considered unusual if it lingers after a full year’s cycle of events. Many events in the first year can be difficult such as the first family dinner, first birthday, first wedding anniversary, or first major religious holiday.

A distinction might be made between returning to everyday activities and experiencing moments of intense grief emotions. It is reasonable to expect that we are starting to return to normal everyday activities in 6 months. But moments of intense grief emotions and longing may linger much longer, especially at anniversaries.

The core symptom to a problematic grief that is lasting past at least six months is a yearning for the deceased that is repetitive, intrusive and excessive. Thoughts and memories of the deceased are intrusive and may be accompanied by severe emotional spells. There may be pervasive feelings of numbness towards others, loneliness, emptiness, meaninglessness, regret, and difficulty acknowledging the death. There may be an avoidance of places that are reminders of the deceased person including family gatherings, social groups, the church where both attended, medical facilities, and other funerals. These symptoms may occur from time to time in most grieving people; it is only when these symptoms are excessive and interfere with normal everyday functioning that the grief is seen as problematic.

Anxiety and worry also frequently accompany bereavement. For example, bereaved elderly may fear that their children or friends may abandon them. Loss of a spouse can create a serious crisis in self-confidence. After decades of a close marriage, some are so used to doing daily activities as a couple, that they are unsure of themselves on their own. One has to gradually build a new independent self-confidence for social situations, and for making decisions by oneself.

Symptoms of traumatic and complicated grief can overlap with post traumatic stress disorder (PTSD) and depression. However, grief is not the same as an anxiety disorder or depression. Depression is indicated by prolonged physical lethargy and fatigue (feeling tired all the time, having no energy), or emotional distress for reasons other than the death. Treatments for depression (medication or psychological) typically alter the depressive symptoms but have less effect on the grief symptoms.

When and how is complicated grief treated?

Grief is not an illness and usually does not require medication or treatment. Treatment of grief should be approached with caution. Keep in mind that grief is a normal response. It is not necessarily desirable to eliminate grief, which is part of a normal emotional adjustment to the death of lifelong partner or loved one.

Early preventative interventions such as bereavement groups can provide useful reassurance if conducted carefully, but appear to have only a temporary positive effect and little evidence of long-lasting benefit. Bereavement groups can be harmful if they convey to the individual that their grief is unhealthy, or undermine the person’s normal coping by forcing onto them an intense emotional grief focusing.

Psychological interventions for longer-term traumatic or complicated grief have a moderate but lasting benefit. Cognitive, brief psychodynamic or other effective psychotherapies are used to help the person think about and understand the impact of the loss. These strategies are often first directed to helping the person understand that grief is normal, and to accept their emotional reactions (no matter how unpleasant). Other individuals may need to work through some of the complicating aspects of their relationship to the deceased.  Regret resolution can be important. For example, it may be useful to revisit past relationship hurts and forgive past faults, regrets, anger, and guilt.

Behavioural interventions are used to help people gradually return to their daily routines. Psychologists work with the bereaved elderly to rebuild their self-confidence in managing on their own. An important component of a psychological treatment for complicated grief is to help the individual to return to situations they are avoiding because of the fear of the distressing memories. Continued avoidance of these situations increases the sensitization to grief emotions, whereas only by entering these situations does the excessive distress gradually dissipate. Cognitive behavioural therapy based on cognitive restructuring and exposure techniques to overcome avoidance has been shown to be more effective than supportive counseling.

PTSD for the circumstances of the death event and depressive reactions may need treatment approaches tailored to those disorders. To prevent depression it is helpful to increase exercise and activities.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, visit http://www.cpa.ca/public/provincialandterritorialassociations. The Canadian Register of Health Service Providers in Psychology also has a listing service and can be reached through http://www.crhspp.ca.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Lorne Sexton, Psychology Program Site Manager at St. Boniface General Hospital, Winnipeg Regional Health Authority, and Associate Professor, Department of Clinical Health Psychology, University of Manitoba.

Revised: October 2009