“Grief is the price we pay for love’”

Determinants of Grief

Certain circumstances of loss can affect the way we experience grief in predictable ways. These are called ‘determinants of grief’. These determinants are split into two separate, but interrelated groups: (i) external circumstances, and (ii) internal circumstances¹.

External Circumstances

1.	Place of death	When a person has died far from home, grieving will be postponed and may take longer.
2.	Coincidental deaths or losses.	Losses occurring simultaneously in a family or community. Each loss needs to be grieved individually and less support may be available for grieving persons.
3.	Successive deaths or losses.	When losses or deaths follow one after the other. The griever does not have time to grieve the first loss, as they try to deal with the next loss.
4.	The nature of the death	When death is sudden, unexpected or traumatic. Suicide is an example of this.
5.	Social networks.	a.     A good support network of family and community is particularly helpful at the time of loss. b.     Ideas, attitudes and behaviour towards death are different for different groups. c.     Groups that are more accepting of death and view it as a part of life, are less likely to deny death and to facilitate grief.

Internal Circumstances

1.	Attachment History	A person’s capacity to work through grief and express feelings is greater if securely attached as a child.
2.	Loss and death history.	When old losses have been difficult for a person to accept, a current loss may open old wounds and make the grieving process more difficult.
3.	Age and stage of griever.	Grief may be more challenging at vulnerable transition points in the life-cycle.
4.	Intimacy level	Linked to the quality of attachment is the intimacy of the relationship with the lost person.
5.	Emotional complexity.	If the relationship has been straightforward without denied feelings, the grieving process will be more straightforward.

Dimensions of Grief

The following dimensions of grief are widely referred to in the counselling literature:

Anticipatory Grief

Anticipatory grief is a term which describes the grief process that a person undergoes before a loss actually occurs.

The concept was originally introduced by Lindemann during the 1940’s, when he noted that in response to the threat of the death of their loved ones, wives of soldiers during World War II experienced patterns of grief and mourning while their spouses were still alive². On return from the war, the soldiers sometimes found that their wives had disengaged and they found themselves no longer loved. This notion, that mourning and detachment could actually exist in people prior to the death event, has stimulated a great deal of research and debate.

Some research studies support the positive effects of anticipatory grief on the recovery of the bereaved and emphasise that a period in which there is time to prepare for the upcoming loss, can result in an easier period of post-death grief for the individual. In contrast, other studies found that subjects who experienced anticipatory grief, did worse in the immediate post-loss period, and over time showed little improvement versus those who had not experienced anticipatory grief.

In the round, the outcomes of these findings on the effects of anticipatory grieving on patterns of post-loss grieving have been inconsistent and until such time as our understanding of the phenomenon of anticipatory grief is more fully clarified, the nature of support interventions to be undertaken by practitioners will remain partial.

Complicated Grief

Complicated grief, also known as prolonged grief, chronic grief, traumatic grief, or pathological grief, is an intense and long-lasting form of grief that takes over a person’s life, results in substantial distress, functional impairment and increased risk of suicide³.

The term “complicated” refers to factors that interfere with the natural healing process. Such factors might be related to characteristics of the grieving individual, to the nature of loss, the circumstances of the loss, or to other extenuating factors surrounding the loss event. Those experiencing complicated grief experience strong feelings of yearning for the loss, which do not diminish over time. These can be combined with feelings of resentment, bitterness or anger, a sense that life has lost its meaning and belief that feelings of happiness or joy can never again be experienced.

Risk factors for complicated grief include premature, sudden, violent, unexpected and traumatic losses, and can result in circumstances in which the grieving person can ruminate irrationally about what they could have done to prevent the loss or fears loss of sanity.

Treatment approaches for complicated grief often follow similar interventions to those employed with those experiencing Post Traumatic Stress Disorder, and can include the use of stress relief interventions, cognitive behavioural methods, and interpersonal techniques aimed at encouraging re-engagement with the world.

Disenfranchised Grief

The concept of ‘disenfranchised grief’ was originally articulated by Doka.  Defining disenfranchised grief as emerging when “survivors are not accorded the ‘right to grieve’”, he envisages situations in which a mourner’s right to mourn a loss is interfered with, either intentionally or unintentionally by others⁴.

Doka emphasises that it is elements of bereavement that can be disenfranchised. Such elements include:

• Relationships which are non-traditional, e.g., homosexual or extra-marital, clandestine, out of church, or disapproved
• Losses where there is a failure to acknowledge the significance of a death, e.g., perinatal deaths, abortions, deaths of prisoners, deaths of wartime enemies, death of a pet or the psychological/social deaths of those suffering from dementia
• Greivers whose capacity for grieving may no be acknowledged, e.g., the elderly, people with mental disabilities or young children
• Circumstances of death, g., suicide, deaths from AIDS, executions or deaths of addicts
• Ways individuals grieve, as for example when ways of grieving do not conform to cultural or social norms, e.g., too little/too much grieving, culturally ingrained stoicism, or wailing
• Outcomes of grieving, as when others respond negatively to mourners who may for example, take too long with their mourning, are slow to “move on” to new relationships, or try to maintain relationships with the lost love

Attig has proposed that the “right to grieve” is a matter of human dignity⁵.   He argues that disenfranchisement of grief represents a serious social failure in respect of:

• Empathy, relating to failure to understand the suffering and hurt of the bereaved,
• Abuse of power and neglect, as the discouragement, interference and sanction the disenfranchisement brings to the lives of those suffering loss adds unnecessarily to their suffering
• Ethics, in so far as denying the right to grieve is a failure of respect for the bereaved

For Attig, overcoming disenfranchisement of grief involves a process of enfranchising hope and love, in which caregivers can support those who are experiencing loss by helping them “to see that though reminders of absence are always possible, they can also open their hearts and give” their loss “a different presence in their lives by keeping memory alive and cherishing enduring legacies” (Attig, 2004, 213).

In our next post we will look at traditional counselling perspectives on dealing with grief and loss.

© Pat Lyons & Margaret Lenihan, 2016

References: 

1. Lendrum, S. & Syme, G. (2004). Gift of Tears. (2^nd ed.). Hove, East Sussex: Routledge.
2. Lindemann, E. (1944) ‘The symptomatology and management of acute grief’. American Journal of Psychiatry, 101, 141-148.
3. Robinaugh, D.J., Marques, L., Bui, E., & Simon, N. M. (2012). Recognizing and treating complicated grief. Current Psychiatry
, 11, 8, 31-35.
4. Doka, K. (Ed.). (1989). Disenfranchised grief: Recognizing hidden sorrow. Lexington, MA: Lexington. See also, Doka, K. (Ed.). (2002). Disenfranchised grief: New directions, challenges, and strategies for practice. Champaign, IL: Research Press.
5. Attig, T. (2004). Disenfranchised grief revisited: discounting hope and love.            Omega, 49, 3, 197-215