You’ve likely heard of Dr. Elizabeth Kübler-Ross’s five stages of grief, a framework that explores how we process denial, anger, bargaining, depression, and acceptance after loss. However, beyond this well-known model, it can still be challenging to understand grief—a universal experience we all face multiple times throughout our lives.
For instance, is grief defined solely by the physical loss of someone? Can we continue to grieve a loss that has occurred years ago? How can we recognise when our grief has evolved into something more complicated? While most of us are no strangers to grief, many of us do struggle to make sense of it.
In this article, we explore the complex nature of grief and loss, how they can manifest in different ways, and when it’s time to seek professional help.
What is grief?
Grief, in the simplest of definitions, is a natural reaction to loss. These reactions can vary from person to person, and manifest in different ways. For instance, after losing a loved one, an individual may openly express their grief and mourning and seek comfort in talking about their memories, whilst others may focus on staying busy or avoid reminders of their loss.
What, then, is loss? This universal experience extends beyond the passing of a loved one. Throughout our lives, we may encounter many forms of loss. Here are some examples:
| Relationships | We may lose a long-term friendship due to a falling-out, separate from a partner because of incompatibilities, or grow distant from family due to estrangement. Those caring for a loved one with dementia may also experience the pain of losing their emotional connection, even as the person remains physically present. |
| Abilities | An accident or health condition can strip us of abilities we once took for granted, such as mobility, hearing, or vision. This may limit our capacity to participate in meaningful activities or to live as independently as before. |
| Roles | Losing a job through retrenchment may deprive us of our professional identity and financial security, while retirement can disrupt the sense of purpose tied to our work. Parents may also face the emotional impact of the empty nest syndrome when their children leave home. |
| Ideals | It can be challenging to cope with the collapse of cherished ideals, such as a vision of family harmony, faith in a political movement, or a long-held belief about justice and fairness in the world. |
| Possibilities | Financial constraints may make higher education or a dream career unattainable, while injuries or impairments can close the door on other ambitions. Similarly, infertility, miscarriages, or pregnancy complications may limit the possibility of becoming a parent. |
In many cases, even positive change can bring loss. For instance, even as moving to a new city offers new opportunities, it might mean leaving behind familiar surroundings and close connections.
Primary and secondary losses
Conversations about grief and loss often revolve around primary losses, which are most acutely felt and cause an individual the most distress. However, secondary loss—the consequences of a primary loss—is often overlooked or discounted.
Consider a child who loses their father, the sole breadwinner of the family. Beyond the primary loss of their father’s presence, they may face tangible losses such as financial stability or reduced closeness with the remaining caregiver, who is also grieving and may now be burdened with additional work responsibilities. Other losses might be more existential, such as a diminished sense of identity, the absence of a father figure to look up to, and the shattered hopes and dreams of having both parents present to witness life’s milestones.
Secondary losses can ripple through the fabric of our social, emotional, physical, and spiritual lives, and they may surface at different stages of life (e.g. graduation, wedding, or other significant milestones). Recognising that grief often extends beyond the acute, initial loss can be a powerful reminder to validate these experiences and to allow secondary losses to be grieved in their own right.
Symptoms of grief and loss
Dr. Elizabeth Kübler-Ross’s model of grief is just one of the many frameworks that shed light on the varied ways people experience grief. Bowlby & Parkes’ grief model, for example, proposes four phases: shock and disbelief, searching and yearning, disorganisation and repair, as well as rebuilding and healing.
Across these models, there are similarities in how people experience and process grief. Common reactions can manifest in various ways, including physical/physiological, psychological, behavioral, social, and spiritual dimensions.
An individual’s symptoms may be predominantly physical, while another’s may be predominantly behavioral. But, more often than not, these symptoms manifest across multiple, if not all, aspects of life.
What is pathological grief?
While grief may look different for everyone, research suggests that we generally follow a “typical” trajectory. When this process is disrupted, the loss cannot be fully integrated. As a result, grief may become chronic, unresolved, or delayed, leading to complicated or prolonged grief.
Prolonged Grief Disorder (PGD), or Persistent Complex Bereavement Disorder, is characterised by intense and persistent grief that cause clinically significant distress or impair functioning in our social, occupational, relational, and other key areas of functioning.
For PGD to be diagnosed, the loss of a loved one must have occurred at least a year ago for adults and at least six months ago for children and adolescents. The individual must have experienced at least three of these symptoms below nearly every day for at least the month prior to the diagnosis. PGD can also co-occur with other mental health disorders, such as anxiety, depression, or post-traumatic stress disorder (PTSD).
Certain types of grief put individuals at greater risk of PGD:
1. Disenfranchised grief
Disenfranchised grief occurs when loss is not recognised or validated socially. For instance, the death of a criminal and deaths due to old age, suicide, or substance use may be considered less significant. Non-death losses, such as an early pregnancy loss or the end of an unhealthy relationship, may also be seen in the same light and contribute to disenfranchised grief.
Grief among children is also often disenfranchised. Despite the fact that children are capable of processing grief and need to do so, they are often overlooked due to the misconception that they experience loss less intensely. This results in a lack of support or minimisation of their internal experiences.
2. Anticipatory grief
Anticipatory grief is a form of complicated grief experienced even before we lose a loved one. As the term suggests, anticipatory grief begins when we expect a loss. This may be associated with death anxiety, suspecting that we or a loved one is terminally ill, or receiving a formal diagnosis. Often linked to ageing and caregiving responsibilities, anticipatory grief can bring myriad emotions. Beyond anger, sadness, and anxiety, it may involve feelings of relief, which can in turn lead to guilt and shame.
3. Traumatic grief
Traumatic grief follows sudden and violent events, or those we perceive as traumatic. These may include accidents, natural disasters, wars, and suicides. In addition to processing grief, we may also have to process trauma, which adds to the complexity. Symptoms of traumatic grief may overlap with those of Post-Traumatic Stress Disorder (PTSD), and they can be accompanied by survivor’s guilt (in cases where the person survived but others did not) and moral injury—the distressing psychological, behavioral, social, and sometimes spiritual aftermath.
4. Ambiguous loss
Ambiguous loss occurs when it is difficult to determine whether a loss has occurred and whether grieving should begin, yet we still feel significant distress.
This may occur in situations where a loved one is physically absent but psychologically present (e.g., a missing person), or physically present but psychologically absent (e.g., a loved one with Alzheimer’s or dementia).
When grief becomes complicated or prolonged to the point where our functioning is impaired or significantly affected, it may be time to seek professional help.
How can counselling/psychotherapy help?
In helping you make sense of grief and loss, your clinician may employ these approaches:
1. Complicated Grief Therapy (CGT)
Developed by Dr. Katherine Shear and her colleagues, CGT is an individualised therapy program that spans over 16 weeks. It integrates attachment theory, Cognitive Behavioural Therapy, and the Dual Process Model of Grief (DPM). Key themes of CGT include:
- Providing psychoeducation to support clients in understanding and accepting grief and the reality of the loss
- Managing emotional pain and symptoms
- Orienting towards the future
- Reconnecting with others
- Learning to live with and connect to reminders and memories of the loss
- Being able to talk about the loss
CGT is not only effective in alleviating grief symptoms and PGD-related impairments; it also reduces anxiety, depression, avoidant behaviours, guilt, self-blame, and negative thoughts about the future.
2. Cognitive Behavioural Therapy
Given that cognitions influence one’s emotions and behaviours, CBT focuses on identifying and changing negative thought patterns, particularly those related to grief.
Key themes of CBT include:
- Cognitive restructuring: Grief and loss can trigger unhelpful thoughts, such as “I must have done something wrong for this to happen” or “This is the end of my life as I know it.” Identifying and reframing these thoughts helps us address unhelpful feelings (e.g., guilt, self-blame), re-interpret our loss, and even find meaning in it.
- Behavioural activation: Following a loss, we may cope by withdrawing and stopping activities that foster social connection and positive feelings. Behavioral activation encourages engagement with such activities, helping to alleviate feelings of isolation and connect us with other forms of social support.
- Therapeutic exposure: In a bid to avoid pain, some of us may actively shun reminders and memories of it, from places we used to visit with our loved one to songs they used to listen to. Therapeutic exposure can help individuals regain control over these stimuli and develop a greater sense of emotional and mental safety.
CBT has been found to be effective in addressing comorbid symptoms or mental health challenges (e.g., depression, anxiety, sleep disturbances) that might be associated with PGD. Trauma-focused CBT approaches can also be helpful for individuals who have experienced a traumatic loss.
3. Social support
When someone is grieving, it can feel like no one else in the world understands the pain they are going through. This is where other forms of intervention come into the picture.
Bereavement groups, for one, can provide a safe space to heal. Through the sharing of others’ stories, we may find reassurance that our reactions to loss are completely normal. From their collective wisdom, we may even learn different strategies to manage grief that we hadn’t thought of before.
Learn to manage grief and loss at Intellect Clinic
At Intellect Clinic, we understand that talking about loss can be deeply painful, and that finding your way through grief takes immense courage. But remember, you don’t have to face this journey alone. As you heal, we are here to walk with you every step of the way.
Reach out to learn more about the services that can best support you.
