There's No Right Way to Grieve

comforting hands

Around 2 a.m. on April 28, 2016, Cathy Semeria made a call no mother should ever have to make.

Her son Nick had been awoken by a friend with troubling news of a fatal crash the night before that involved five University of Georgia students -- possibly including his sister Christina. Nick urged his parents to call Athens Regional Medical Center near where she went to school. Hands shaking, Cathy dialed the number.

“I said, ‘You just need to let me know that my daughter is OK,’” she recalls. “There was total silence on the other end.”

She threw the phone at her husband and collapsed in disbelief. In the coming days, as news unfolded about the accident that killed 19-year-old Christina Semeria and three friends and left another critically injured, Cathy waded through waves of shock and daze. At first, she couldn’t cry. “Was that normal?” she asked herself. Six weeks later, she started crying and couldn’t stop.

A year later, she still bristled when well-meaning friends suggested her daughter “would want her to be happy.” And she often replayed the details of the accident in her mind: No drugs. No alcohol. No speeding. Yet their car drifted across the center line. Why?

Today, she has found solace in her community, and through carrying on “Tini’s” legacy via social media. But when a friend of her daughter -- the youngest of her four children -- gets married or graduates from college, the pain pulls Cathy under again.

“Grief is like being in an ocean and you don’t know when a wave is going to hit you, or how high it is going to be, or how long you are going to get caught in the riptide,” she says.

While Cathy’s journey may sound familiar to some, it is -- new research suggests -- wholly her own.

Fifty years after psychiatrist Elisabeth Kubler-Ross introduced the now iconic five stages of grief -- denial, anger, bargaining, depression, and acceptance -- scientists in the growing field of bereavement research say it’s not so simple.

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Men grieve differently than women. Soldiers grieve differently. More than 60% of people, recent research shows, bounce back surprisingly quickly. But about a quarter take a year or two, and 1 in 10 have what is known as “complicated grief” -- a persistent, debilitating yearning that can last years.

Grief changes the body in different ways, too: People who grieve longer have different brain activity, different hormone patterns, and a higher risk of bereavement-related health problems.

“There has been this idea in the past that grief proceeds in the same somewhat lockstep sequence for everyone,” says David Feldman, PhD, a professor of counseling psychology at Santa Clara University in California. “We now know it just doesn’t work that way. People often attack themselves for doing grief wrong when, really, we are all entitled to our own way.”

 

The Truth About the Five Stages

David Kessler, who co-authored several books with Kubler-Ross, says her work has been “widely misunderstood.”

He notes that when she introduced the stages in the 1969 book On Death and Dying, they were intended to describe the emotional process of a dying person at the end of life.

In 2004, On Grief and Grieving was published. The book, authored by Kessler and Kubler-Ross (who passed away before the book’s publication), formally adapted the stages to the bereaved, and the authors included an often overlooked notice on page one.

“We explained that they are tools to help us frame and identify what we may be feeling, but they are not stops on some linear timeline,” Kessler says.

That said, he still uses the stages in his workshops and on his website, grief.com, to describe what many go through.

Denial, which sometimes shows up as shock, helps us pace our grief, he says, letting in only as much pain as we can handle. Anger is “pain’s bodyguard,” letting have connections without being too vulnerable.

“A connection made through the strength of anger feels better than nothing,” he says.

Bargaining helps us make a plan to climb out of grief -- we’ll volunteer in our loved one’s name or vow to live our own lives more fully. Depression is a given, he says, once we let the reality of the loss sink in. Then there is acceptance.

“Not everyone goes through all the stages, and they are not in any prescribed order,” Kessler stresses.

 

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The Broad Spectrum of Grief

George Bonanno, PhD, a professor of clinical psychology at Teachers College at Columbia University in New York City, says he has seen no evidence that these stages are universal among the grieving and, in fact, the five-stages theory has in some ways done more harm than good.

“In the ‘90s, the idea was that everyone must go through this painful, elaborate working-through process, and if they didn’t, either they didn’t care about the person or they were in denial and needed treatment,” he says. “A lot of people were getting treatment when they really didn’t need it.”

In one groundbreaking study of 205 widows and widowers, Bonanno found 46% showed little depression, intense yearning, or longing in the 18 months after the death of their spouse. Ten percent had improved mental health, as the chronic stress of caregiving subsided. Another 2015 study -- of 2,512 people who had lost spouses or children -- found that 69% were “resilient,” having little depression at three follow-up time points.

As Bonanno writes, “These individuals are not cold and unfeeling or lacking in attachment but, rather, are capable of genuine resilience in the face of loss.”

On the other end of the spectrum is complicated grief, also known as prolonged grief disorder.

“Imagine feeling the way you felt in the early days after a friend or family member died, only it is years later,” says Katherine Shear, MD, founding director of the Center for Complicated Grief at the Columbia School of Social Work.

About 7% to 10% of the bereaved struggle with it, but it’s more common among those who have lost a loved one to homicide, suicide, or other violent incident. About 24% of parents who have lost children and 23% of military families have it.

They often rearrange their lives to avoid reminders of the deceased -- a park a child used to play in; a spouse’s favorite restaurant.

“All of a sudden there are a ton of places they can’t go,” says Shear, recalling one patient who --four years after the death of her son -- seldom left the house because she was afraid she’d run across something that would trigger her grief.

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Over time, people who once offered support begin to fall off, Shear says. “Then people start to say things like, ‘I know this is really hard, but it’s time to get over it.’”

Research also suggests that men and women differ in their grief, with women grieving more chronically and men grieving more acutely.

“In the beginning, I felt like I had been dismembered -- like half of my body was missing,” recalls Sam Feldman, of Martha’s Vineyard in Massachusetts, whose wife of 53 years, Gretchen, died of cancer in 2008.

Four weeks after her death, he attended a dinner party with friends and was struck by the fact that no one brought up her name. He finally got up and left.

“In retrospect, I realize that they were uncomfortable bringing her up,” he recalls. “But I wanted to talk about her. Sometimes I don’t think people realize that.”

Because husbands tend to rely heavily on their wives for social plans and have more trouble sharing their feelings, he says widowers are often struck with profound loneliness.

“We have a lot of acquaintances but sometimes not a lot of intimacy, so it’s hard to find people to talk to,” Feldman says.

But when he attended a support group, he walked in to discover it was all women and they, as he puts it, seemed to be on a different path than he was.

He ended up founding his own all-men’s group, now known as the National Widowers Organization, to help fill that gap. And he has since remained strongly involved in the arts community, of which Gretchen (a painter) was a part.

At age 90, he has a new partner and is happy.

But he still drives by Gretchen’s nearby grave almost daily and thinks of her often.

“It’s not a negative thing. She’s just a part of who I am now,” he says.

 

Your Brain on Grief

While the research is young, studies have begun to shed light on what happens in the brain and body during grief.

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In the days after a loved one’s death, the bereaved person’s body pumps out stress hormones like epinephrine and cortisol, boosts blood pressure, and weakens immune response, studies show. In fact, in the first 3 months after the death of a spouse, the odds of dying are twice as high for men and 1.5 times as high for women.

In most cases, those changes fade over time.

But in people with prolonged or complicated grief, things are different.

Studies show they continue to have higher levels of the stress hormone cortisol and may also have an imbalance of the hormone oxytocin, a.k.a. “the mothering hormone,” which helps people form bonds with one another.

Meanwhile, brain imaging studies show that when healthy people are shown a photo of the deceased many months later, it still activates those regions associated with physical pain.  But in people with prolonged grief, a reward center called the nucleus accumbens -- which is also linked to yearning for food or drugs -- also lights up.

“In a way, people who lose a loved one and can’t get over it are like drug addicts,” Bonanno says. “Their reward system is in hyperdrive, and they are in a constant state of yearning for a person who is not there and is not going to be there.”

 

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A New Way to Manage Grief

While it may help some people, in many cases, the bereaved do not require long-term therapy or medication, says Bonanno, author of The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss.

“Most people recover pretty quickly,” he says. “It’s not that they aren’t sad. But they can work and continue with their lives and experience joy and pleasure, sometimes even in the early days after a loss.”

But for those with complicated grief, professional counseling is recommended.

Shear has come up with a 16-week program in which people explore when and how to face their grief and when it’s appropriate to set it aside. In one exercise, they are asked to recount the story of when and how they first learned of the death. In others, they’re encouraged to return to the places they’ve been avoiding, take steps to strengthen relationships with the living, and plan for the future.

They also develop healthy ways to stay connected with their lost loved ones.

“Grief is not all bad,” Shear says. “It is not something we need to make go away or get rid of or not talk about. We need to allow it a place in our lives and our communities.”

 

The Sixth Stage

In November, Kessler will publish a follow-up to the book he authored with Kubler-Ross, adding a sixth stage, which he has come to understand better since the death of his own 21-year-old son.

“I was devastated, and I tried to do what I told everyone else to do,” he says, recalling how he sat in grief counseling groups, his book on the table, where no one knew he’d written it. The stages rang true to him. But one was missing: Meaning.

“We are not a generation that is just OK with finding acceptance,” he says. “We want to transform our grief into something more meaningful.”

Cathy Semeria says that of all the stages of grief she’s heard about, she identifies with this one the most.

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Despite the occasional comment that she’s being too vocal on Facebook, or that her grief is lingering too long, she continues to post candidly and speak publicly about her grief process, has started a support group for grieving parents, is more active than ever in her church, and intends to write a book.

“Even in the deepest of grief, I continue to live my life with purpose and meaning and share my story,” she says.

Is she over the grief? No, she says. There is no climbing over it.

But she has gained the strength to walk through it.

 

How to Avoid Saying the Wrong Thing to Someone in Grief

By SETH J. GILLIHAN, PHD, clinical psychologist

Many years ago when my wife and I lost our first two pregnancies less than 6 months apart, a friend of ours reassured us that “everything happens for a reason.” I was furious. While I knew she meant to be helpful, I found the remark deeply uncomforting. Rather than acknowledging our grief, her comment seemed to dismiss it.

You’ve probably been on both sides of this dynamic. When faced with another person’s grief, you want to be comforting, but you worry that you’ll say “the wrong thing” and inadvertently make it worse. When faced with your own grief, you may have been told things that were unhelpful, or even upsetting.

Here’s a sample of potentially less-than-helpful comments:

  • They’re in a better place.
  • At least they’re not suffering anymore.
  • Time will heal this.
  • You’ll feel better if you _____ [fill in the blank].
  • This too shall pass.
  • You’re lucky you had 36 years with your dad.
  • I’m surprised you’re still so upset about this.
  • Everything happens for a reason.
  • Your parents dying is a blessing in disguise -- you won’t have to watch them grow old.
  • It doesn’t get easier.

The common theme in most of these statements is an attempt to tell the person it’s not as bad as they think it is. And while the comments were meant to be comforting, they more likely felt invalidating, as though a person shouldn’t feel the way he or she does.

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So what is helpful? Thankfully, it’s very simple.

Show up. The most important thing is to be present. Your continued presence may be especially appreciated after the acute period of loss and grief, after some time has passed, when most people have returned to life as usual but the pain remains for the one who is grieving.

Express your care and concern. You can use whatever words feel natural for you -- you don’t have to follow any prescribed phrasing. Just let the person know you’re with them and you care about them.

Acknowledge and validate their feelings. More than anything, we need the space to feel what we feel when we’re grieving. Any response that tries to point out a silver lining is likely to feel like a rejection of a person’s feelings, as though he or she is “grieving wrong.” You can validate their experience even if you know their perspective will change over time -- the passage of time has a power that words lack. 

Be aware of your own feelings about loss. Most of us have our own feelings about death and other forms of loss, and if we’re not aware of them, they can color our interactions with the grieving person in unhelpful ways. When you recognize your own “stuff,” you can focus more directly on the other person.

Listen. Offer a listening ear if a person wants to talk. You probably don’t have to say much, and you certainly aren’t expected to “solve” the grief. Just having someone they can express their thoughts and feelings to can be an invaluable part of healing. Or you might even sit in silence with them.

Find more articles, browse back issues, and read the current issue of WebMD Magazine .

 

 

WebMD Magazine - Feature Reviewed by Neha Pathak, MD on February 04, 2020

Sources

George Bonanno, professor of clinical psychology, Teachers College, Columbia University, New York City; author, The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss.

David Feldman, PhD, professor of counseling psychology, Santa Clara University, CA.

David Kessler, death and grieving expert, grief.com; co-author, On Grief and Grieving.

Katherine Shear, MD, professor of psychiatry, Columbia School of Social Work; founder, Center for Complicated Grief.

Psychology of Aging: “Prospective Patterns of Resilience and Maladjustment During Widowhood.”

Dialogues in Clinical Neuroscience: “Immunological and neuroimaging biomarkers of complicated grief.”

Journal of Psychiatric Research: “Trajectories of depression following spousal and child bereavement: A comparison of the heterogeneity in outcomes.”

Australian Critical Care: “What is normal in grief?”

Mary-Frances O’Connor, PhD, associate professor of psychology, University of Arizona.

Cathy Semeria.

Sam Feldman.

Seth J. Gillihan, PhD, clinical psychologist and WebMD Mental Health blogger.

 

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