Dr Patricia Pitta | Psychologist, Manhasset, New York

Grief and Bereavement

A loss whether it is sudden or expected is accompanied by a grieving process that everyone needs to journey through at their pace and own timing. The ability to navigate through the stages of grief is essential to help individuals or families to make as healthy an adjustment as possible so lives can return to their usual state of productivity. Grief and bereavement therapy is a necessary step for one to heal the pain of loss. Following is an article that Dr. Pitta wrote in reaction to the loss that people felt from 911 which are the stages that are common to all who grieve.

Published in the Independent Practitioner. Permission of Div 42, American Psychological Association.

Journey Through Grief

We are all grieving. Whether our emotional pain stems from the death of a loved one on 9/11, a natural death in the family, or the feeling of no longer being safe, all people are experiencing loss.

Knowledge, however, is power. The more we know about grieving, the better we will be able to deal with it. Therefore, as part of a pro bono project, I contributed the following article to help readers better understand the grieving process.

I owe much of my material to Surviving Grief, by Dr. Catherine Sanders. Her descriptions of the stages of grief are based on an extensive study done in Tampa, Florida. At the end of the article are other references for those who may wish to know more. Also, feel free to copy this material and give it to anyone who may need it.

Introduction

Since 9/11, individuals, families and communities have been stricken with grief. Mourning and grief are natural responses both to sudden traumatic loss and to natural death. I believe that if we are clear about what we are feeling both emotionally and physically; we will more easily negotiate the grieving process, and thus summon the strength to deal with our new realities. Knowledge is strength; may the Lord help us develop the strength we need to persevere and grow. May we work for the betterment of ourselves, our families, our communities, our nation and a world at peace.

Some definitions: Bereavement is an objective state or condition of loss. In anticipating or experiencing bereavement, we feel grief, a psychic state of mental anguish. Mourning is the process a grieving person goes through, as well as the social expression of the grief. (Sanders, 1992)

Grief is about loss and the threat of loss. The stronger the bond between us and the person we have lost, the more we will hurt both physically and emotionally. When we are torn from a family member or friend, a part of us dies as well. Our natural need for attachment gets severed, often bringing the return of childhood fears. The world feels like a more dangerous place. As a result, we may feel out of control. We ache to have the loved person back. We know in the rational part of our minds that the person is not coming back, but it also seems impossible to let him go. We will remain emotionally conflicted until we can release our loved ones.

Because letting go is so difficult, we must do it slowly. This painful period of giving up our loved one is known as “grief work.” We experience strong emotions, including guilt, shame, anger and frustration. No two people grieve alike. Also, the manner of death will affect the grief process. Sudden and unexpected death, like what happened on 9/11, will lead to a more complicated mourning process (Cable, 1996).

The shock ensuing from sudden death causes an extreme assault on the survivor’s physical and psychological state. Mourning is slowed since there is so little energy available to do the grief work. The mourner needs to rebuild his strength in order to enter the grief process. Support from friends and family is critical in helping us get through it. Later, as we begin to feel safer and more secure, we can open ourselves to the pain of grief, learn to accept it, and grow.

Recovery from grief does not occur in a steady progression. We are more likely to go up and down, sometimes with one step ahead and two steps back. Eventually, our mood swings become less intense. We are able to feel good some of the time, awful at other times, and sometimes just neutral.

According to Sanders (1992), to progress through grief, we need to pass through five distinct phases.

Shock
Awareness of loss
Conservation/withdrawal
Healing
Renewal

I. Understanding Shock

Shock can be defined as a sudden and violent disturbance of the mind or emotions. No one is truly prepared for the death of a loved one; the more unexpected the death, the more a person will tend to be in shock. Also, if there is a traumatic death, such as through murder or terrorism, the longer this initial period will last, and the more complicated will be the process of resolving the grief. The grief process doesn’t change us, but it exaggerates our usual response patterns.

No one grieves in the same way and shock will affect each person in different ways.

We feel the blow on all levels, physical, emotional, and social, at once. Common physical symptoms are:

Dry Mouth
Sighing or yawning
Generalized Weakness
Crying
Trembling
Strong startle response
Insomnia
Poor appetite

Emotional symptoms tend to be:

State of alarm
Disbelief
Confusion
Restlessness
Feelings of unreality
Helplessness

We need to avail ourselves of all the help we can get to go through the funeral rituals. At times we may feel we are going to collapse and may need to be both emotionally and physically held. We may feel numb or unresponsive. We may scream, faint, rage or withdraw. All of these responses are NORMAL.

As a result of experiencing shock, many people withdraw from their friends and family as well as their usual everyday activities. They become preoccupied with thoughts of their lost loved one. After the funeral is over, friends and family may go back to their regular lives, but we are left with the loneliness of grief.

Following are ways to ease the shock phase:

Safety is very important at this time. Surround yourself with people who are kind and who enable you to feel safe
Express what you feel. Holding in emotions takes more energy than sharing your feelings.
Allow others to nurture you. During the shock phase, you experience anxiety and helplessness, which are NORMAL and appropriate. You need others to support you.
Ask for support. Some people are afraid to approach you because they don’t want to intrude or may feel uncomfortable dealing with death. Give your friends and family the signal that they can help you.
Be patient with yourself. Your might find yourself losing things. You may frequently feel restless and agitated. Do not judge yourself. These are NORMAL responses.
Don’t be concerned if you feel your loved one has not died. This is a frequent and normal occurrence.
Take part in any rituals that are being planned. They will enable you to feel more in control
Make no major decisions while in shock.

II. Awareness of Loss Phase

During the first stage of grief, shock provides a temporary buffer against the emotional turmoil of loss. When we enter the second phase, the insulation is stripped away and we are left feeling raw and exposed (Sanders, 1992). This stage resembles having a tooth with its nerve exposed; causing anything we put in our mouths to touch off the nerve ending and give us pain. Like a toothache, the pain from the awareness of loss can be experienced for moments, hours, days, or months. At times the pain is bearable, but at other times it is excruciating in its power.

Common symptoms of this phase are yearning, frustration, crying, anger, and guilt, shame; sleep disturbances, fear of death, over-sensitivity and disbelief. We may dream of the deceased or even sense her presence.

We may experience separation anxiety, feeling alone and unsafe in the world. This period uses enormous amounts of psychic and physical energy. We can feel debilitated from prolonged stress.

There are often conflicts among family members, possibly manifesting as fights over money or over who gets what possessions, but they are really over the grief that everyone feels. At this time it’s best to keep things as simple as possible and not make any hasty changes.

There are post-traumatic symptoms. With the continuous media coverage of 9/11, the traumas get relived over and over. Thus, it has become more difficult for families and the population at large to resolve their grief.

Intellectually, we know that the person is lost, but emotionally we are not convinced and we wish, bargain, yearn and search for some sign that our lost one is close by. Many people report getting signs from the dead that seem to indicate that they are still connected to us. This comforts us for the moment, but leads to terrible disappointment when the signs do not consistently appear.

The tasks of the Awareness of loss phase are:

Many people try to distract themselves during this phase, but it is important to do your grief work by allowing yourself to feel your intense emotions. Realize that the pain of loss must be experienced. Do not try to escape it. Short periods of distraction, however, are healthy.

At times you will feel crazy. This is a NORMAL feeling and will pass.
Give yourself permission to cry. If you fear crying, allow yourself to do it for a short period of time and then go back to whatever you are doing. This will prove to you that you can cry and then regain your functioning.
Vent your anger. It is normal to be angry because of the emotional turmoil caused by loss, deprivation, conflict and confusion.
Expect to feel extra sensitive while you are grieving. If someone says something that appears insensitive, don’t go into an emotional tailspin. Recognize that we all have our limitations. If the person continues, it might be better to distance yourself for a while.
Joining a support group will let you know that you are not alone. If you share your feelings of guilt and shame, you will discover that others have them too.
As you share, you will get continued support.
Talk about your loss over and over. You might think it is excessive, but this is the work of grief, which will eventually allow you to accept your loss.
Exercise to let out the extra adrenaline that your body is pumping into your system. It will also help you to control your emotional reactions. Also, eat a balanced diet. Although it is common to lose your appetite at this time, you still need good nutrition.

We can endure only so much emotional and physical pain until sheer exhaustion sets in. This exhaustion initiates the next stage of grief.

Through all of the difficulty, hope can remain. During grieving, it’s hard to conceptualize because the world appears to be a dismal place. Remember, grief will lessen. The misery will not last forever.

III. Conservation and the Need to Withdraw

As we journeyed first through shock and then through exposure to the loss, we are now exhausted from feeling so much psychic pain. In the next stage, withdrawal, we need to conserve what little energy we have left. Now, we welcome being alone; we fear falling apart if we continue feeling such intense emotions. We may find ourselves not wanting to return phone calls, preferring not to communicate with others.

Characteristics of this stage are:

Weakness
Fatigue
Great need for sleep
Weakened immune system
Helplessness
Feeling a loss of control

As we hibernate, we obsessively review and ruminate about the death. We question why it happened, we wonder if we could have done something to prevent it from happening.

Finally, we come to an understanding that life will never be the same as it was in the past. We start moving at this time to a realization that, without forgetting our precious memories, we will need to find new experiences and ways of perceiving life.

Main tasks of this phase are:

Allow yourself to withdraw. In order to grieve at this time, you need to be alone.
You might fear you are going crazy. Reassure yourself that you are not. It is a time of deep emotion and exhaustion.
Learn to conserve your energy so that you may heal from your shock and stress. Sleep more; take little naps. Nurture yourself. Do things that make you feel good (massage, baths, walks).
Simplify your life. Find shortcuts for everything possible.
If you are developing dependency behaviors (drinking, drugs), break the patterns and attitudes that are perpetuating them.
Allow yourself to think about your lost one—the good and bad times. Review photos or videotapes of your life with the deceased. Visually looking at your life puts it in perspective.
When feeling low emotionally, know that these periods will begin to get shorter and shorter.
If your own grief pattern doesn’t seem to follow the stages, don’t be concerned. Grieving patterns are individual.

IV. Healing Phase

Our grief work gives us a death and resurrection experience “As we die to our old life, a new one is being forged in its place.” (Sanders, 1992) As we lessen our withdrawal, we reach a turning point. New events emerge or we simply wake up one morning and realize that we are feeling a little more hopeful. We are now moving towards a resolution that we had doubted would ever come. People reach this healing phase in their own time. For some it takes months, while for others the process can last much longer. What is good to know is that we all reach this phase eventually. It’s important to remember, however, that we will still have periods in which we regress to earlier stages of mourning, particularly when we are reminded of our loved ones.

At this time, it is likely we will feel better physically, have increased energy, better sleep and a stronger immune system. Allow yourself to enjoy the return of energy. Celebrate it!

According to Sanders (1992) there are a number of tasks that need to be accomplished during this phase.

Relinquishing roles: As we build our internal resources, we begin to think of ourselves as individuals rather than as the parent, child, or sibling of the deceased. One of the hardest tasks of bereavement is giving up former roles. Throughout our lives we became accustomed to doing things in a certain way in relation to the deceased person. We need to rethink the way we organize our lives. It’s NORMAL to feel that you have become a different person.
Forming a new identity: In the process of making changes slowly, we eventually find ourselves with new routines and new opportunities. One of the most important tasks of bereavement is carving out a new life based on what we need for ourselves. It’s time to begin to trust ourselves to make decisions that will foster our individual development. This is not selfish. One needs to love the self. Only then can you love another.
Assuming control: We begin to take responsibility for decisions that we had put aside. Trust your decisions. No one is perfect. If you make a mistake, try again. Also, it’s important not to make too many decisions at once. Remember healing is a slow, step-by-step process.
Self-care: Take care of yourself by eating well, exercising and going for check-ups. Develop a hobby or take a course. Take time off from grief. Laugh with friends and make new ones.
Centering ourselves: When we grieve, we feel scattered. We often run away from ourselves and our feelings. Now we have the task of finding our own center. This is a time for self-soothing and becoming the best parent you can be to yourself. This process will enable you to make decisions based on your thoughts, needs, and feelings rather than on what others think you should do. You might possibly have allowed the people who have been supporting you to tell you what to do. Now is the time to take responsibility for yourself. You can help center yourself through meditation, relaxation, and spiritual guidance. A good reference for meditations for healing after a death is A Time to Grieve by Carol Staudacher.
Forgiving and forgetting: We need to forgive our loved one for dying and ourselves for living. Forgiving comes when we have worked through the emotions of guilt, anger and shame associated with our loved one’s death. We never forget our loved ones, but we accept that we will never have them in our physical life again.
Searching for meaning: It’s natural to try to find the meaning of a beloved person’s death. Meaning may come from the way our lost one lived his life. Some people find it in helping others who are themselves experiencing loss. People who feel a strong connection with God or a higher power derive peace from their spiritual relationship.
Closing the circle: In some cultures, families have rituals to mark the passage from an old to a new phase of life. We don’t abandon the people and way of life we knew, but we open to new circles of friends, new activities and new dreams. Sometimes the bereaved feel guilty about not spending their time as they did in the past. However, it’s NORMAL and HEALTHY to do things differently, even if it’s sometimes scary.
Renewing Hope: When we stop idealizing the deceased, and we can remember both the happy and the sad times with her realistically, we are ready to move to the final stage of healing: Renewal.

V. Renewal

As we have journeyed through the stages of shock, awareness of loss, conservation and withdrawal and healing, we never thought that we would get to renewal. We may have thought our life was over, but little by little, we have rebuilt out lives, with some things the same and others very different. We are not the same people. The old self dies and we are met with a new self that opts for life. (Sanders, 1992) “Your time of loss becomes a time of discovery” (Miller, 1994) Now we find a new strength that we did not know we possessed.

At this time, we find ourselves re-energized. The energy we lost to grief has returned and we can use it for new experiences. We feel more stable; our emotional ups and downs have diminished. At anniversaries and holidays, some of the grieving feelings return, but they soon pass.

Tasks of the Renewal Phase: (Sanders, 1992)

Keeping loneliness in perspective; learning to live without: Loneliness is a by-product of grief. In their difficulty in being alone, many people look to substitute the deceased too quickly. We need to face our loneliness, meaninglessness, guilt and isolation and realize that we will not be overtaken by these feelings. As we learn to master the feelings, we become stronger and feel a freedom that we never knew.
Not until we reach a “personal renewal” can we be open to new people and new experiences. Loneliness does not last forever, but we need to be patient with ourselves. We will eventually reach a point where the search for a replacement will be successful. Now we are not replacing the deceased, but making a new life and sharing new experiences with another person
Enduring the anniversaries: These special days will probably cause grief reactions to return. Many people fear they are going through grief all over again. As it is normal to re-experience sad feelings at anniversaries, it is also normal for them to subside quickly.
Renewing self-awareness: Loss may push us to do things we may never have previously envisioned. As you feel stronger, give yourself permission to celebrate the new roles, activities and experiences you are having Your loved one would have wanted you to go on with your life and be happy.
Accepting responsibility for and living for ourselves: Most people can take responsibility for their daily routines, but the biggest challenge is being responsible for your emotional independence. Most of us have spent much of our energy living with another. When that other dies, we are left with a large void inside ourselves. We need to acknowledge the new freedom, which in the beginning seemed like a life sentence. We now have an opportunity to live in a different way. Some people are so frightened to grow that they remain embittered and inflexible. People who choose life take risks, try out new experiences, form new relationships. We need to center ourselves through such activities as meditation, prayer and reading to help us determine what we really want from others and ourselves.
Focusing: As we have learned to center, now we need to put into action what we have learned about ourselves and then focus our energies on our new goals.
Reaching out: Since your world has been so shaken by your loss, this might be one of your most difficult tasks. After centering and focusing yourself, the next step is to reach out to others. Friends and family are very welcome at this time. It’s helpful to join groups and activities that bring people together. Be patient with yourself and don’t overdo it. Try one thing and add another when you feel ready. Remember, all this takes energy. Even though you now have more energy available, be respectful of your own well being.
Understanding the long process of grief: Grief is a long process and is different for each of us. Be patient with yourself. Research indicates that mourning the loss of a spouse takes three to five years. If you lose a child, it may take ten to twenty years or even a lifetime (Sanders, 1992)

Ending the renewal phase

Continue to talk about the deceased for as long as you need to. “I am the only one who can tell my story—the story of my relationship with my loved one, the story of my loved one’s death, and all that goes with it. In my mind I hold the conversations, the sights and sounds, the details surrounding the death. It is all right to tell the story that wells up inside of me. I don’t need to hold it in and press it down. I can tell it and tell it until I no longer need to. Each time I tell my story, I remove one small bit of hurt from inside me. I ease my wound.” (Staudacher, 1994)

Maintain your physical and mental health
Accept the new you and your new-found freedom
Plan a ritual to end your grief
Ask for what you need from friends, families and new acquaintances
Allow for brief regressions at anniversary times
Accept that you will feel lonely at times
Reach out to others
Be patient; remember that we all grieve differently

Remember that as you make a new life, the wisdom, love and caring from your loved one will always be with you. “Death ends a life, but not a relationship.” (Alborn, 1997) The bonds that you had with the deceased take on another meaning, but do not end. (Klass, Silverman & Dennis, 1996) I hope that by reading A Journey through Grief you will realize that many of your painful, overwhelming and almost unbearable feelings are normal aspects of mourning that need to be faced in your journey. The hope is that you will gradually be able to work through your loss and develop a new life, with the gift of wisdom gained from your lost dear one.

clinical and family psychologist

Dr. Patricia Pitta, Ph.D., ABPP

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