BMJ. 1998 Mar 14; 316(7134): 856859.

PMCID: PMC1112778

Coping with loss

Bereavement in adult life

Colin Murray Parkes, consultant psychiatrist

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This article has been cited by other articles in PMC.

Doctors are well acquainted with loss and grief. Of 200 consultations with general
practitioners, a third were thought to be psychological in origin; of these, 55a
quarter of consultations overallwere identified as resulting from types of loss. 1 In
order of frequency the types of loss included separations from loved others,
incapacitation, bereavement, migration, relocation, job losses, birth of a baby,
retirement, and professional loss.
After a major loss, such as the death of a spouse or child, up to a third of the people
most directly affected will suffer detrimental effects on their physical or mental
health, or both.2 Such bereavements increase the risk of death from heart disease and
suicide as well as causing or contributing to a variety of psychosomatic and
psychiatric disorders. About a quarter of widows and widowers will experience
clinical depression and anxiety during the first year of bereavement; the risk drops to
about 17% by the end of the first year and continues to decline thereafter.2 Clegg
found that 31% of 71 patients admitted to a psychiatric unit for the elderly had
recently been bereaved.3
Despite this there is also evidence that losses can foster maturity and personal growth.
Losses are not necessarily harmful.
Yet the consequences of loss are so far reaching that the topic should occupy a large
place in the training of health care providersbut this is not the case. One
explanation for this omission is the assumption that loss is irreversible and
untreatable: there is nothing we can do about it, and the best way of dealing with it is
to ignore it. This attitude may help us to live with the fact that, despite modern
science, 100% of our patients still die and that before they die many will suffer lasting
losses in their lives. Sadly, it means that, just when they need us most, our patients
and their grieving relatives find that we back away.
Summary points

Losses are a common cause of illness; they often go unrecognised

Conflicting urges lead to a variety of expressions of grief; even so there is a
pattern to the process of grieving
A knowledge of the factors that predict problems in bereavement enables these
to be anticipated and prevented
Grief may be avoided or it may be exaggerated and prolonged
Doctors can help to prepare people for the losses that are to come
People may need permission and encouragement to grieve and to stop grieving

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Recent approaches to loss

A 1944 study of bereaved survivors of a night club fire focused attention on the
psychology of bereavement, and led to the development of services for the bereaved
and to other types of crisis intervention services. 4 It established grief as a distinct
syndrome with recognisable symptoms and course, amenable to positive or negative
influences. This, in turn, fuelled interest in the new fields of preventive psychiatry and
community mental health. Elizabeth Kubler Rosss studies extended this
understanding to dying people,5 and helped to provide a conceptual framework for the
humanitarian work of Dame Cicely Saunders and the other pioneers of the hospice
movement.
More recently the improvements in palliative care have led to improvements in home
care for the dying. Home care nurses have bridged the gap and general practitioners
have had a central role, not only in caring for dying patients and their families but
also in supporting people through many other losses. This is the main theme of this
series, which draws together authorities with special knowledge of the losses which
afflict our patients and their families and looks at the practical implications for
doctors.
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The components of grief

Three main components affect the process of grieving. They include the urge to look
back, cry, and search for what is lost, and the conflicting urge to look forward, explore
the world that now emerges, and discover what can be carried forward from the past.
Overlying these are the social and cultural pressures that influence how the urges are
expressed or inhibited. The strength of these urges varies greatly and changes over
time, giving rise to constantly changing reactions.
Most adults do not wander the streets crying aloud for a dead person. Bereaved
people often try to avoid reminders of the loss and to suppress the expression of grief.
What emerges is a compromise, a partial expression of feelings that are experienced
as arising compellingly and illogically from within.
Much empirical evidence supports the claims of the psychoanalytic school that
excessive repression of grief is harmful and can give rise to delayed and distorted
griefbut there is also evidence that obsessive grieving, to the exclusion of all else,
can lead to chronic grief and depression. The ideal is to achieve a balance between
avoidance and confrontation which enables the person gradually to come to terms
with the loss. Until people have gone through the painful process of searching they
cannot let go of their attachment to the lost person and move on to review and
revise their basic assumptions about the world. This process, which has been termed
psychosocial transition, is similar to the relearning that takes place when a person
becomes disabled or loses a body part.
The course of grief

Numbness
Pining
Disorganisation and despair
Reorganisation

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The normal course of grief
Human beings can anticipate their own death and the deaths of others. Unlike the
grief that follows loss, anticipatory grief increases the intensity of the tie to the person
whose life is threatened and evokes a strong tendency to stay close to them.
Although the moment of death is usually a time of great distress, this is usually
quickly repressed and, in Western society, the impact is soon followed by a period of
numbness which lasts for hours or days. This is sometimes referred to as the first
phase of grieving.6 It is soon followed by the second phase, intense feelings of pining
for the lost person accompanied by intense anxiety. These pangs of grief are
transient episodes of separation distress between which the bereaved person continues
to engage in the normal functions of eating, sleeping, and carrying out essential
responsibilities in an apathetic and anxious way.
All appetites are diminished, weight is lost, concentration and short term memory are
diminished, and the bereaved person often becomes irritable and depressed. This
eventually gives place to the third phase of grieving, disorganisation and despair.
Many find themselves going over the events which led up to the loss again and again
as if, even now, they could find out what went wrong and put it right. The memory of
the dead person is never far away and about a half of widows report hypnagogic
hallucinations in which, at times of drowsiness or relaxation, they see or hear the dead
person near at hand. These hallucinations are distinguished from the hallucinations of
psychosis by the circumstances in which they arise and by their transiencethey
disappear as soon as the bereaved arouse themselves. A sense of the dead person near
at hand is also common and may persist.
As time passes the intensity and frequency of the pangs of grief tend to diminish,
although they often return with renewed intensity at anniversaries and other occasions
which bring the dead person strongly to mind. Consequently the phases of grief
should not be regarded as a rigid sequence that is passed through only once. The
bereaved person must pass back and forth between pining and despair many times
before coming to the final phase of reorganisation.
After a major loss such as the death of a loved spouse or partner, the appetite for food
is often the first appetite to return. By the third or fourth month of bereavement the
weight that was lost initially has usually returned, and by the sixth month many
people have put on too much weight. It may be many more months before people
begin to care about their appearance, and for sexual and social appetites to return.
Most people will recognise that they are recovering at some time in the course of the
second year.
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Assessing the risk
Much research, in recent years, has enabled us to identify people at special risk after
bereavement either because the circumstances of the bereavement are unusually
traumatic or because they are themselves already vulnerable (box). These risk factors
can give rise to complicated forms of grief that can culminate in mental illness. A
clear understanding of these factors will often enable us to prevent psychiatric
disorder in bereaved patients.
Factors increasing risk after bereavement

Traumatic circumstances Death of a parent (particularly in early childhood or

adolescence)Death of a spouse or child
with horrific circumstances)Sudden, unexpected, and untimely deaths (particularly
if associated
Multiple deaths (particularly disasters)
Deaths by suicide
Deaths by murder or manslaughter
Vulnerable people Low self esteemGeneral:
Low trust in others
Previous psychiatric disorder
Previous suicidal threats or attempts
Absent or unhelpful family
Specific:
Ambivalent attachment to deceased person
Dependent or inter-dependent attachment to deceased person
and learned helplessness)Insecure attachment to parents in childhood (particularly
learned fear
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Complicated grief
Bereavement has physiological as well as emotional effects (lower box). It also
affects physical health: after bereavement, the immune response system is temporarily
impaired7,8 and there are endocrine changes such as increased adrenocortical activity
and increases in serum prolactin and growth hormone,2 as in other situations that
evoke depression and distress.
Complications of bereavement

Physical
Impairment of immune response system
Increased adrenocortical activity
Increased serum prolactin
Increased growth hormone
Psychosomatic disorders
Increased mortality from heart disease (especially in elderly widowers)

Psychiatric Non-specific:
Depression (with or without suicide risk)
Anxiety or panic disorders
Other psychiatric disorders

Specific:
Post-traumatic stress disorder
Delayed or inhibited grief
Chronic grief

A variety of psychiatric disorders can also be caused by bereavement, the commonest

being clinical depression, anxiety states, panic syndromes, and post-traumatic stress
disorder. These often coexist and overlap with each other, as they do with the more
specific morbid grief reactions. These last disorders are of special interest for the light
that they shed on why some people come through bereavement unscathed or
strengthened by the experience while others break down.
It is a paradox that people who cope with bereavement by repressing the expression of
grief are more likely to break down later than are people who burst into tears and get
on with the work of grieving. The former are more liable to sleep disorders,
depression, and hypochondriacal symptoms resembling the symptoms of the illness
that caused the bereavement (identification symptoms). Not all psychogenic
symptoms, however, are a consequence of repressed or avoided grief. Some reflect
the loss of security which often follows a major loss and causes people to misinterpret
as sinister the normal symptoms of anxiety and tension.
At the other end of the spectrum of morbid grief are people who express intense
distress before and after bereavement. Subsequently they cannot stop grieving and go
on to suffer from chronic grief. This may reflect a dependent relationship with the
dead person, or it may follow the loss of someone who was ambivalently loved. In the
former case the bereaved person cannot believe that he or she can survive without the
support of the person on whom they had depended. In the latter, their grief is
complicated by mixed feelings of anger and guilt that make it difficult for them to
stop punishing themselves (Why should I be happy now that my partner is dead?).
Some degree of ambivalence is present in all relationships. To some degree its effects
can be assuaged by conscientious care during the last illness, and many people will
recall We were never closer. If members the family have been encouraged and
supported so that they have been able to care, and the death has been peaceful, anger
and guilt are much less likely to complicate the course of grieving.
These two patterns of grieving often seem to occur in avoiders (people with a
tendency to avoidance) and sensitisers (those with a tendency to obsessive
preoccupation), respectively.9
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Preventing and treating complicated grief

Doctors are in a unique position to help people through the turning points in their
lives which arise at times of loss. In order to fulfil this role we need information and
skills. One of our problems as caregivers is our ignorance of our patients view of the
world. Not only do we seldom know what they know or think they know about the
situation they face, we do not even know how that situation is going to change their
lives. It follows that we need to find out these things and, where possible, add to their
knowledge or correct any misperceptions, taking care to use language that they can
understand. (This is easier said than done when words like cancer and death mean
different things to doctors than they do to most patients.) Above all, we should spend
time helping them to talk through and to make sense of the implications of the
information we have given. If need be, we should see them several times to facilitate
this process of growth and change. General practitioners, because they are likely to
know the person, are often well placed to provide this trickle of care. For most
bereaved people the natural and most effective form of help will come from their own
families, and only about a third will need extra help from outside the family.

Anticipatory guidance

Members of health care teams can often prepare people for the losses that are to
come. People need time to achieve a balance between avoidance and confrontation
with painful realities, and we need to take this into account when we impart
information that is likely to prove traumatic. One way is to divide the information that
needs to be confronted into bite sized chunks. Doctors do this when we break bad
news a little at a time, telling a patient as much as we think he or she is able to take in.
Patients seldom ask questions unless they are ready for the answers, and they will
usually ask precisely what they want to know and no more. It follows that we should
invite questions and listen carefully to what is asked rather than assuming that we
know what the patient is ready to know. By monitoring the input of information, a
person can control the speed with which they process that information.
Although a little anxiety increases the rate and efficiency with which we process
information, too much anxiety slows us down and impairs our ability to cope, our
thought processes become disorganised and we go to pieces. Anything that enables
us to keep anxiety within tolerable limits will help us to cope better with the process
of change. If we are breaking bad news (box) it helps to do so in pleasant, home-like
surroundings and to invite the recipient to bring someone who can provide emotional
support. A few minutes spent putting people at their ease and establishing a
relationship of trust will not only make the whole experience less traumatic for them
but it will increase their chance of taking in and making sense of the information
which we then provide.
Breaking bad news

Consider social support (who to ask to be present)

Consider setting (where to meet)
Try to establish a relationship of mutual respect and trust
Discover what the patient or the family knows or think they know already
Invite questions
Give information at a speed and in a language that will be understood
Monitor what has been understood
Recognise that it takes time to hear and understand bad news
Give the patient or the family time to react emotionally
Give verbal and non-verbal reassurance of the normality of their reaction
Stay with the patient or the family until they are ready to leave
Offer further opportunities for clarification, information, or support

Supporting bereaved people

A visit from the general practitioner to the family home on the day after a death has
occurred enables us to give emotional support and to answer any questions about the
death and its causes that may be troubling the family. Newly bereaved people often
feel and behave, for a while, like frightened and helpless children and will respond
best to the kind of support that is normally given by a parent. A touch or a hug will
often do more to facilitate grieving than any words.
During the next few weeks bereaved people need the support of those they can trust.
We can often reassure them of the normality of grief, explain its symptoms, and show
by our own behaviour and attitudes that it is permissible to express grief. If we feel
moved to tears at such times there is no harm in showing it. Bereaved people may
need reassurance that they are not going mad if they break down, that the frightening
symptoms of anxiety and tension are not signs of mortal illness, and that they are not
letting the side down if they withdraw, for a while, from their accustomed tasks.
As time passes people may also need permission to take a break from grieving. They
cannot grieve all the time and may need permission to return to work or do other
things that enable them to escape, even briefly, from grief. It is only if they get the
balance between confrontation and avoidance wrong that difficulties are likely to
ensue.
The first anniversary is often a time of renewed grieving, but thereafter the need to
stop grieving and move forward in life may create a new set of problems. People may
need reassurance that their duty to the dead is done, as well as encouragement to face
the world that is now open to them. The most important thing we have to offer is our
confidence in their personal worth and strength. We should beware of becoming the
strong doctor who will look after the weak patient for ever, but this does not
mean that we become angry and dismissive, reprimanding the patient for becoming
dependent. In the end, most bereaved people come through the experience stronger
and wiser than they went into it. It is rewarding to see them through.