Stages and Types of Grieving

Due to the nature of the last book of the month- “The Death Class- A True Story About Life” by Erika Hayasaki I wanted to pull from my nursing education and use this next blog post for educational purposes. The book talked a lot about death and about “death anxiety”, which is actually very common. But what happens when we experience this?

Let’s talk about grieving :

Grief refers to the absence of something that was valued. This can be actual (recognized and verified by others) or perceived. BOTH ARE VERY REAL to the person experiencing them. Grief is the internal part of a loss- the emotional feelings.

FYI-much of the information and techniques below are taken from a nursing book I studied and kept from college. Nonetheless, I believe that all people can benefit from learning how to communicate with others, regardless of the topic. Educating yourself on the background of any issue is only the beginning. So..in that case, we will start with going through the stages of grieving and then we will go into how to talk to someone who is suffering through them.

There are stages of grief defined by Dr. Elisabeth Kübler-Ross in her 1969 book “Death and Dying” (there are additional models as well out there). These stages are widely accepted and taught within the topic of grief. Although all people experience loss in their lifetime and there are general stages in which the internal process of this follows, it can vary. For example, people can experience stages out of order or simultaneously, and the length of each stage can be different. All of this is greatly affected by the type of loss and the person it is happening to. The stages listed are the “normal” way that someone goes through the grief process, but it is important to remember that it is all individual to a person’s experience.

THE FIVE STAGES OF GRIEF by Elisabeth Kübler-Ross:

  1. DENIAL-refers to either denying the loss itself or denying the feelings related to the loss. This stage is important because it helps the person to survive and cope with the loss. It can be accompanied with “shock”. The person may feel numb and like life makes no sense. It helps prevent the person from feeling overwhelmed. Denial allows for the pacing of feelings.
  1. ANGER– this stage is necessary for reconnecting with one’s self. It gives the person something to hold on to and some type of structure within their life. This is better than denial because the person is now starting to face the feelings related to the loss and starting to connect with reality. Anger is challenging for many and most try to suppress it. It is important to remember it is a natural part of the process. It is also very important to remember that this anger can be directed toward anything and anyone-try not to take it personally. 
  1. BARGAINING– the person starts to bargain with themselves by saying things like “what if” or “if this…then that” or “I will do anything to get such and such back.” They are trying to make sense of the situation and it often can be accompanied by guilt. 
  1. DEPRESSION-a feeling of intense sadness will occur once the person realizes that what has happened is real. Thoughts come flooding in and causes an even deeper level of grief. The person feels empty and may withdraw from daily activities. It would be unusual for someone not to experience some type of sadness after a loss. While this stage does not mean that the person has a mental illness, they still may need to get help.
  1. ACCEPTANCE-the last stage is finally coming to terms with your new reality. This does not mean that the person is okay with what happened, or ever will be. They are accepting that this is their new life and it is permanent. They learn to live with this reality and start to accept their new roles. New connections and relationships may be formed. It is essential for them to listen to their needs and evolve in order to survive.

OTHER STAGES:

Shock (comes before denial)-a sense of numbed disbelief. It is the emotional buffer and helps a person control their emotions so they are not overwhelmed with feelings all at once.

Testing (comes after bargaining and before acceptance)-the person may try to find realistic solutions to deal with the loss. They are trying to rebuild their life in this new reality. During this stage other stages may flow in and out as well.

It is important to note that grief is considered to be the loss of something valued. This means it can be experienced for any type of significant change unrelated to death- like the loss of a job, loss of a physical function, loss of control, a breakup or divorce, etc.

TYPES OF GRIEF:

  1. Anticipatory= this type of grief is experienced before the actual loss. The person involved has a chance to begin the grief process with their loved ones. Examples of when this may occur: terminal illness, chronic diagnosis, scheduled surgery (perhaps limb amputation), or any other big change in a person’s life that is planned or expected.
  1. Complicated=this type occurs when the grief process is debilitating. The situation does not improve over a long period of time. Although, there is no set time for each stage there is a general progression and the effects should not be crippling or damaging in the end. 

Signs & Symptoms of Complicated Grief (taken from the 2020 scholarly article titled “Nursing Grief and Loss” by Julianne R. Oates and Patricia A. Maani-Fogelman):

  • Intense sorrow, pain, and rumination over the loss
  • Inability to focus on anything other than the loss itself
  • Intense and persistent longing or pining for the deceased
  • Difficulty accepting the death
  • Numbness or detachment
  • Bitterness about loss
  • Feelings that life holds no meaning or purpose
  • Lack of trust in others
  • Inability to enjoy life or even remember any positive experiences of a loved one
  • Have trouble carrying out normal routines

So, how do we communicate with someone who may be experiencing feelings of grief? 

It is so important to remember to practice ACTIVE listening, build a rapport and trust between you and the person, and show empathy in the best way that you can. You can provide resources or ask for help from professionals at any point during the stages too.

Here are some communication techniques that you can use as well:

The American Association of Critical Care Nurses supports a method for therapeutic communication during emotional conversation topics called the NURSE technique (Oates, 2020):

For example, someone may say “I feel so sad and scared.” 

N(ame): “you feel sad and scared”-name or repeat what they just said. This seems so simple but it actually helps the person feel that you are hearing what they are saying to you rather than just sitting there pretending to listen. It really shows them that you care.

U(understand): “tell me more about this feeling…how can I help you?”-try to understand what the person is feeling more deeply to determine what you can do to help. Even simply asking how you can help them leads to a better understanding.

R(espect): “I am so proud of how well you are handling this difficult situation.” -acknowledge the person and express your respect to them. This gives them confidence and shows that you are hearing AND SEEING them.

S(upport): “I will be here all day” or “I am here for you.”- tell them you are there for them to support them through this situation. You can put it in more specific terms or make it general.

E(xplore): “what makes you feel scared?”-delve more deeply into the topic. Use an open ended question.

Taken from the book “Communication for Nurses-Talking with Patients” here are other ways you can communicate with grieving people (Kennedy, 2009):

  • Listen to the person’s experience, helping them to express their feelings.
  • Assess their support system (friends, family, clergy, etc.)
  • Be present and actively listen to them.
  • Allow time for them to repeat their story of their loss.
  • Encourage a discussion about what the future may look like now.
  • Avoid the use of “you will be better in no time” or “you’ll be okay” or “it was their time” or “they are better off now.”
  • Allow for individual differences in the grieving process.
  • Suggest support groups or other resources.
  • Refer appropriately to counselors or suggest this.

Keep in mind these communication tips above will need to be adjusted as each individual is different and their situation is unique. Like I said before, the above bullet points are based on the nursing profession. BUT they can be applied to real life if the person is comfortable.

The word “comfortable” sounds funny in this situation. Regardless if you are trained or not, there is nothing comfortable about this topic. Most of the time you really will not know what to say. I am a nurse and have sadly experienced a lot of death and dying in my lifetime, even though I am only 27 years old. Hey, it is part of the profession and I am happy I can be there for others when they truly need it most. But, I can tell you it doesn’t get easier. I say this because each situation is so different. Every person is unique. Every family is unique. But that is what makes it so specia. 

The best tip I can give you is to just take time out of your day to spend with that person or people who need it most. Set aside time, sit with them, text them, call them, get on their level and show them that even if you do not fully understand what they are going through, you are there and they can count on you. Another tip is to not make empty promises or say things you may not be able to follow through on. You may mean it at the time but if it actually doesn’t happen it can be harmful. First and foremost, you need to gain the person’s trust!

For example, as a nurse I would make sure to set aside even just 10 minutes to pull up a chair and talk with my patients and families. If I said “I will be back in one hour”…I made sure I was back in one hour. And if I couldn’t do that, I made sure someone was. This doesn’t necessarily mean you have to talk about the actual topic of grief. Even just asking them how they are doing, how their day was, noticing something about them, or bringing them a drink or snack helps. Honestly, it is the little things that can go a long way!

Oh and DON’T WORRY, it’s okay to acknowledge that you may not know what to say. Just being there for that person in a caring way is enough. The below quote explains this in more detail.

The scholarly article mentioned by titled “Nursing Grief and Loss” states:

“Sometimes it is hard to know what to say to someone experiencing grief and loss. The most important thing is to be there and to listen. Allowing a loved one to share a memory or a feeling about the person they are grieving can be invaluable. It is okay not to know what to say. Acknowledge that by saying, “I wish I had the right words, just know I care.” Or, “I am so sorry for your loss.” It is important to understand that not everyone experiences feelings the same, so it is not appropriate to say “I know how you feel.” Instead, say, “I don’t know how you feel, but I am here to help in any way I can.” Then follow through by providing any help that you can, be that an appropriate referral or simply a hot drink or listening ear” (Oates, 2020).

For extra information, listed below are two other models. Although there are many kinds, they all generally follow the same process.

Other phases and tasks of Grief from “Communication for Nurses-Talking with Patients” (Kennedy, 2009).

FOUR STAGES OF MOURNING:

  1. Phase of Numbness- general feeling that may include denial.
  2. Phase of Yearning and Searching-trying to find the loss within your environment.
  3. Phase of Disorganization and Despair-giving up hope and becoming depressed.
  4. Phase of Reorganization-remaking life in new reality and making new connections.

FOUR TASKS OF MOURNING:

  1. Accept the reality of the loss.
  2. Work through the pain and grief.
  3. Adjust to the environment in which the deceased is missing.
  4. Relocate the deceased emotionally and move on with life.

Resources used for this blog post below. The information above was learned and obtained from: Oates, R. Julianne and Patricia A. Maani-Fogelman, Nursing Grief and Loss, https://www.ncbi.nlm.nih.gov/books/NBK518989/ 2020; Lisa Kennedy Sheldon, PhD, APRN, Communication for Nurses-Talking with Patients, Second Edition, Jones and Barlett Publishers, LLC, Sudbury, Massachusetts, 2009.

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