Types of loss, models of grieving: stage, task, continuing bonds and dual process; grief following miscarriage; COVID-19 impact; loss of pets; loss and grief in foster care; grief associated with young people; practice approach ideas
This page has three sections:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Loss can be primary or secondary in nature. Primary loss is often physical, e.g. the termination of an attachment or relationship, body parts amputated, or the death of someone close. Secondary loss flows from primary loss and can be symbolic loss, e.g. foster care placement, children leaving home for independent living, unemployment, and changes in health status, or developmental loss, i.e. loss that is a consequence of life changes/ageing. Both primary and secondary loss usually leads to some form of grieving or mourning. It is important to realise that the grieving process will be different for each person.
Grief & Mourning
Grief is not simply feelings. It is a dis-ease, a discomforting disturbance of everyday equilibrium. Many reactions are associated with grieving, all of which are normal.
Sadness, anger, guilt, anxiety, loneliness, fatigue, helplessness, numbness, shock and even relief
Tightness in the chest or throat, lack of energy, stomach distress
Confusion, inability to concentrate or remember details, auditory or visual experiences that mimic hallucinations
Sleep disturbance, loss of appetite, and restlessness
Over time these reactions should diminish. If intense distress persists for a long period (i.e. a chronic, heightened state of mourning, problems accepting the loss), treatment for complicated grief may be needed.
Grief, a natural response to loss, is considered disenfranchised when it is not acknowledged or attended to by society. Disenfranchised grief can occur when (i) the loss is not acknowledged as significant (e.g. the loss of an animal/pet), (ii) the relationship is not recognized (e.g. the loss of a mistress), (iii) the griever is excluded (e.g. a child’s “inability” to grieve), (iv) the loss is disenfranchised (e.g. suicide), and (v) the grieving style is considered socially unacceptable (e.g. a female who is an instrumental griever) (Mitchell, 2018).
Grief and bereavement in a COVID-19 world
Deaths from COVID-19 may occur in hospitals or aged care facilities where the barriers that keep the infection controlled may also isolate the patient, family and loved ones at the end of life. Grieving, bereavement and ritual in the era of COVID-19 will change as a result. As people are dying in the current climate of self-isolation, they are now facing the lack of a traditional funeral or gathering to celebrate that person’s life. Family members are being instructed to avoid any contact with the deceased (such as touching or kissing). People may be buried or cremated quickly as the numbers of those dying increases, and while this is familiar and usual within some cultures and religions, it is not in many others.
If people are unable to say goodbye in the traditional way, then different rituals of mourning and of remembrance will need to be created. One way may be via the online environment (Skype, Facetime) or social media (Facebook) where this has become a more familiar sight in recent years. Even if people are not able to physically attend a funeral, a ritual can be organised to remember that person – perhaps lighting a candle, playing their favourite music while reminiscing about them, spending time in the garden if that was one of the things they loved doing. Even though there are physical restrictions, this does not mean people need to be emotionally cut off from saying goodbye. Many funerals can be recorded via video or audio for those unable to attend. During this pandemic period people all over the world have found creative ways to communicate and stay connected to others – think outside the box and create a personal memorial. Another longer-term possibility is to plan for a memorial service or funeral to be held later, as sometimes the planning itself can help.
In the longer term, some people may suffer the effects of sudden deaths, the inability to say goodbye or from the lack of a traditional funeral or being unable to attend one. The effects of social isolation in grief and loss could also impact on mourning. Grieving and mourning from a distance can also be very hard if people are unable to travel. Health professionals need to be aware that while COVID-19 will come to an end, the effects could be longer term (End of Life Essentials, 2020).
Grieving following the loss of a pet
The death of a pet can be difficult for an owner. Research shows over 80% of dog and cat owners find the companionship and unconditional love offered by their animals as benefits. 92% regarded companion animals as family members. Owning a pet teaches children responsibility and develop an emotional attachment to them; for children support is received from their mothers, their pet and then their fathers (Rujoiu & Rujoiu, 2013).
Pet owners develop three types of bonding relationships: weakly bonded (the owner provides the companion only bare necessities: food and hygiene), moderately bonded (the pet owner spends time with their companion, understanding much more of their needs, but when the death of the animal occurs, the grief is exceeded in a short time) and profoundly bonded (the emotional involvement of the owners is strong and they are convinced that they know what their companion feels and needs). The owners from the last category consider the pet as a family member and they manage with great difficulty the grief when the pet dies because, often, the grief is not understood or accepted by those around. In these kinds of situations, the grief manifested by a bereaved owner is disenfranchised because the person has incurred a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. In some situations, the grief manifested by a pet owner can develop into complicated grief (Rujoiu & Rujoiu, 2013).
Choosing to put a pet down can be difficult: the pet owner struggles between the animal’s quality of life versus the owner’s desire to have more time with the pet. Many owners feel guilty that they have not discovered earlier the disease of their companion animal in order to have it treated. On the other hand, that they “are responsible for the death of the animal.” This guilt is profound (deeper guilt). In such situations, social support is very important (Rujoiu & Rujoiu, 2013).
Models of Grieving
There have been a number of models proposed for the grieving process.
Stage or phase models: In 1969 Kubler-Ross proposed an ordered, six-stage model—shock, denial, anger, bargaining, depression and acceptance/resolution. In 1972 Parkes suggested shock and numbness, yearning and searching, disorganisation and despair, and reorganisation.
Task models: In 1991 Worden suggested that people have to accomplish certain tasks to move through the grieving process—(i) Accepting the reality of the loss, (ii) Experiencing and working through the pain of grief, (iii) Adjusting to the new environment without the deceased, (iv) Emotionally relocating the deceased and moving on with life.
Continuing bonds model: In 1996 Silverman and Klass proposed that grieving involved maintaining a continuing bond with the deceased person rather than severing bonds with, or letting go of the deceased. The deceased becomes incorporated into the person’s ongoing life, remains part of it and helps in reconstruction of life.
Dual Process model: In 1999 Strobe and Schut suggested the dual process model—mourning oscillating between two processes: both coping with the loss and moving forward towards healthy living again.
Tonkin—Growing Around Grief: Rather than thinking about grief getting smaller over time, in 1996 Tonkin proposed that grief and loss don’t get smaller, but life slowly gets bigger. Life grows around the loss.
Loss and Grief in Older Adults
As well as adjusting to loss through death, older people are adjusting to symbolic and developmental losses associated with carrying out roles such as spouse, employee, parent, and grandparent. They have to adjust to employment-related loses that include loss of professional identity, potential loss of income and social status as well as more long-term and chronic illness-related losses such as loss of independence and loss of mobility, all of which can impact on wellbeing.
Grief in Family Contexts
Family members do not grieve the same, and often do not have the same issues. Grieving by one family member can raise the discomfort or anxiety of others in the family. Each family member has a narrative to tell and should be listened to.
There is no one model of grieving. People oscillate between loss-oriented feelings (e.g. grief, breaking bonds, denial, anger, depression) and restoration-oriented feelings (doing new things, grieving, new roles / relationships, developing a continuing bond with the past / deceased). As they do this people gradually (i) accept the loss, (ii) experience and work through the pain of grief, (iii) adjust to a new environment without the past / deceased, and (iv) emotionally relocate the past / deceased and move on with life.
A practice approach for people experiencing grief and loss could involve
Preventive interventions Provide information about normal grief reactions and practical and emotional support (e.g. funeral directors, Centrelink, informing others, life insurance claims, property, wills, childcare, finance ).
Monitoring, with social support Ensure people have others who will make regular contact with them so they can discuss the loss if necessary.
Bereavement support groups Link people with these groups to help reduce isolation, relieve psychosocial distress, and enhance coping skills.
Individual or family grief counselling There is nothing magical about grief counselling: Create a strong therapeutic relationship with the client, listen to their pain and loss, and be there for the long haul as they gradually recover and build their lives again. General counselling skills are important: empathy, active listening, reflecting, paraphrasing, minimal encouragers, therapeutic silence, and open-ended questions.
People experiencing complicated grief should be referred to grief therapy.
A psychosocial assessment may be appropriate: family and significant relationships, social relationships, employment, financial status, leisure/recreation interests, substance use history, spiritual beliefs.
Problem-solving and solution-focused models may also be appropriate.
The reaction of young people to loss can be even more unconventional than those of adults. Young people generally do not effectively process their emotions internally and verbally. As a result, they tend to demonstrate their grieving in external ways, such as aggression and risk-taking behaviours.
The need for attachment is rooted in our brain-body chemistry. A strong attachment to something causes strong positive feelings. When we experience withdrawal from this attachment it can cause anxiety and increase stress hormones to be realised in our bodies causing a range of symptoms including, sleeplessness, nausea, depression, aggression.
When working with adolescents who have experienced major loss it is imperative to create positive warm relationships to help build a healthy brain and improve mental health through contact and connection to caring people during their grieving process. Additionally, the chance to remember the person, and to talk about the loss, will be useful in terms of being able to make a healthy ‘separation’ and to move on (Genito, 2018).
Non-death loss and grief in foster care
Because of their “temporary” placement in foster care, children experience multiple non-death losses: ambiguous loss of family and friends (the people are psychologically present even though physically absent), the loss of community, the loss of identity, and the loss of normalcy. If unattended, these losses can result in loneliness, hopelessness, depression and despair. They can challenge a youth’s self-worth and, if not acknowledged, can lead to disenfranchised grief. However, not all youth in foster care experience unattended grief. For some their grief is enfranchised by, for example, case managers, foster parents, other foster children, group home staff and pastors (Mitchell, 2018). Social workers can play an important role in ensuring grief is enfranchised for those in foster care.
For someone experiencing a miscarriage:
Acknowledge miscarriage is a loss, e.g. “I am sorry for your loss.” By doing this you are giving the person reassurance that miscarriage is indeed a loss worthy of grief.
Ask the person if they would like to talk about it in any way. Some people will want to talk; others won’t. Remember that each loss is personal, and people will react in different ways.
Don’t seek to minimise the grief, e.g. don’t say ‘It happened for a reason’, ‘It wasn’t meant to be’, or ‘Just focus on everything you do have’.
Supportive Actions in Grief (Cacciatore et al., 2021)
Placement into aged care
Family caregivers who have to place a loved one in an aged care home also experience grief and loss. If involved with this it is important to remember the following strategies.
Recognise the phases that family caregivers will go through.
(i) making the decision, often with a feeling of guilt and shame,
(ii) living with the decision – oscillating between feeling relief and questioning the decision,
(iii) adjusting to the new caring role, i.e. monitoring someone else’s care, and
(iv) forming a new relationship with the family member and staff
At the same time family caregivers need to realise
o not everyone passes through these phases,
o the phases do not occur in a fixed order, and
o the phases can overlap.
Engage in physical activity.
Seek professional or informal external support if the process is becoming too much personally or as a family. Informal support often comes from family and friends who have had the same experiences.
Avoid friends who express negative opinions about residential care.
Look at the positives that have occurred or will occur as a result of the family member being placed in care, both for the person concerned and the family as a whole.
If possible, visit the family member regularly.
Create positive relationships with the staff
Be positive with staff, recognising and commenting on efforts to help the family member adjust to changing circumstances.
Engage with staff about family member’s needs in a non-threatening and collaborative manner. If possible, offer to assist in any changes to care.
Remain actively involved with the staff and seek to inform them of the family member’s interests and ongoing needs. Ask to be involved in any review of family member’s needs.
(available on request)
Cacciatore, J., Thieleman, K., Fretts, R., & Jackson, L. B. (2021). What is good grief support? Exploring the actors and actions in social support after traumatic grief. Plos One, 16(5), 1 – 17. https://doi.org/10.1371/journal.pone.0252324
Crayne, M. P. (2020). The traumatic impact of job loss and job search in the aftermath of COVID-19.Trauma Psychology, 12(S1), S180-182.http://dx.doi.org/10.1037/tra0000852.Retrieved from http://www.cokmed.net/ps-sistem/dosyalar/kutuphane/Traumatic%20Impact%20of%20Job%20Loss%20and%20Job%20Search%20in%20Aftermath%20of%20Covid-19.pdf
End of Life Essentials. (2020). Grief and bereavement for health care professionals COVID-19. Retrieved from https://www.endoflifeessentials.com.au/Portals/14/document/COVID-19/Grief%20Bereavement%20and%20Ritual%20for%20Health%20Care%20Professionals%20COVID-19.pdf This resource includes a list of resources and supporting organisations
around grief and COVID-19.
Grief and Loss – Fact or Myth (2019).
Understanding Grief (Palliative Care, 2015)
Graneheim, U. H., Johansson, A., & Lindgren, B-M. (2014). Family caregivers’ experiences of relinquishing the care of a person with dementia to a nursing home: insights from a meta-ethnographic study. Scandinavian Journal of Caring Science, 28, 215-224.
Genito, T. (2018).Young people’s experience of loss. Social Work Focus, 3(1)
Grief and Bereavement for Health Care Professionals COVID-19
Grief and Loss (University of Tasmania) (2016)
Mitchell, M. B. (2018). “No one acknowledged my loss and hurt”: Non-death loss, grief and trauma in foster care. Child and Adolescent Social Work Journal, 35, 1 – 9. doi: 10.1007/s10560-017-0502-8
Rujoiu, O., & Rujoiu, V. (2013). Human-animal bond: Loss and grief. A review of the literature. Revista de Asistenta Sociala, 12(3), 163-171.
What not to say to someone who’s experiencing a miscarriage (ABC, 2020)
What’s your grief? (2021). https://whatsyourgrief.com/