Grief, Bereavement, and Coping With Loss (PDQ®)NCI PDQ Summaries for Patients
People cope with the loss of a loved one in different ways. Most people who experience grief will cope well. Others will have severe grief and may need treatment. There are many things that can affect the grief process of someone who has lost a loved one to cancer. They include:
- The personality of the person who is grieving.
- The relationship with the person who died.
- The loved one's cancer experience and the way the disease progressed.
- The grieving person’s coping skills and mental health history.
- The amount of support the grieving person has.
- The grieving person’s cultural and religious background.
- The grieving person’s social and financial position.
This summary defines grief and bereavement and describes the different types of grief reactions, treatments for grief, important issues for grieving children, and cultural responses to grief and loss. It is intended as a resource to help caregivers of cancer patients.
Bereavement and Grief
Bereavement is the period of sadness after losing a loved one through death.
Grief and mourning occur during the period of bereavement. Grief and mourning are closely related. Mourning is the way we show grief in public. The way people mourn is affected by beliefs, religious practices, and cultural customs. People who are grieving are sometimes described as bereaved.
Grief is the normal process of reacting to the loss.
Grief is the emotional response to the loss of a loved one. Common grief reactions include the following:
- Feeling emotionally numb.
- Feeling unable to believe the loss occurred.
- Feeling anxiety from the distress of being separated from the loved one.
- Mourning along with depression.
- A feeling of acceptance.
Types of Grief Reactions
Anticipatory grief may occur when a death is expected.
Anticipatory grief occurs when a death is expected, but before it happens. It may be felt by the families of people who are dying and by the person dying. Anticipatory grief helps family members get ready emotionally for the loss. It can be a time to take care of unfinished business with the dying person, such as saying “I love you” or “I forgive you.”
Like grief that occurs after the death of a loved one, anticipatory grief involves mental, emotional, cultural, and social responses. However, anticipatory grief is different from grief that occurs after the death. Symptoms of anticipatory grief include the following:
- Feeling a greater than usual concern for the dying person.
- Imagining what the loved one's death will be like.
- Getting ready emotionally for what will happen after the death.
Anticipatory grief may help the family but not the dying person.
Anticipatory grief helps family members cope with what is to come. For the patient who is dying, anticipatory grief may be too much to handle and may cause him or her to withdraw from others.
Anticipatory grief does not always occur.
Some researchers report that anticipatory grief is rare. Studies showed that periods of acceptance and recovery usually seen during grief are not common before the patient’s actual death. The bereaved may feel that trying to accept the loss of a loved one before death occurs may make it seem that the dying patient has been abandoned.
Also, grief felt before the death will not decrease the grief felt afterwards or make it last a shorter time.
Normal or common grief begins soon after a loss and symptoms go away over time.
During normal grief, the bereaved person moves toward accepting the loss and is able to continue normal day-to-day life even though it is hard to do. Common grief reactions include:
- Emotional numbness, shock, disbelief, or denial. These often occur right after the death, especially if the death was not expected.
- Anxiety over being separated from the loved one. The bereaved may wish to bring the person back and become lost in thoughts of the deceased. Images of death may occur often in the person’s everyday thoughts.
- Distress that leads to crying; sighing; having dreams, illusions, and hallucinations of the deceased; and looking for places or things that were shared with the deceased.
- Periods of sadness, loss of sleep, loss of appetite, extreme tiredness, guilt, and loss of interest in life. Day-to-day living may be affected.
In normal grief, symptoms will occur less often and will feel less severe as time passes. Recovery does not happen in a set period of time. For most bereaved people having normal grief, symptoms lessen between 6 months and 2 years after the loss.
Many bereaved people will have grief bursts or pangs.
Grief bursts or pangs are short periods (20-30 minutes) of very intense distress. Sometimes these bursts are caused by reminders of the deceased person. At other times they seem to happen for no reason.
Grief is sometimes described as a process that has stages.
There are several theories about how the normal grief process works. Experts have described different types and numbers of stages that people go through as they cope with loss. At this time, there is not enough information to prove that one of these theories is more correct than the others.
Although many bereaved people have similar responses as they cope with their losses, there is no typical grief response. The grief process is personal.
There is no right or wrong way to grieve, but studies have shown that there are patterns of grief that are different from the most common. This has been called complicated grief.
Complicated grief reactions that have been seen in studies include:
- Minimal grief reaction: A grief pattern in which the person has no, or only a few, signs of distress or problems that occur with other types of grief.
- Chronic grief: A grief pattern in which the symptoms of common grief last for a much longer time than usual. These symptoms are a lot like ones that occur with major depression, anxiety, or post-traumatic stress.
Factors that Affect Complicated Grief
Researchers study grief reactions to try to find out what might increase the chance that complicated grief will occur.
Studies have looked at how the following factors affect the grief response:
Whether the death is expected or unexpected.
It may seem that any sudden, unexpected loss might lead to more difficult grief. However, studies have found that bereaved people with high self-esteem and/or a feeling that they have control over life are likely to have a normal grief reaction even after an unexpected loss. Bereaved people with low self-esteem and/or a sense that life cannot be controlled are more likely to have complicated grief after an unexpected loss. This includes more depression and physical problems.
The personality of the bereaved.
Studies have found that people with certain personality traits are more likely to have long-lasting depression after a loss. These include people who are very dependent on the loved one (such as a spouse), and people who deal with distress by thinking about it all the time.
The religious beliefs of the bereaved.
Some studies have shown that religion helps people cope better with grief. Other studies have shown it does not help or causes more distress. Religion seems to help people who go to church often. The positive effect on grief may be because church-goers have more social support.
Whether the bereaved is male or female.
In general, men have more problems than women do after a spouse’s death. Men tend to have worse depression and more health problems than women do after the loss. Some researchers think this may be because men have less social support after a loss.
The age of the bereaved.
In general, younger bereaved people have more problems after a loss than older bereaved people do. They have more severe health problems, grief symptoms, and other mental and physical symptoms. Younger bereaved people, however, may recover more quickly than older bereaved people do, because they have more resources and social support.
The amount of social support the bereaved has.
Lack of social support increases the chance of having problems coping with a loss. Social support includes the person's family, friends, neighbors, and community members who can give psychological, physical, and financial help. After the death of a close family member, many people have a number of related losses. The death of a spouse, for example, may cause a loss of income and changes in lifestyle and day-to-day living. These are all related to social support.
Treatment of Grief
Normal grief may not need to be treated.
Most bereaved people work through grief and recover within the first 6 months to 2 years. Researchers are studying whether bereaved people experiencing normal grief would be helped by formal treatment. They are also studying whether treatment might prevent complicated grief in people who are likely to have it.
Complicated grief may be treated with different types of psychotherapy (talk therapy).
Researchers are studying the treatment of mental, emotional, social, and behavioral symptoms of grief. Treatment methods include discussion, listening, and counseling.
Complicated grief treatment (CGT) is a type of grief therapy that was helpful in a clinical trial.
Complicated grief treatment (CGT) has three phases:
- The first phase includes talking about the loss and setting goals toward recovery. The bereaved are taught to work on these two things.
- The second phase includes coping with the loss by retelling the story of the death. This helps bereaved people who try not to think about their loss.
- The last phase looks at progress that has been made toward recovery and helps the bereaved make future plans. The bereaved's feelings about ending the sessions are also discussed.
In a clinical trial of patients with complicated grief, CGT was compared to interpersonal psychotherapy (IPT). IPT is a type of psychotherapy that focuses on the person's relationships with others and is helpful in treating depression. In patients with complicated grief, the CGT was more helpful than IPT.
Cognitive behavioral therapy (CBT) for complicated grief was helpful in a clinical trial.
Cognitive behavioral therapy (CBT) works with the way a person's thoughts and behaviors are connected. CBT helps the patient learn skills that change attitudes and behaviors by replacing negative thoughts and changing the rewards of certain behaviors.
A clinical trial compared CBT to counseling for complicated grief. Results showed that patients treated with CBT had more improvement in symptoms and general mental distress than those in the counseling group.
Depression related to grief is sometimes treated with drugs.
There is no standard drug therapy for depression that occurs with grief. Some health care professionals think depression is a normal part of grief and doesn't need to be treated. Whether to treat grief-related depression with drugs is up to the patient and the health care professional to decide.
Clinical trials of antidepressants for depression related to grief have found that the drugs can help relieve depression. However, they give less relief and take longer to work than they do when used for depression that is not related to grief.
Children and Grief
A child's grief process is different from an adult's.
Children do not react to loss in the same ways as adults. These are some of the ways children's grief is different:
- Children may seem to show grief only once in a while and for short times. This may be because a child is not able to feel strong emotions for long periods of time. A grieving child may be sad one minute and playful the next. Often families think the child doesn’t really understand the loss or has gotten over it quickly. Usually, neither is true. Children’s minds protect them from what is too much for them to handle emotionally.
- Mourning is a process that continues over years in children. Feelings of loss may occur again and again as the child gets older. This is common at important times, such as going to camp, graduating from school, getting married, or having children.
- Grieving children may not show their feelings as openly as adults. Grieving children may throw themselves into activities instead of withdrawing or showing grief.
- Children cannot think through their thoughts and feelings like adults. Children have trouble putting their feelings about grief into words. Strong feelings of anger and fears of death or being left alone may show up in the behavior of grieving children. Children often play death games as a way of working out their feelings and worries. These games give children a safe way to express their feelings.
- Grieving adults may withdraw and not talk to other people about the loss. Children, however, often talk to the people around them (even strangers) to see how they react and to get clues for how they should respond to the loss.
- Children may ask confusing questions. For example, a child may ask, "I know grandpa died, but when will he come home?" This is a way of testing reality and making sure the story of the death has not changed.
Several factors can affect how a child will cope with grief.
Although grief is different for each child, several factors can affect the grief process of a child:
- The child's age and stage of development.
- The child's personality.
- The child's previous experiences with death.
- The child's relationship with the deceased.
- The cause of death.
- The way the child acts and communicates within the family.
- How stable the family life is after the loss.
- How the child continues to be cared for.
- Whether the child is given the chance to share and express feelings and memories.
- How the parents cope with stress.
- Whether the child has ongoing relationships with other adults.
Children at different stages of development have different understandings of death and the events near death.
Infants do not recognize death, but feelings of loss and separation are part of developing an awareness of death. Children who have been separated from their mother may be sluggish and quiet, may not respond to a smile or a coo, may have physical symptoms (such as weight loss), and may sleep less.
Age 2-3 years
Age 3-6 years
At this age children see death as a kind of sleep; the person is alive, but only in a limited way. The child cannot fully separate death from life. Children may think that the person is still living, even though he or she might have been buried. The child may ask questions about the deceased (for example, how does the deceased eat, go to the toilet, breathe, or play?). Young children know that death is physical, but think it is not final.
The child’s understanding of death may involve "magical thinking". For example, the child may think that his or her thoughts can cause another person to become sick or die.
Age 6-9 years
Children at this age are often very curious about death, and may ask questions about what happens to the body when it dies. Death is thought of as a person or spirit separate from the person who was alive, such as a skeleton, ghost, angel, or bogeyman. They may see death as final and scary but as something that happens mostly to old people (and not to themselves).
Grieving children can become afraid of school, have learning problems, show antisocial or aggressive behavior, or become overly worried about their own health and complain of imaginary symptoms. Children this age may either withdraw from others or become too attached and clingy.
Boys often become more aggressive and destructive (for example, acting out in school), instead of showing their sadness openly.
When one parent dies, children may feel abandoned by both the deceased parent and the living parent, whose grief may make him or her unable to emotionally support the child.
Age 9 and older
Children aged 9 and older know that death cannot be avoided and do not see it as a punishment. By the time a child is 12 years old, death is seen as final and something that happens to everyone.
|Infancy to 2 years||Is not yet able to understand death.||Quietness, crankiness, decreased activity, poor sleep, and weight loss.|
|Separation from mother causes changes.|
|2-6 years||Death is like sleeping.||Asks many questions (How does she go to the bathroom? How does she eat?).|
|Problems in eating, sleeping, and bladder and bowel control.|
|Fear of being abandoned.|
|Dead person continues to live and function in some ways.||"Magical thinking" (Did I think or do something that caused the death? Like when I said I hate you and I wish you would die?).|
|Death is not final.|
|Dead person can come back to life.|
|6-9 years||Death is thought of as a person or spirit (skeleton, ghost, bogeyman).||Curious about death.|
|Asks specific questions.|
|May have fears about school.|
|Death is final and scary.||May have aggressive behavior (especially boys).|
|Worries about imaginary illnesses.|
|Death happens to others, it won’t happen to me.||May feel abandoned.|
|9 and older||Everyone will die.||Strong emotions, guilt, anger, shame.|
|Increased anxiety over own death.|
|Death is final.||Fear of rejection; not wanting to be different from peers.|
|Even I will die.||Changes in eating habits.|
|Regressive behavior (loss of interest in outside activities).|
|Feels guilty about being alive (especially related to death of a brother, sister, or peer).|
Most children who have had a loss have three common worries about death.
Children coping with a loss often have these three questions:
Did I make the death happen?
Children often think that they have "magical powers". If a mother is irritated and says, "You’ll be the death of me" and later dies, her child may wonder if he or she actually caused the mother’s death. Also, when children argue, one may say (or think), "I wish you were dead." If that child dies, the surviving child may think that those thoughts caused the death.
Is it going to happen to me?
The death of another child may be very hard for a child. If the child thinks that the death may have been prevented (by either a parent or a doctor) the child may fear that he or she could also die.
Who is going to take care of me?
Since children depend on parents and other adults to take care of them, a grieving child may wonder who will care for him or her after the death of an important person.
Talking honestly about the death and including the child in rituals may help the grieving child.
Explain the death and answer questions.
Talking about death helps children learn to cope with loss. When talking about death with children, describe it simply. Each child should be told the truth using as much detail as he or she is able to understand. Answer questions in language the child can understand.
Children often worry that they will also die, or that their surviving parent will go away. They need to be told that they will be safe and taken care of.
Use the correct language.
When talking with the child about death, include the correct words, such as "cancer," "died," and "death." Using other words or phrases (for example, “he passed away,” “he is sleeping,” or “we lost him”) can confuse children and cause them to misunderstand.
Include the child in planning and attending memorial ceremonies.
When a death occurs, children may feel better if they are included in planning and attending memorial ceremonies. These events help children remember the loved one. Children should not be forced to be involved in these ceremonies, but encourage them to take part when they feel comfortable doing so. Before a child attends a funeral, wake, or memorial service, give the child a full explanation of what to expect. A familiar adult or family member may help with this if the surviving parent's grief makes him or her unable to.
There are books and other resources with information on helping a grieving child.
The following books and videos may be helpful with grieving children:
Cultural Responses to Grief and Loss
Cultures have different ways of coping with death.
Grief felt for the loss of loved ones occurs in people of all ages and cultures. Different cultures, however, have different myths and mysteries about death that affect the attitudes, beliefs, and practices of the bereaved.
Individual, personal experiences of grief are similar in different cultures.
The ways in which people of all cultures feel grief personally are similar. This has been found to be true even though different cultures have different mourning ceremonies and traditions to express grief.
Cultural issues that affect people who are dealing with the loss of a loved one include rituals, beliefs, and roles.
Helping family members cope with the death of a loved one includes showing respect for the family’s culture and the ways they honor the death. The following questions may help caregivers learn what is needed by the person's culture:
- What are the cultural rituals for coping with dying, the deceased person’s body, and honoring the death?
- What are the family’s beliefs about what happens after death?
- What does the family feel is a normal expression of grief and the acceptance of the loss?
- What does the family consider to be the roles of each family member in handling the death?
- Are certain types of death less acceptable (for example, suicide), or are certain types of death especially hard for that culture (for example, the death of a child)?
Death, grief, and mourning are normal life events. All cultures have practices that best meet their needs for dealing with death. Caregivers who understand the ways different cultures respond to death can help patients of these cultures work through their own normal grieving process.
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PDQ® Supportive and Palliative Care Editorial Board. PDQ Grief, Bereavement, and Coping With Loss. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/bereavement-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389267]
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