The death of loved ones is an everyday occurrence. The period of mourning that the surviving relatives face is also an everyday occurrence. In the Netherlands alone, approximately 130,000 people die every year (Van den Bout, Boelen & de Keijser, 1998), leaving behind approximately 500,000 loved ones. Research has shown that in one fifth of deaths serious problems arise for the surviving relatives (Van den Bout, et al., 1998). These people have the option of seeking professional help. But when is that necessary or not?
The grieving process: theoretical framework
The term grief indicates the set of reactions following the loss of a loved one (Van der Wal, 1988; in Van den Bout, et al., 1998). Scientific literature frequently emphasizes that grief is a normal and healthy response to a loss (Van den Bout, et al., 1998; Kleber & Brom, 2003; Sadock & Sadock, 2003; Stroebe, Hansson, Stroebe & Schut, 2001 ). After all, the surviving relative is faced with the difficult task of accepting that the loss suffered is irreparable and that he must say goodbye to the deceased as he lived with the surviving relative (Van den Bout, et al., 1998). Normally, grief does not require professional assistance. Support from the social network or contact with fellow sufferers provides sufficient help to the surviving relatives.
Normal grief
After the death of a loved one, various reactions may occur among surviving relatives. The first reaction to a death is often one of shock and disbelief (Van den Bout, et al., 1998; Sadock & Sadock, 2003). Gradually feelings take over and people experience intense sadness. Then reactions such as gloom and protest occur. The negative emotions slowly decrease in intensity and eventually daily life is resumed. This standard view of grief provides a global description; however, there is no such thing as the grieving process. The individual differences are too great to provide a uniform picture of grief (Van de Bout, et al., 1998). Symptoms of normal grief can be divided into affective, behavioral, cognitive, and physiological dimensions (Stroebe, et al., 2001). Examples of symptoms on these dimensions include depression, anxiety, fatigue, crying, helplessness, concentration problems, and loss of appetite and energy.
Complicated grief
Only in a minority of relatives does the severity of the grief complaints lead to seeking professional help (Stroebe, et al., 2001; Stroebe, Schut & Stroebe, 2005). In this case it is called complicated grief. Complicated grief is defined as a deviation from the (cultural) norm in duration, intensity, specific or general symptoms of grief (Stroebe, et al., 2001). There are various manifestations of complicated grief, such as chronic grief and denied grief. Given the fact that the grieving process does not exist (Van den Bout, et al., 1998), the distinction between normal and complicated grief is not always easy to make. Several factors influence the severity of grief symptoms. The literature mentions, among other things, the nature of the death, characteristics of the surviving relative, circumstances in the aftermath of the death (such as the presence of social support) and the nature of the relationship with the deceased (Boelen, De Keijser & Van den Bout, 1998; Kleber & Brom, 2003; Parkes, 1998; W. Stroebe & Schut, 2001; Stroebe, et al., 2005).
Processing a loss
In Western society there is a well-known view that a loss must be worked through in order to prevent serious problems. This view is known as the grief labor hypothesis (Stroebe, 1992; in Stroebe & Schut, 1999). However, empirical research shows that working through loss cannot necessarily be associated with better loss coping (Van den Bout, et al., 1998). Other theories about the (normal) grieving process often take the form of phase or task models; the various phases or tasks would have to be completed or performed to adequately process the loss. The dual process model (DPM) integrates existing theories about the grieving process, such as stress and trauma theories, general theories about grief and models about coping (Stroebe & Schut, 1999; MS Stroebe & Schut, 2001). The DPM divides stressors into two groups, namely those oriented towards loss or recovery. The grieving process consists of an alternation of confrontation and avoidance of these two types of stressors. Furthermore, the DPM emphasizes the importance of grieving; that is, every now and then the survivor needs a break from grieving, so to speak. In complicated grief, this dosage or the process of alternating between confrontation and avoidance of stressors may be disturbed.
Interventions in the grieving process
Research has shown that in one fifth of deaths the surviving relatives are confronted with serious grief problems (Van den Bout, et al., 1998). Grief therapy is indicated in this group. However, relatives with relatively mild grief problems do not always benefit from guidance from professional care providers (De Keijser, Van den Bout, Kleber, Boelen & Hopmans, 1998; W. Stroebe & Schut, 2001). Compared to surviving relatives who have not been supported, they even experience a setback in some areas.
Interventions in normal versus complicated grief
A study by Beem et al. (1999) among 18 Dutch widows who were not at increased risk of developing serious grief problems showed that grief therapy did not improve the psychological and immunological functioning of these women. Stroebe et al. (2005) also conclude in their review that interventions do not help in the case of surviving relatives without complicated grief problems. A possible explanation for this finding is suggested that relatives mainly suffer from emotional loneliness, in the sense that the survivor lacks a close emotional bond with the deceased. Stroebe et al. suggest that this type of loneliness can only decrease with the passage of time and that this process cannot be accelerated by interventions. Schut, Stroebe, van den Bout and Terheggen (2001) published a review of 16 studies on the effectiveness of grief interventions. Interventions were classified into three groups, namely primary, secondary and tertiary preventive interventions. The first group was open to all surviving relatives. The second group consisted of relatives with an increased risk of developing complicated grief and the last group consisted of relatives who had to deal with complicated grief. Schut et al. concluded that primary interventions were not effective in reducing grief symptoms. This finding can be explained by the fact that this group consisted largely of surviving relatives who did not experience complicated grief or an increased risk thereof. This group generally does not benefit from professional guidance. Findings regarding secondary preventive interventions showed that they had a modest positive effect (Schut, et al., 2001; Stroebe, et al., 2005), especially when participants were selected with high levels of anxiety. Finally, the tertiary interventions often proved to be effective.
From the above, the overall conclusion can be drawn that the chance that interventions in the grieving process are effective appears to increase as the grieving process presents more complications.
Conclusion
Grief is a normal and healthy response to loss and does not normally require professional help. Research seems to conclude that interventions are mainly effective when there is complicated grief. The well-known saying if it doesn’t help, it doesn’t hurt does not apply here. Scientific literature not only shows that relatives with relatively mild grief problems do not always benefit from guidance from professional care providers, but also that they can even experience a relapse in some areas. Parkes (1998) also notes that the loss of a loved one does not necessarily have to be harmful. Seen in this light, offering interventions to relatives with mild grief problems, with the associated risk of relapse, is not only useless, but also irresponsible. In my opinion, the focus for interventions in the grieving process should therefore be on the group of surviving relatives with complicated grief or an increased risk thereof.