Bereavement

Bereavement is a distressing but common experience. Most of us, at some time in our life, will experience the death or loss of someone we love.

Yet in our everyday life we think and talk about death very little, perhaps because we encounter it less often than our previous generation did. For them, the death of a brother or sister, friend or relative, was a common part of life in childhood, or during the teenage years. For us, these losses usually happen later in life. So, we do not have the chance to learn about grieving - how it feels, what are the right things to do, what is 'normal'. And we don’t have the experience of coming to terms with it.

Despite this, we must cope when we are finally faced with the loss of someone we love. We are all individuals and have our own ways of grieving – but there are experiences that most of us share while grieving.

We grieve after any sort of loss, but most powerfully after the death of someone we love. Grief is not just one feeling, but a whole succession of feelings. They take a while to live through and each person will do this at their own pace.

We will most often grieve for someone that we have known for some time. However, people who have had stillbirths or miscarriages, or who have lost very young babies, grieve in the same way. They need the same sort of care and consideration.

People can go through a number of different emotions while grieving. These feelings do not appear in any particular order. A feeling will sometimes come back after you thought it was over. Some of us will not have some of these feelings at all.

Shock

Following the death of a close relative or friend, most people go into a shock, as though they cannot believe it has actually happened. They may feel like this even if the death has been expected.

This sense of emotional numbness can sometimes be a help in getting through all the important practical arrangements that have to be made, such as getting in touch with relatives and organising the funeral. However, this feeling of unreality may become a problem if it goes on too long. Seeing the body of the deceased may, for some, be an important way of startng to overcome this.

For many people, the funeral or memorial service is an event when the reality of what has happened really starts to sink in. It may be distressing to see the body or attend the funeral, but these are ways of saying goodbye to someone we love. At the time, you may feel that it is too painful, say, to go to the funeral. But, if they do not, many people feel regretful about this in future years.

Denial

Soon though, this numbness disappears and may be replaced by a sense of denial. You find it hard to accept what has happened. You find it hard to convince yourself, of the loss even you know the facts. You find yourself just yearning for the dead person. You just want, somehow, to find them, even though this is clearly impossible. This makes it difficult to relax or concentrate and it you can find it hard to sleep properly. Dreams can be very upsetting.

Some people feel that they 'see' their loved one everywhere they go - in the street, the park, around the house, anywhere they had spent time together.

Anger and guilt

You can also feel very angry at this time - towards doctors and nurses who did not prevent the death, towards friends and relatives who did not do enough, or even towards the person who has, by dying, left you. You can even feel angry at yourself for not doing enough.

Another common feeling is guilt. You find yourself going over all the things you would have liked to have said or done. You may even think that, by doing things differently, that you could have somehow prevented the death. Of course, a death is usually beyond anyone's control and the bereaved person may need to be reminded of this. You can even feel guilty if you find yourself feeling relieved that your loved one has died after a painful or distressing illness. This feeling of relief is natural, understandable and very common.

Sadness

This state of agitation is usually followed by times of quiet sadness or withdrawal and silence, when you just want to be on your own. These sudden changes of emotion can be confusing to friends or relatives, but they are one of the normal parts of grieving. 

Although you feel less agitated, the periods of depression become more frequent with passage of time. You may get spasms of grief from time to time, sparked off by people, places or things that bring back memories of the person you have lost.

Other people may find it difficult to understand or be embarrassed when the you suddenly burst into tears for no obvious reason. At this stage it may be tempting to keep away from other people who do not fully understand or share the grief. However, avoiding others can store up trouble for the future, and it is usually best to start to return to one's normal life (as far as possible) after a couple of weeks or so.

During this time, it may appear to others as though you are spending a lot of time just sitting, doing nothing. In fact, you are probably thinking about the person you have lost, going over again and again both the good times and the bad times you had together. This is a quiet but essential part of coming to terms with a death.

As time passes, the fierce pain of early bereavement begins to fade. The depression lessens and it is possible to think about other things and even to look again to the future. However, the sense of having lost a part of yourself never goes away entirely.

If you have lost a partner there are constant reminders of their new singleness, in seeing other couples together and from media images of happy families. Even so, after some time you can feel whole again, even though a part of your life is missing. Even so, years later you may sometimes find yourself talking as though the person you have lost is still with you.

Acceptance

These various experiences may overlap and show themselves in different ways in different people. Most of us recover from a major bereavement within one or two years. The final art of grieving is a letting go of the person who has died and the start of a new sort of life. Your mood lifts, your sleep improves, and your energy returns to normal. You come back to your usual self, with even your sex drive returning.

Having said all this, people from different cultures deal with death in their own distinctive way. In some communities, death is seen as just one step in the continuous cycle of life and death; rather than as a 'full stop'. The rituals and ceremonies of mourning may be very public and demonstrative, or private and quiet. In some cultures, the period of mourning is fixed, in others not. The feelings experienced by bereaved people in different cultures may be similar, but their ways of expressing them are very different.

Even though children may not understand the meaning of death when they are very young, they feel the loss of close relatives in much the same way as adults. Even from infancy, children grieve and feel great distress.

However, they have a different experience of time from that of adults and may go through the stages of mourning quite rapidly. In their early school years, children may feel responsible for the death of a close relative and so may need to be reassured that it was not their fault. Young people may not speak of their grief for fear of adding extra burdens to the grown-ups around them.

The grief of children and adolescents, and their need for mourning, should not be overlooked when a member of the family has died. They should usually, for instance, be included in the funeral arrangements.

It can be particularly hard to deal with the death by suicide of someone you know. As well as the usual feelings of bereavement, there can be a number of conflicting emotions. You may feel:

• angry with the person for taking their own life.
• rejected by what they have done.
• confused as to why they did it.
• guilty - most people take their own life as an act of desperation: how could you not have noticed how the deceased was feeling?
• guilty for not having been able to stop their death – you may go over in your mind the times they spent with the deceased and ask yourself if you could have prevented it
• worried about whether the deceased suffered
• glad that you no longer must endure their distress
• relieved that you no longer must be there to support the person or deal with their suicidal thoughts and urges
• ashamed by what they did - particularly if the culture or religion sees suicide as sinful or disgraceful
• reluctant to talk to other people about it because a) the stigma of suicide in their culture or b) they feel that other people are more interested in the drama of the situation rather than feelings or the person who has died
• isolated – it can help to talk to other people who have lost a loved one through suicide.

NICE Guideline 105 (Section 1.8) provides recommendations for supporting people bereaved or affected by a suspected suicide.  Other useful resources include:

• The National Suicide Prevention Alliance's (NSPA) Help is at Hand booklet. 
• The Support After Suicide Partnership website.
• The NSPA's guide on local suicide support services. 

An autopsy

An autopsy is usually done after any unexpected death. If this goes against a person’s religious or cultural beliefs, their friends or relatives need to make the Coroner, and any professionals involved, aware of this as soon as possible.

An inquest will usually follow. Evidence is presented to the Coroner at a court hearing to try to find out what exactly happened. You may find it helpful to go to the inquest – but if you decide not to, then you can still get a full report of the inquest from the Coroner's Office (there is no fee for this).

More information can be found in the government's guides to coroner services and coroner investigations and what happens when a death is reported to a coroner. 

• You can help by spending time with the person who has been bereaved. More than words, they need to know that you will be with them during this time of pain and distress. A sympathetic arm around the shoulders will express care and support when words are not enough.
• It is important that, if they want to, a bereaved person can cry with somebody and talk about their feelings of pain and distress without being told to pull themselves together. In time, they will come to terms with it, but first they need to talk and to cry.
• Others may find it hard to understand why the bereaved person must keep talking about the same things again and again, but this is part of the process of resolving grief and should be encouraged. If you don't know what to say, or don't even know whether to talk about it or not, be honest and say so. This gives the bereaved person a chance to tell you what he or she wants. People often avoid mentioning the name of the person who has died for fear that it will be upsetting. However, to the bereaved person it may seem as though others have forgotten their loss, adding a sense of isolation to their painful feelings of grief.
• Remember that festive occasions and anniversaries (not only of the death, but also birthdays and weddings) are particularly painful times. Friends and relatives can make a special effort to be around.
• Practical help with cleaning, shopping or looking after children can ease the burden of being alone. Elderly bereaved partners may need help with the chores that the deceased partner used to handle - coping with bills, cooking, housework, getting the car serviced and so on.
• It is important to allow people enough time to grieve. Some can seem to get over the loss quickly, but others take longer. So, don't expect too much too soon from a bereaved relative or friend - they need the time to grieve properly, and this will help to avoid problems in the future. 

There are people who seem hardly to grieve at all. They do not cry at the funeral, avoid any mention of their loss and return to their normal life remarkably quickly. This is their normal way of dealing with loss and no harm results, but others may experience from strange physical symptoms or repeated spells of depression over the following years. Some may not have the opportunity to grieve properly. The heavy demands of looking after a family or business may mean that there just isn't the time.

Sometimes the problem is that the loss is not seen as a 'proper' bereavement. This happens often, but by no means always, to those who have had a miscarriage or stillbirth, or even an abortion. Again, frequent periods of depression may follow.

Some may start to grieve but get stuck. The early sense of shock and disbelief just goes on and on. Years may pass and they still find it hard to believe that the person they loved has died. Others may carry on being unable to think of anything else, often making the room of the deceased into a kind of shrine to their memory.

Occasionally, the depression that occurs with every bereavement may deepen to the extent that food and drink are refused, and thoughts of suicide arise.

Bereavement turns our world upside-down and is one of the most painful experiences we endure. It can be strange, terrible and overwhelming. Despite this, it is a part of life that we all go through and usually does not require medical attention. However, there are times when grief becomes a serious problem.

• If someone’s grief just does not lift after a few months, their GP can help. For some, it will be enough to meet people and talk with others who have been through the same experience. Others may need to see a bereavement counsellor or psychotherapist, either in a special group or on their own for a while.
• Occasionally, sleepless nights may go on for so long as to become a serious problem. The doctor may then prescribe a few days' supply of sleeping tablets.
• If the depression continues to deepen, affecting appetite, energy and sleep, antidepressants may be helpful; see our leaflet on antidepressants for more information. If the depression still does not improve, your GP may well arrange an appointment with a psychiatrist.
• For those people who lost someone through a terminal illness, many hospices will offer you a free bereavement service and support.
• For those who do run into trouble, help is at hand, not only from doctors, but from the organisations listed below.

Bereavement Advice Centre

Helpline: 0800 634 9494

Supports bereaved people on a range of practical issues via a single freephone number. It offers advice on all aspects of bereavement from registering the death and finding a funeral director through to probate, tax and benefit queries.

Breathing Space Scotland

Helpline: 0800 83 85 87

Experienced advisors are available to listen and give advice and information to those who are depressed and need to talk.

Child Bereavement UK

Support and information line: 0800 02 888 40

A national charity that helps grieving families and the professionals who care for them.

Cruse Bereavement Care and Cruse Bereavement Care Scotland

Helpline: 0808 808 1677

Helpline (Scotland): 0845 600 2227

Supports people after the death of someone close. Face-to-face and group support delivered by trained bereavement support volunteers across the UK.

Dying Matters

A coalition of 32000 members across England and Wales which aims to help people talk more openly about dying, death and bereavement, and to make plans for the end of life.

Rosie Crane Trust

Helpline: 01460 55120

Email: contact@rosiecranetrust.co.uk

The Trust supports bereaved parents through their grief after the loss of a son or daughter of any age.

Samaritans

Helpline: 116 123

Email: jo@samaritans.org

A national organisation offering support to those in distress who feel suicidal or despairing and need someone to talk to.

Support After Suicide Partnership

A network of organisations that support people who have been bereaved or affected by suicide.

Survivors of Bereavement by Suicide

Helpline: 0300 111 5065

A self-help organisation for bereaved adults across the UK, run by people who have been bereaved.

The Compassionate Friends: supporting bereaved parents and their families

Helpline: 0345 123 2304

A charitable organisation of bereaved parents, siblings and grandparents who have suffered the death of a child/children.

The Lullaby Trust

Phone: 0808 802 6868

Email: support@lullabytrust.org.uk

A charity that provides specialist support for bereaved families who experience the sudden loss of a baby, promotes expert advice on safer baby sleep and raises awareness of sudden infant death.

The Loss Foundation

A charity to support people who have lost their loved ones to cancer. It operates support groups in London and Oxford (mainly for students), and other supportive events.

WAY: Widowed and Young

A charity for men and women aged 50 or under when their partner dies.

Winston's Wish

Winston’s Wish is a national UK charity that provides bereavement support to children, young people (up to 25) and their families when someone close to them dies.

Freephone helpline: 08088 020 021

Email: ask@winstonswish.org

Further reading

• A grief observed, by C.S. Lewis.
• You'll get over it: the rage of bereavement, by Virginia Ironside.
• Cruse Bereavement Care also provide a range of recommended materials.

Zisook, S., & Shear, K. (2009). Grief and bereavement: what psychiatrists need to know. World Psychiatry, 8 (2), 67-74.

Bonanno, G.A., & Kaltman, S. (2001). The varieties of grief experience. Clinical Psychology Review, 21 (5), 705-734.

Zisook, S., et al. (2014). Bereavement: Courses, consequences and care. Current Psychiatry Reports, 16, 482-492.

Lobar, S.L., Youngblut, J.M., & Brooten, D. (2006). Cross-cultural beliefs, ceremonies and rituals surrounding death of a loved one. Pediatric Nursing, 32 (1), 44-50.

Watson-Jones, R.E., Busch, J.T.A., Harris, P.L., & Legare, C.H. (2017). Does the body survive death? Cultural variation in beliefs about life everlasting. Cognitive Science, 41 (Suppl.3), 455-476.

Bibby, R.W. (2017). Life after death: Data and reflections on the last information gap: A research note. Studies in Religion, 46 (1), 130-141.

Perkins, H.S., Cortez, J.D., & Hazuda, H.P. (2012). Diversity of patients’ beliefs about the soul after death and their importance in end of life care. Southern Medical Journal, 105 (5), 266-272.

Bonoti, F., Leondari, A., & Mastora, A. (2013). Exploring children’s understanding of death: through drawings and the death concept questionnaire. Death Studies, 37, 47-60.

Slaughter, V. (2005). Young children’s understanding of death. Australian Psychologist, 40 (3), 179-186.

Willis, C.A. (2002). The grieving process in children: strategies for understanding, educating and reconciling children’s perceptions of death. Early Childhood Education Journal, 29 (4), 221-226.

Simon, N.M. (2013). Complicated grief. JAMA, 310 (4), 416-423.

Horowitz, M.J., et al. (1997). Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry, 154 (7), 904-910.

Monk, T.H., Germain, A., & Reynolds, C.F. (2008). Sleep disturbance in bereavement. Psychiatric Annals, 38 (10), 671-675.