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People who are grieving often turn to health care profession-als for help, but clinicians may feel uneasy with this situation, as grief does not fall neatly under one diagnostic category with a specific algorithm for treatment. Nevertheless, we know that grief may make an impact on a person’s ability to function and work and engage in relationships, so it is important for clini-cians to recognize and address this common experience in the clinical setting.

As one author who wrote about grief points out, “health pro-fessionals are often reluctant to address the subject with those experiencing grief, even though it is one of the most universal experiences of human life.”1 The good news is that increasing research suggests that there are common themes in a person’s grieving experience and ways in which clinicians can offer sup-port to their patients.

This article reviews facts about grief, common themes in the grieving experience, and ways in which clinicians may facilitate their patients’ processes.

What is Normal?

Grief, in all of its varied forms, often follows loss or change. The world contains many opportunities for loss, and grief may occur after a diagnosis, death, trauma, or other major life change. The bottom line is, if a person lives long enough, that person will grieve for someone or something.

Is grief a diagnosis or an experience? One author who wrote about sorrow states: “Of course, it is not always easy to tell ‘proper sorrows’ from intense grief, ‘pathological’ grief, or clinical depression. Indeed, it is very doubtful that these are strictly delineated categories.”2 He adds that grief probably falls along a spectrum of conditions, and comments: “Moving from less to more severe, we may distinguish normal sadness or sorrow; normal grief; complicated (pathological) grief; and majordepression as gradations along this continuum.”

Rarely do two people experience grief in the same way, and clinicians should be careful not to judge what types of loss should be grieved the most intensely or for the longest dura-tion. A writer of an article on dealing with grief comments: “All

experiences connected to loss may occur in various strengths and lengths independent of what is lost.”3

Naomi M. Simon, MD, MSc, a board-certified psychiatrist, an associate professor at Harvard Medical School, and direc-tor of the Complicated Grief Program at Massachusetts Gen-eral Hospital in Boston, Massachusetts, agrees that there is no single way to grieve and no single definition of “normal” grief. She comments:

A large body of research supports that people follow different trajectories after a loss of a loved one, with a broad range of religious and cultural differences in the way that they grieve. It is normal for bereaved indi-viduals to experience a range of intense emotions and negative cognitions and also altered behaviors, such as social withdrawal, for a period of time after a loss. The sole presence of intense distress and sadness right after a loss does not imply psychopathology. This is not to say that bereaved individuals do not benefit from support from their communities, and many traditions include ac-tivities that bring people together after a death. The vast majority of people who lose a loved one do not require formal psychiatric intervention. The presence of suicidal ideation or behaviors, however, is one example of a sign that clinical evaluation is indicated.

Grief is a biologic process that may have physical, mental, emotional, and spiritual effects. Common manifestations of grief include: withdrawal; low energy; crying; outrage; ru-minating about the loss; blaming God; and yearning for the deceased person or a desire to be with the deceased person.4 Grief often presents differently in adults versus children, and a National Cancer Institute (NCI) document on “Grief, Be-reavement and Coping with Loss,” which is available on the NCI website, spells out some of these important differences.5 Cultural and ethnic differences must also be considered. The NCI comments that, typically, grief reactions are marked by “a gradual movement toward an acceptance of the loss and, although daily functioning can be very difficult, managing to continue with basic daily activities.”5

Moving Through Loss

Jane Hart, MD

Addressing Grief in Our Patients

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However, sometimes grief is more persistent and pervasive and becomes what experts refer to as “complicated” grief. Si-mon comments:

Complicated grief is not a formal diagnosis in the psy-chiatric nomenclature, though it is being discussed for possible inclusion in DSM5,* and formal diagnostic criteria have been proposed.6 Complicated grief is not considered a syndrome until 6 or 12 months after a loss, and can be thought of as a lack of progression from acute grief, with associated persistent, intense separation distress or preoccupation with the circumstances of the death, as well as other cognitive, emotional, and behav-ioral symptoms, such as avoidance of reminders of the deceased. Individuals with complicated grief have an el-evated risk for suicide, so screening for hopelessness and suicidal ideation, and doing an assessment of suicide risk is critically important.

Factors that contribute to complicated grief are not fully un-derstood, according to Simon. However, she says that preexist-ing mood or anxiety disorders can interfere with one’s ability to process the loss naturally and may increase a person’s risk for problems.

Clinicians should also be aware that grief may wear vari-ous “masks.” A significant loss may lead to both emotional and physical problems, and substance abuse is high on the list of comorbidities that may accompany grief. One study suggests an increased risk for alcohol consumption, particularly in the first 2 years of grieving and particularly among men.7 Other masks for grief may include anger and isolation.

“The presence of alcohol or substance abuse after a signifi-cant loss should be a warning sign that the bereaved individual is in distress and may not be able to access alternative cop-ing strategies without support or intervention,” says Simon. She adds: “Many individuals with complicated grief also meet criteria for comorbid conditions such as post-traumatic stress disorder and/or major depression.”

Ways That Clinicians Can Help

How grief is expressed and how it is received affects the health outcomes of our patients. Clinicians should ask about and acknowledge the losses their patients are experiencing, assess their needs, and connect these patients with resources.

One article recommends that an integrated approach to grief and loss must be individualized, and the individual experienc-ing grief must move into a changed world with new ways of meeting that world.3 The authors of that article suggest that “relearning the world” and “adaptation” are key factors in the grieving process independent of the cause of grief. The authors

also suggest that there is ongoing movement on the continuum between despair and hope, lack of understanding and insight, meaning disruption and creating meaning, and bodily discom-fort and a reintegrated body.

As mentioned above, there are many patients who will not need professional or adjunctive help during the normal griev-ing process, and still others will benefit from support to help ease their symptoms and move forward in their lives. The goal is to bring relief and a new way of being comfortable in the world. However, people who have complicated grief may need more intensive assessment and professional treatment. Here are some specific ways that clinicians may support patients who are experiencing normal grief.

Talk with patients—The first step in helping patients is to talk with them about their losses or the grief that is being ex-perienced. Unfortunately, death is a topic that many people do not feel comfortable talking about, and Simon comments that “this leaves bereaved individuals feeling as if they shouldn’t be talking about their losses with the people in their lives, includ-ing clinicians and family members.” She says the most impor-tant step a clinician can take is to ask patients about their losses and how these patients are coping, without assumptions or ex-pectations based on time since the loss.

“Giving the patient a space to talk can be extremely helpful,” says Simon. She adds:

It is also important to screen by asking questions about symptoms, such as depressed mood, anxiety, nightmares or insomnia, guilt, ruminations, avoidance, and suicidal thinking. Social support is another key factor to inquire about, as this can be a protective factor against suicide, and persistent social isolation and lack of any planning for future activities should trigger greater screening and consideration of need for intervention.

Encourage expression—The literature suggests that expres-sion is very important in the grieving process, and this may come through talking about the circumstances that have led to the grief with friends, family, a support group, a health coach, or in a psychotherapeutic setting. Expression may also come through narrative, and many documents looking at the topic of grief comment on the benefits of writing, journaling, and nar-rative in healing grief.8 A patient may gain important insights through talking, writing, and reading about grief.

One writer comments: “Independent of the original cause, several elements in grief work are to create hope through ex-pressing grief, what is lost, acknowledging it, and maintaining ties to what is lost.”3

Assess support—While isolation may be an initial normal reaction to grief, in fact, healing often comes from eventually seeking support and rejoining the community. People may re-ceive varying types of support from people close to them, in-cluding friends and family. Formal support groups for people who are grieving provide another opportunity for empathy, a

*Forthcoming next version of the Diagnostic and Statistical Manual of Mental Disorders, by the American Psychiatric Association.

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sense that they are not alone, and an opportunity for learning new insights and coping skills.8

Community centers, religious and spiritual centers, and health care facilities are likely sources for such groups as are health or-ganizations that offer support groups centered around a com-mon diagnosis or theme such as a lung-cancer support group or caregivers support group. Clinicians should inquire about a patient’s support system and suggest ways to build that support if there are gaps.

Assess spiritual beliefs—Spiritual and religious beliefs affect the way a person grieves, and attention to a person’s spiritual beliefs may be important for helping that person get through the grieving process.9 Clinicians could take a “spiritual inven-tory” to understand their patients’ beliefs and the role such be-liefs plays in patients’ lives.10

For a patient with a spiritual or religious orientation, a cli-nician may inquire about what comfort a person has derived from spiritual or religious activities, asking if such activities might bring relief in the present. Spiritual directors and reli-gious leaders who are experienced in working with grief may also be good resources for supporting patients and may also help patients who are struggling with existential issues and feelings that God has abandoned or is punishing them.

One professional working in bereavement support points out that “the best care is provided when it comes from an in-terdisciplinary team comprising healthcare and other profes-sionals who are qualified to address each dimension of hurt a person will experience.”11

Consider complementary therapies—Various complementary therapies may be helpful for easing a person’s transition through grief. Art therapy may help a person transform feelings and emotions and is one form of therapy commonly used to help people process loss.12 Music therapy is also used to facilitate healing during the grieving process and is very common in cancer settings with both patients and caregivers benefit-ting.13 Yoga, massage, and other complementary therapies that ease stress and promote relaxation may also be of benefit for some individuals.

Conclusion

As one author points out, “life, death, and grief are the three things that all people have in common. All are born, all must die, and in between birth and death, all will experience some

type of grief.”11 We must provide the time and space in our interactions with patients during which we acknowledge and address their grief, and there are times when patients need our help with moving through loss. Diagnosis or no diagnosis, grieving patients need our attention in naming their sadness and providing support and resources for them. n

References

1. Reed KS. Grief is more than tears. Nurs Sci Q 2003;16:77–81.2. Pies R. The anatomy of sorrow: A spiritual, phenomenological, and neuro-logical perspective. Philos Ethics Humanit 2008;3:17.3. Furnes B, Dysvik E. Dealing with grief related to loss by death and chronic pain: An integrated theoretical framework: Part 1. Patient Prefer Adherence 2010;4:135–140.4. British Columbia Ministry of Health. Palliative Care for the Patient with Incurable Cancer or Advanced Disease: Part 3. Grief and Bereavement: Guidelines and Protocols. Online document at: www.bcguidelines.ca/pdf/pal liative3.pdf Accessed March 15, 2012.5. National Cancer Institute. Grief, Bereavement, and Coping with Loss (PDQ®). Online document at: www.cancer.gov/cancertopics/pdq/supportive care/bereavement/HealthProfessional/page1/AllPages/Print Accessed March 15, 2012.6. Shear MK, Simon NM, Wall M, et al. Complicated grief and related be-reavement issues for DSM-5. Depress Anxiety 2011;28:103–117.7. Pilling J, Thege BK, Demetrovics Z, et al. Alcohol use in the first three years of bereavement: A national representative survey. Subst Abuse Treat Prev Policy 2012;7:3. 8. Dysvik E, Furnes B. Dealing with grief related to loss by death and chronic pain: Suggestions for practice. Part 2. Patient Prefer Adherence 2010;4:163-170.9. Walsh K, King M, Jones L, et al. Spiritual beliefs may affect outcome of bereavement: Prospective study. BMJ 2002:324:1–5.10. Borneman T, Ferrell B, Puchalski CM. Evaluation of the FICA tool for spiritual assessment. J Pain Symptom Manage 2010;40:163–173.11. Wess M. Bringing Hope and healing to grieving patients with cancer. J Am Osteopath Assoc 2007;107(12[suppl7]):ES41–ES47.12. Hart J. Art therapy and cancer care. Altern Complement Ther 2010;16:140–144.13. Hart J. Music therapy for children and adults with cancer. Altern Comple-ment Ther 2009;15:221–225.

Jane Hart, MD, is a clinical instructor in internal medicine and chair of the Integrative Medicine Committee at Case Western Reserve University School of Medicine, in Cleveland, Ohio.

To order reprints of this article, e-mail Karen Ballen at: Kballen@liebertpub.com or call (914) 740-2100.

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