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Responding to the Grief of Others

Research explores public stigma toward people who have lost a loved one.

Key points

  • Prolonged grief reactions—severe, persistent responses to the death of a close other—affect 1 in 10 people experiencing loss.
  • The way we perceive and respond to people who have lost a loved one varies, and has a strong impact on the bereaved.
  • Research finds greater public stigma toward those who have a severe grief reaction to loss.
  • Understanding the stigma around loss helps us support those in need and anticipate our own needs around grieving.

One dark Friday evening in 1979, a father returned home with a terrible burden, to tell the three of his children who were home that their 43-year-old mother had died that day after a long battle with cancer. I was the youngest of those three. The date was November 2—forty-two years ago today. Over time, I've worked with and reflected upon that experience to arrive at a place of relative peace.

Approximately 5 percent of children lose a parent early on in life, making it rare among peers and socially challenging. Children with early parental loss are more likely to experience a variety of problems, including greater risk for depression and anxiety, difficulty with self-regulation with food, alcohol, and substances, and in relationships.

The shadow of the object

Thus, the shadow of the object fell upon the ego, and the latter could henceforth be judged by a special agency, as though it were an object, the forsaken object. In this way, an object-loss was transformed into an ego-loss, and the conflict between the ego and the loved person into a cleavage between the critical activity of the ego and the ego as altered by identification.—Sigmund Freud

Especially with traumatic loss early in development, the loss can create a divide within the personality, with one part identified with living and survival, and another part identified with death and dying, or as Freud (1917) noted in Mourning and Melancholia1, the lost "object". This struggle between life and death can be defining, and helps us understand why people with early shocks appear to do both very well and/or very poorly, but rarely seem to follow a conventional path.

This sets the stage for self-criticism and narcissistic disturbances which for many require psychological attention sooner or later. Early loss is a major adverse childhood event and may be associated with both post-traumatic reactions and resilient responses characterized by posttraumatic growth.

A shared experience

Loss becomes more and more common as we get older. The same coping responses that serve us well at one time—disengaging from emotion, focusing on moving forward—may later lead to struggle as those adaptations characteristically pose barriers to self-awareness and connection with others. Healthy grieving requires not only drawing upon personal resources but also receiving appropriate support from those around us. This includes cultural responses to death and dying.

One common problem is public stigma toward people experiencing grief,2 especially severe grief. In recognition that severe grief may become a clinical concern, the recent 11th ICD (International Classification of Disease) and American DSM-5 (Diagnostic and Statistical Manual) include Prolonged Grief Disorder (PGD, called Persistent Complex Bereavement Disorder in the DSM-53) as a diagnosis—with some controversy over concerns about “pathologizing” grief while recognizing that people with powerful and sustained reactions to loss interfering with their lives need more help. PGD affects about 1 in 10 people who experience a significant loss, and in many ways it parallels PTSD (Post-Traumatic Stress Disorder).

Research on attitudes toward prolonged grief

In order to better understand the impact of stigma toward people who are grieving, researchers Dennis, Eisma and Breen (2021) designed an experiment published in the Journal of Nervous and Mental Disease in which participants reviewed eight vignettes depicting people who experienced recent loss. The vignettes (full text below4) varied only a few factors, with a focus on highlighting different levels of grief: whether the death was sudden or expected and whether or not the participant had Prolonged Grief Disorder (PGD).

The 195 participants read the vignettes and completed a series of survey measures of public stigma:

  • Emotional Reactions Scale: Asks about three core emotional reactions: anger, fear, and “prosocial” (positive social) reactions.
  • Negative attributions: How does the person in the vignettes seem to the reader? To what extent are they seen as: competent, warm, emotionally stable, dependent, and sensitive? This measures the readers' projections or attributions, not the characteristics of the main character.
  • Social Distance Scale: This instrument, common in grief studies, estimates how much the reader would want to pull away, or socially distance themself, from the person in the vignette, with questions such as “How would you feel about introducing the person in the story to a friend?”

Study findings

The analysis found that prolonged grief was associated with statistically significant increased public stigma. PGD evoked greater perceived prosocial reactions but also greater attributions of fear and anger to the bereaved. Participants indicated they would seek greater social distance from those with stronger grief reactions.

People depicted in the stories were perceived as being less competent, emotionally colder, and less emotionally stable. Gender and suddenness of the death did not significantly change public stigma measures.

Helping each other in times of need

This research is an important early study in understanding how bereaved people are seen by others around them. Those who are seen as having severe and persistent reactions, specifically diagnosed with PGD, are seen with greater stigma and viewed as less competent and socially desirable, with emotional coldness and instability.

While not a real-world study of how people respond to actual loss in those close to them, this accepted experimental paradigm of using vignettes to probe attitudes shows that there is heightened stigma and characteristic perceptions toward people with severe grief. These experimental results are in line with the lived experiences of people who have undergone loss—on one hand, others tend to be sympathetic, while at the same time they often appear awkward and keep their distance.

Future work can extend these preliminary findings to look at how public stigma plays out in real relationships, school and work settings, as well as parse out the impact of having a diagnostic label versus showing severe reactions without the diagnosis named.

Paying attention to our own reaction toward those who are grieving is important. Others’ losses evoke our own feelings about the death of others and remind us of our own personal finiteness, increasing “mortality salience.” Grief, especially severe grief, is often stigmatized, making others uncomfortable, leading them to make general and often false assumptions about the bereaved and overall risking making things worse. Meeting each person where they are, finding out what they need, and keeping track of one’s own responses enables us to best respond when tragedy strikes.

References

1. "In mourning we found that the inhibition and loss of interest are fully accounted for by the work of mourning in which the ego is absorbed. In melancholia, the unknown loss will result in a similar internal work and will therefore be responsible for the melancholic inhibition. The difference is that the inhibition seems puzzling to us because we cannot see what it is that is absorbing him so entirely. The melancholic displays something else besides which is lacking in mourning—an extraordinary diminution in his self regard, an impoverishment of his ego on a grand scale. In mourning it is the world which has become poor and empty; in melancholia it is the ego itself. The patient represents his ego to us as worthless, incapable of any achievement and morally despicable; he reproaches himself, vilifies himself and expects to be cast out and punished. He abases himself before everyone and commiserates with his own relatives for being connected with anyone so unworthy. He is not of the opinion that a change has taken place in him, but extends his self-criticism back over the past; he declares that he was never any better. This picture of a delusion of (mainly moral) inferiority is completed by sleeplessness and refusal to take nourishment, and—what is psychologically very remarkable—by an overcoming of the instinct which compels every living thing to cling to life."

2. This is true for every age group, but is especially impactful early in life. Children who are ostracized for any reason face serious narcissistic challenges to maintain a healthy sense of self, often struggling with feeling both less-than as well as better-than others. Being cut-out of social circles at any stage of life leads to feelings of isolation, rejection and loneliness which negatively impact well-being.

3. Persistent Complex Grief Disorder is diagnosed when there is the death of a close other, with at least 12 months of persistent symptoms causing clinically significant distress or impairment, including feeling on most days persistent yearning for the deceased, intense sorrow and emotional pain, preoccupation with the person who died or preoccupation with how they died. In addition, at least 6 of the following are present, including clear difficulty accepting the death, disbelief or emotional numbness, difficulty with positive memories of the deceased, bitterness or anger related to the loss, negative self-appraises related to the loss, a desire to die related to be with the deceased, difficulty trusting others, feeling alone or detached, feeling that life is meaningless or empty without the deceased, confusion about one's role in life or reduced sense of personal identity, difficulty pursing one's own interests or to plan for the future.

4. Vignettes

PGD diagnosis/male bereaved/ unexpected death

Mark is 50 years old. His wife died more than 2 y ago. He had not expected her death. He finds everything extremely difficult and does not function well at work or at home. Since the loss, he yearns strongly for his deceased wife. Mark has difficulties accepting the loss and experiences strong feelings of guilt. He withdraws socially and engages in few activities. On the basis of this behavior, a mental health professional diagnosed him with PGD.

PGD diagnosis/male bereaved/ expected death

Mark is 50 years old. His wife died more than 2 years ago. He had expected her death. He finds everything extremely difficult and does not function well at work or at home. Since the loss, he yearns strongly for his deceased wife. Mark has difficulties accepting the loss and experiences strong feelings of guilt. He withdraws socially and engages in few activities. On the basis of this behavior, a mental health professional diagnosed him with PGD.

No PGD/male bereaved/ unexpected death

Mark is 50 years old. His wife died more than 2 years ago. He had not expected her death. Although he was very sad after the loss and strongly yearned for his deceased wife, he is now able to live with the loss. He functions well both at work and at home. Mark has accepted the loss of his wife more, experiences less feelings of guilt, and participates in activities that he finds meaningful.

No PGD/male bereaved/expected death

Mark is 50 years old. His wife died more than 2 years ago. He had expected her death. Although he was very sad after the loss and strongly yearned for his deceased wife, he is now able to live with the loss. He functions well both at work and at home. Mark has accepted the loss of his wife more, experiences less feelings of guilt, and participates in activities that he finds meaningful.

PGD diagnosis/female bereaved/unexpected death

Lisa is 50 years old. Her husband died more than 2 years ago. She did not expect his death. She finds everything extremely difficult and does not function well at work or at home. Since the loss, she yearns strongly for her deceased husband. Lisa has difficulties accepting the loss and experiences strong feelings of guilt. She withdraws socially and engages in few activities. On the basis of this behavior, a mental health professional diagnosed her with PGD.

PGD diagnosis/female bereaved/expected death

Lisa is 50 years old. Her husband died more than 2 years ago. She had expected his death. She finds everything extremely difficult and does not function well at work or at home. Since the loss, she yearns strongly for her deceased husband. Lisa has difficulties accepting the loss and experiences strong feelings of guilt. She withdraws socially and engages in few activities. On the basis of this behavior, a mental health professional diagnosed her with PGD.

No PGD/female bereaved/ unexpected death

Lisa is 50 years old. Her husband died more than 2 years ago. She had not expected his death. Although she was very sad after the loss and strongly yearned for her deceased husband, she is now able to live with the loss. She functions well both at work and at home. Lisa has accepted the loss of her husband more, experiences less feelings of guilt, and participates in activities that she finds meaningful.

No PGD/female bereaved/expected death

Lisa is 50 years old. Her husband died more than 2 years ago. She had expected his death. Although she was very sad after the loss and strongly yearned for her deceased husband, she is now able to live with the loss. She functions well both at work and at home. Lisa has accepted the loss of her husband more, experiences less feelings of guilt, and participates in activities that she finds meaningful.

Freud, S. (1917). Mourning and Melancholia. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works, 237-258

Dennis, Hayley BPsych(Hons)*; Eisma, Maarten C. PhD†; Breen, Lauren J. PhD*,‡ Public Stigma of Prolonged Grief Disorder, The Journal of Nervous and Mental Disease: October 5, 2021 - Volume - Issue - doi: 10.1097/NMD.0000000000001427.

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