Definitions & Types of Grief

In 1989, psychologist, educator and author Kenneth Doka, Ph.D.  coined the term “disenfranchised grief” to describe the experience of people whose grief is not acknowledged by society due to the nature of their loss. Specifically, he outlined social, political and cultural norms that determine what losses are considered “worthy” of grief and which are not. He also addressed the suffering that denying mourners a socially acceptable outlet for their grief can cause. Doka’s theory of disenfranchised grief has since become widely accepted by mainstream psychologists and grief counselors worldwide. 

Also known as unacknowledged grief or hidden grief, disenfranchised grief can result from many different kinds of loss. These include: 

Unacknowledged relationships 

Many people have close ties to others that, for whatever reason, they choose to hide from friends and family. Lingering ties may also still exist between people who are no longer close but who shared a significant portion of their lives. Some examples or unacknowledged relationships include:

• A partner that you haven’t openly acknowledged, such as the LGBTQ+ partner of someone who is not “out” or a romantic partner who is married or in a relationship with someone else. 
• An ex-spouse or partner 
• A birth mother or father of an adopted child or adult
• An unborn child

When these relationships end, the grieving person is often denied the support and understanding of others because they feel compelled by social norms to pretend the loss didn’t happen or wasn’t important to them. 

Children and people with developmental disabilities may also go unacknowledged when they suffer a loss because loved ones think they are too young or too intellectually challenged to mourn. Unfortunately, this is almost never the case. 

“Less” Significant Relationships

In our society, we tend to rank relationships in terms of their “importance.” Our relationships with spouses, siblings, children and parents are ranked high in the social hierarchy, whereas other relationships are seen as less significant. Some examples of these relationships include:

• A friend or co-worker
• A pet
• A teacher or mentor
• A cousin, niece or nephew
• A grandparent

Of course, when you love someone or something, that relationship is not insignificant to you, and your grief after their death may be intense. Nonetheless, it’s not uncommon for people who have experienced such losses to find that friends and family can’t acknowledge or relate to the depth of their pain. 

Intangible Losses

Also known as “ambiguous losses,” intangible losses are losses of things we value that are not associated with someone’s death. An ambiguous loss may seem negligible or unimportant to others, but it can cause deep pain and long-lasting disenfranchised grief. Some examples of ambiguous losses include:

• Divorce
• Betrayal by a friend or romantic partner
• Loss of health (either one’s own or that of someone you love)
• Loss of financial security (such as being laid off or fired)

• Loss of a sense of safety or security (for instance, due to domestic violence, sexual assault or being robbed)
• Incarceration of a loved one
• Addiction in a loved one
• Someone in your life is missing and can’t be found
• Infertility
• Loss of a dream (for example, a child’s divorce, having to drop out of school)
• Loss of a home (to a fire, natural disaster, or act of war)

Although uniquely painful, ambiguous losses often go unacknowledged because they lack the finality of death. But it is precisely this lack of finality that often makes intangible losses so difficult to bear.

Stigmatized losses

Stigmatized losses or stigmatized deaths include those that society views as the “fault” of the person who died. Examples of stigmatized loss include:

• Overdose deaths
• Death by suicide
• Drunk driving deaths 
• Some homicide deaths
• Abortion

Because of the stigma attached to these “at fault” kinds of deaths, the families and loved ones of the person who died are often stigmatized as well. Many people feel that they can’t reach out for support because they will be viewed in a negative light, so they hide their pain and their grief. 

Sources

“Ambiguous Loss and Its Disenfranchisement: The Need for Social Work Intervention”. SAGE Journals. https://journals.sagepub.com/doi/abs/10.1177/1044389418799937 

Collective grief occurs when a group or community shares in a mourning experience, typically after a significant loss or traumatic event. These events can include the death of a public figure, natural disasters, war or acts of violence, where the impact resonates deeply within a community. As opposed to individual grief, which is often a solitary process, collective grief unites people in their sorrow, which can help with healing as it allows people to process their emotions together with a sense of solidarity and shared experience. Shared mourning can be facilitated through communal rituals (such as candlelight vigils), public memorials (which can range from leaving notes and flowers at a specific site to large-scale monuments), and even social media expressions. These practices allow individuals to connect and support each other.

It can be challenging to let yourself feel sadness about the loss of someone you didn’t know personally. However, when grief is acknowledged on a collective level, it can provide a sense of validation, making it easier to express your feelings.

Sources

“Collective Grief”. Cruse Bereavement Support. https://www.cruse.org.uk/understanding-grief/grief-experiences/collective-grief/ 

Cumulative grief, also known as compounded grief or bereavement overload, refers to the intense compounding effect that occurs when an individual experiences multiple losses within a short period of time. It often involves experiencing another loss before the previous loss can be processed. As these losses compound, the affected individual may experience intense distress and an extended mourning process that might not otherwise be experienced under normal circumstances. With each additional loss that occurs, the individual may have more difficulty coping and may find that the grieving process feels more complex or overwhelming.

Although cumulative grief typically refers to losses that occur within a short timeframe, the compounding factor can occur within any period of time. It is frequently thought to require a close succession of losses but can be cumulative over the period of a lifetime. Some individuals may feel that they are not adequately prepared to process and accept the most recent loss since they have not yet successfully recovered from the losses that occurred prior. Additionally, although support from family and friends may be more readily available after the initial loss, having access to a consistent support system can become more challenging as other losses emerge. 

Individuals who are affected by cumulative grief may feel as if they are always in a state of intense sorrow. This prolonged experience of grief often becomes exhausting and can make them feel more vulnerable. It can also make it more difficult for these individuals to attain a sense of acceptance following each loss, which can potentially delay the healing process. Individuals with cumulative grief may feel that new losses cause the pain and grief of previous losses to feel fresh again.

Those who have cumulative grief or bereavement overload are encouraged to prioritize self-care and mindfulness to help them soothe and stabilize the intense internal response that often emerges with each loss. Making time to honor and remember loved ones that have been lost can aid in efforts to achieve a sense of peace around the loss.. If friends and family cannot be a consistent source of support, joining a support group or connecting with a grief counselor or therapist can be an excellent alternative. Counseling or therapy can be especially helpful in developing and solidifying healthy coping skills that can be used throughout the grieving process. 

Sources 

“How to handle an overload of grief”. Vox. Retrieved from https://www.vox.com/even-better/23445017/cumulative-grief-loss-overwhelming-cope-mental-health 

“What is compounded grief?”. Very Well Mind. Retrieved from https://www.verywellmind.com/compounded-grief-symptoms-causes-diagnosis-and-coping-6979518 

Climate grief, sometimes also called climate anxiety or ecological grief, refers to the experience of psychological and emotional distress associated with climate change. Climate grief centers around anticipating or witnessing the loss of ecosystems, biodiversity, and other elements of the Earth’s natural environment. It is characterized by feelings of despair, sadness, fear, anxiety, or hopelessness when faced with concerns pertaining to the well-being of the planet and future generations. Some individuals may also experience a general fear for the future in relation to species extinction, disruption of ecosystems, loss of landscapes, or an increase in natural disasters and extreme weather events. 

Since human actions have significant potential to exacerbate climate change, some individuals may experience guilt or feel directly responsible for potential consequences to the Earth. Factors such as burning fossil fuels, increased greenhouse gas emissions, or deforestation are all components that contribute to climate change and are often connected to behaviors or actions taken on an individual and collective level. Individuals who aim to incorporate more green or sustainable practices into their lifestyle may struggle with feelings of hopelessness or despair since eco-friendly efforts often need to be implemented among the larger population in order to achieve the desired outcome. 

Climate grief can also manifest collectively, such as among communities or indigenous people who have a direct and personal connection to the land. The destruction and amplified damage of the Earth can prompt a profound sense of loss for Indigenous people, particularly since it can threaten their relationship with nature, their livelihood, and traditions or rituals that are deeply connected with the surrounding environment. In these instances, environmental damage and loss of land are often associated with disrupting natural ecosystems to establish modern cities through urbanization and widespread construction. 

Sources

“Is climate grief something new?” American Psychological Association. https://www.apa.org/members/content/climate-grief 

“What is Climate Grief?” Climate & Mind. https://www.climateandmind.org/what-is-climate-grief 

“Climate grief is real – and I cannot keep watching images of our dying planet”. The Guardian. https://www.theguardian.com/commentisfree/2023/jul/05/climate-crisis-grief-is-real-solastalgia-dying-planet 

Preparatory grief is a term used to describe the grief process that is experienced by terminally ill individuals who are facing their own death. It is a type of grief that people experience to prepare themselves for their final stage of life. Although these individuals will grieve the reality of the inevitable loss of life during this period, they will also grieve other upcoming losses, such as the loss of physical or cognitive ability, loss of mobility, or the loss of autonomy and independence. Many individuals also grieve over the loss of experiences, such as missing out on milestones like a family member’s wedding or the birth of a grandchild. 

There are five stages to the preparatory grief process: shock, chaos, introspection, re-adaptation, and restitution. Most people who are dying will experience at least one of these phases. The phases do not have to occur in any specific order and it is possible to skip phases or experience multiple phases at the same time. Other people may not realize that the terminally ill individual is experiencing preparatory grief since some of the behaviors or emotions associated with these phases may be mistaken for mood swings or emotions resulting from a chronic medical condition. 

Individuals in the shock phase tend to struggle with a sense of disbelief and misery. They may have minimal energy since they are deeply focused on the news they have received regarding their prognosis. In the chaos phase, they may refuse to accept time constraints or limitations associated with their disease. People in this phase may try to force themselves to participate in activities or an old routine that they maintained prior to receiving their prognosis. Eventually, disease progression and the related symptoms will force them to accept the truth about their mortality.

With disease progression, the phase of introspection often begins. Individuals in this phase may experience frustration due to the gradual loss of their ability to complete simple tasks and the sensation of their body becoming weaker. They may begin to question why they became terminally ill or if they brought this outcome on themselves somehow. Although these can be difficult and emotional questions to reflect on, most individuals will eventually move past this phase and begin to focus on how they can make the most of their remaining time prior to death. 

The re-adaption phase is when individuals focus on what they can accomplish in what remains of the future. Some may still reflect heavily on the past, but many will consider goals or activities that they would like to complete before they die. This is often the phase where they will start forming a bucket list of things they’d like to do prior to death. 

In the restitution phase, dying individuals may still experience occasional bursts of emotion, but they have generally accepted the truth of their fate.

Understanding and acknowledging preparatory grief can be important in fostering the healing process following difficult news. It enables dying individuals to confront their emotions and fears regarding their circumstances, reach out for support, and explore different methods for coping with their loss. In doing so, they can more effectively navigate their grief journey and use the remainder of their time to focus on crafting a legacy that aligns with their beliefs and core values. 

Sources 

“Assessing Preparatory Grief in Advanced Cancer Patients as an Independent Predictor of Distress in an American Population”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC6436024/ 

“Dying and Preparatory Grief”. American Family Physician. https://www.aafp.org/pubs/afp/issues/2002/0301/p897.html 

Over the past decade, researchers have found that some bereaved people suffer more intensely and for longer periods of time than people experiencing “normal” grief. While still emphasizing that grief is an individual and unpredictable process, they have noted that these people have much more trouble coping with their reactions to a significant loss. Despite the passage of what is typically considered to be an adequate period of time (6 months to 2 years) they do not recover physically or emotionally and continue to experience intense, disabling distress. These people are said to be suffering from prolonged grief disorder or complicated grief.. 

Prolonged grief occurs in about 10% of people who have experienced the loss of a loved one, and appears to be unrelated to the circumstances of the person’s death. 

After a great deal of consideration and debate (much of which is still ongoing) in 2022, the authors of the Diagnostic and Diagnostic and Statistical Manual of Mental Disorders or DSM added Prolonged Grief Disorder to its list of diagnosable mental health conditions. This decision “officially” differentiated prolonged grief disorder from “normal” grief and categorized it as a pathological process requiring intervention and treatment. 

According to the American Psychiatric Association, the criteria for diagnosis of prolonged grief disorder includes:

• The loss of a loved one that occurred at least one year ago for adults and 6 months ago for children and adolescents
• At least three of the following symptoms for at least one month:
  • Identity disruption (e.g., feeling as though part of oneself has died).
  • Strong disbelief that the person has died
  • Avoidance of reminders of the death
  • Intense emotional anguish, such as sorrow, anger, bitterness
  • Difficulty engaging with friends, pursuing  interests or planning for the future
  • Emotional numbness
  • Feeling life is meaningless or not worth living
  • Extreme loneliness or feelings of isolation from others
  • Difficulty managing painful emotions

The symptoms should be consistently present and cause disruption in the person’s day to day functioning at home, school, and/or work. 

Predisposing Factors 

Prolonged grief disorder can occur in anyone who has experienced a loss. However, research shows that certain individuals are more likely to develop PGD. This includes:

• A history of depression, anxiety or bipolar disorder
• Perceived lack of social support
• Poor physical health 
• Being a caregiver for the person who died, especially those who were caring for a spouse or partner
• Family conflict or difficulties at end-of-life
• A lack of education 
• People whose loved one died a sudden or traumatic death

It is also important to note that prolonged grief disorder may co-occur with other mental health conditions, which may make diagnosing and treating the condition more challenging. Specifically, researchers have found that a significant percentage of individuals with prolonged grief disorder also suffer from major depressive disorder, anxiety disorders and PTSD. 

If you believe you need help coping with your grief, use this tool from the Center for Prolonged Grief at  Columbia University to find a therapist in your area. If you want to locate additional resources, the CCG offers a number of self-assessment tools and handouts in the Resources section of its website. 

Sources

“Complicated Grief and Related Bereavement Issues for DSM-5”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC3075805/ 

“Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)”. American Psychiatric Association. https://www.psychiatry.org/psychiatrists/practice/dsm 

“Prolonged Grief Disorder”. American Psychiatric Association. https://www.psychiatry.org/patients-families/prolonged-grief-disorder 

“Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment”. Psychiatry Online. https://psychiatryonline.org/doi/10.1176/appi.focus.20200052 

“Find a Therapist”. The Center for Prolonged Grief. https://prolongedgrief.columbia.edu/find-a-therapist-contact-us/ 

Anticipatory grief is a term used to describe the emotional reactions that loved ones experience prior to a terminally ill person’s death. It frequently involves many of the same feelings that occur after a death, such as sadness, anxiety and fear of the unknown. Both family and caregivers may experience anticipatory grief. A similar type of grief experienced by the dying person is referred to as preparatory grief.

Anticipatory grief can be useful and therapeutic. During a period of anticipatory grieving, both the person who is dying and their loved ones have the chance to complete “unfinished business” and say goodbye. This sometimes helps to diminish the intensity of the grief that friends and family members experience after the death occurs. But this is not always the case. In fact, knowing that a loved one’s death is imminent sometimes intensifies a person’s attachment to them. This can cause their grief following the person’s death to be more intense. 

Family caregivers are especially susceptible to anticipatory grief because their attachment to the person who is dying is so intimate and, in most cases, long-term. Many people in this situation feel conflicted and even ashamed because they don’t want to lose the person they love, yet desperately want their suffering to end. Some caregivers experience such chronic, long-term anticipatory grief that it leads to depression, which can make caregiving more difficult and grief after the death occurs more intense. 

With that said, some experts believe that true anticipatory grief is actually very rare because it is impossible to truly mourn someone’s death while they are still alive. Nevertheless, people often mourn other losses before a death occurs. For example, they may grieve for the loss of their loved one’s companionship; the loss of the future they planned together; or the sense that their own future was certain and secure. These are all components of anticipatory grief. 

Like all grief, anticipatory grief varies greatly between individuals. It’s important for family members to understand this, and accept that their loved ones are likely in different places in their grief journey during the period before a loved one dies. Some people may not have grieved at all, while others may have begun to separate themselves emotionally from the person who is dying. Neither reaction is right or wrong. 

Sources

“Grief and Mourning”. MedicineNet. https://www.medicinenet.com/loss_grief_and_bereavement/article.htm 

“Dementia Grief: A Theoretical Model of a Unique Grief Experience”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC4853283/