The processes of grief in the face of loss are, psychologically and biologically speaking, a completely normal and expected reaction. It is possible to observe periods of grief in response to any kind of loss, be it an object, a relationship, a social role, or even the abandonment of an addictive substance that the person has been struggling with for several years, such as quitting smoking. These reactions and processes occur to a greater or lesser extent whenever a person faces any kind of loss.
The loss of a loved one is usually the most common in the psychotherapeutic field. The roots of this reaction and the consequent process can be traced to the development of attachment relationships, evidence of which is that grief is not exclusive to the human race but is also observable among animals (Lorenz 1963).
Firstly, a key aspect must be highlighted: the grieving process in the face of the death of a loved one should not be categorized as a mental illness but, rather, as a process of recovery from an imbalance, a return to homeostasis if preferred. The closest explanatory metaphor at a biological level would be similar to the healing process of a wound. We would agree that denying pain, hiding its existence from professional help, or constantly manipulating it will not allow the body to execute its healing correctly.
When we talk about grieving processes, an essential reference is William Worden and his well-known four-phase model. Here, Worden rightly argues that the first step, however obvious it may seem, is to accept the reality of the loss, which can lead to a reorganization of the subject’s schemas. This is the phase where blockages can appear due to the shock produced by the disappearance, especially if it has been sudden or there hasn’t been enough time to say goodbye. We will find two defense mechanisms blocking this: denial, which manifests, for example, by keeping everything exactly as it was when the person was alive, by making their possessions untouchable, as if they were going to return at any moment (Gorer 1965); or, at the opposite extreme, by producing a minimization of the impact of the event (if a bond existed) through an obviously excessive indifference, which would be to continue as “if nothing had happened.” Both positions are usually indicative of unresolved grief. Here, therefore, physical actions and rituals (funeral, farewell letter, etc.) become especially important, as they help to gradually accept the irreversibility of the loss. Likewise, there are tasks we work on in psychotherapy that can help complete this phase when the person has not had time or has not said goodbye properly, such as farewell rituals like letters to the deceased or reorganizations associated with objects. The idea is to help the affected person mark a before and after, to change, modify, or execute something that impresses upon their mind the irreversibility of the event.
Secondly, it is necessary to work through emotions and pain. In many cases, current society hides or tries to minimize everything related to death, unlike many more primitive societies that resolve these processes excellently and creatively. This fact sometimes leads to a poor tolerance of negative emotional expressions, which are absolutely necessary, especially in these cases: pain and the possibility of expressing it are necessary (Pincus 1974). Taking refuge in idealizations, being unable to impartially observe one’s own feelings towards the deceased person, or resorting to drugs to anesthetize dysphoric emotional states stemming from memories of the deceased, often leads to blockage, and avoiding grief can lead, sooner or later, to a collapse or the manifestation of depressive symptoms (Bowlby 1980).
Subsequently, an adaptation phase is reached: the person attends to an environment in which the deceased is absent and must again face situations, places, or tasks that they performed with support or will have to replace the deceased person. Here we must place special emphasis on patriarchal family models and on financially dependent individuals or those whose self-esteem is based on caring for others. In these cases, this phase will be the most complex step for them, as on the one hand, they must face or replace the resources provided by the deceased and, at the same time, try to prevent their social circle from becoming “burned out” due to expressions of sorrow. It is of great importance to maintain social contacts and seek their support, as this is where they can provide more solutions and practical help, in addition to emotional support. On several occasions, it has been proven that external individuals react better and provide more support to those who face losses or catastrophes proactively. Isolation will emerge as the main threat in this phase of the process, capable of blocking the person. It should be noted that we are also talking about the loss of a role, which has generally been developed with the deceased person for years in a relationship of emotional, material, or social complementarity; it is not uncommon for self-esteem to be directly affected (Zaiger 1985).
Finally, it is expected that if the previous phases have been correctly processed, the person will be able to emotionally re-place the deceased; this is the phase of continuing to live, as William Worden points out, and it can last for the rest of the person’s life; essentially, it is a turning point from which the affected individual can rebuild their life and activities, without ceasing to remember the loved one. This is the serenity sought at the end of a grieving process and does not have a precise resolution time, despite what medical, psychiatric, and psychological literature has tried to propose by delimiting periods.
It should be added that we will probably encounter a series of reactions in these phases, symptomatology that is perfectly normal to observe in a person processing grief, without categorizing it as pathological: feelings of anxiety, sadness, helplessness, nightmares, and even hallucinations with the loved one are not pathological. The well-known sense of presence is a brain reaction adapting to a loss, a fact that we must respect within a reasonable timeframe. It should also be noted that it should not be surprising that the phases are not linear, so the possibility of regressions or relapses into previous phases must be considered, without this implying that the work is being done incorrectly. On the contrary, it can provide the patient with self-knowledge and help them realize where each course of action, each chain of thoughts, leads them, and help them glimpse where they may need more help or new resources.
Given these complex processes, which extend, retract, seem to improve only to go back… how can we know when things are not going correctly? To know when we are facing unresolved grief, since it would be crude to do so with a rigid time limit (except in openly very extensive cases), we can take a simple guideline: in my experience, the existence or sensation of blockage on the part of the individual is especially important; this is one of the best ways to detect it. If, after some time, the person has not been able to accept the loss, continues to act and speak of the deceased person in the present tense, avoids the topic with extreme anxiety, has isolated themselves from their environment, or has seen their capacities severely limited… you can ask them the famous question that Francine Shapiro asked her patients blocked with PTSD: what did you do before that you can’t do now? Their answer can give us great clues as to where the normal grieving process has become stuck.
Regarding the use of psychopharmaceuticals, it should be noted that it would be a very incorrect approach to routinely administer antidepressant medication. The most advisable course of action may be some prescribed and temporary medication dedicated to alleviating anxious symptoms or direct problems such as insomnia (Hacket 1974). Grief does not necessarily produce depression, and the latter cannot be correctly treated with psychopharmacology until the grief has been properly processed and worked through.
The professionals involved in these processes can range from healthcare professionals (doctors, nurses, social workers, psychologists…) to informal support groups where those affected feel comfortable or identified and can share common experiences, preferably with a professional member to guide and redirect. It is more advisable to decidedly avoid any group with a possible sectarian deviation (spiritualist or mystic-magical groups) that exploit the emotional instability of those affected for economic gain, not only because of the loss of money but also because of the consequences for the individual’s mental state, as these groups are often based on irrational beliefs that, rather than helping, block the correct grieving process. Today, it has been proven that the joint action of professionals and self-help groups also correlates with a lower probability of future mental and psychosomatic disorders (Parkes 1980).
Finally, it should be emphasized that we must not lose sight of the potential level of frustration that both professionals and volunteers will often perceive, being able to dedicate many sessions to accompaniment or active listening. It is very important to respect the timing, as the circumstances of each person, and especially those of the death, can produce such varied manifestations that we may encounter guilt or rumination (thinking over and over again how the death could have been avoided), with feelings of strong injustice (such as the death of a small child) that can lead to a rethinking of values and spiritual beliefs, an aspect that is a priority to respect regardless of the religious confession of the therapist or the institution providing the help. We could also observe a very different development in cases where the uncertainty of the demise persists (in declarations of death by disappearance); all of this results in a different, idiosyncratic, and highly individualized approach, which, even going through the phases we have discussed, must focus on gradually achieving reintegration at mental, social, and work levels, along with psychological work and accompaniment supervised by professionals when necessary or when blockage is evident.