Guide
Grief is the natural reaction to losing someone we love. It touches everything: emotions, the body, thoughts, daily life, the meaning of one’s own life. Many mistaken ideas circulate on this subject. Here is what research says, explained simply.
What grief is not
- It isn’t an illness. Suffering after a loss is normal, even when it is very intense and lasts a long time.
- There is no compulsory order. The famous “five stages” (denial, anger, bargaining, depression, acceptance) come from Elisabeth Kübler-Ross’s work with people at the end of their lives, not with bereaved people. They were never a path that has to be followed.
- There is no right way to grieve. Some people cry a lot and others little; some talk and others act. Not crying doesn’t mean you didn’t love.
- It isn’t about “forgetting” or “moving on”. You learn to live with the absence, and the bond with the person can continue in another way.
A little theory · A study of bereaved people followed from 1 to 24 months after the death found that acceptance was the most common feeling from the start, and that yearning (the intense wish to be with the person again) was the most present painful feeling, far more than disbelief or anger (Maciejewski et al., 2007). Some researchers have warned that presenting the “stages” as the normal path can make people believe they are grieving “wrongly” (Stroebe et al., 2017).
Very different paths, and a lot of resilience
Studies that follow people before and after losing a loved one show several trajectories. Many people feel real pain, but keep functioning and regain their balance within a few months. Others struggle for longer. A minority get stuck in intense suffering.
A little theory · In a study that had interviewed older people several years before the death of their partner, and then at 6 and 18 months, the most common trajectory was resilience: sadness, but with functioning preserved (Bonanno et al., 2002; Bonanno, 2004). Being resilient doesn’t mean feeling nothing or having loved less.
Oscillating between loss and life: the dual process model
The psychologists Margaret Stroebe and Henk Schut describe grief as a back and forth between two movements:
- loss-oriented: thinking about the person, crying, looking at photos, feeling the absence;
- restoration-oriented: dealing with daily life, learning what the person used to do (the paperwork, the cooking…), finding new roles, making plans, and also taking a rest from grief.
Both are necessary. Being distracted, laughing or going out isn’t a betrayal: it is part of grief. Conversely, completely avoiding everything that recalls the loss prevents you from integrating it.
A little theory · According to this model, what helps is the alternation: staying all the time with the loss, or all the time in avoidance, is associated with more difficulties (Stroebe and Schut, 1999, 2010). The dose differs from person to person and across cultures.
What grief asks us to do
The psychologist J. William Worden describes four “tasks”, which don’t follow a fixed order and can come back:
- Accepting the reality of the loss, with the head and with the heart.
- Working through the pain, rather than avoiding it at all costs.
- Adjusting to a world without the person: daily life, roles, the way you see yourself.
- Keeping a bond with the person while carrying on living.
The bond continues, in another way
For a long time it was thought that you had to “detach” from the person who died. Today we know that many people keep a living bond: talking to them, keeping an object, continuing a tradition, wondering what they would have said. It is often a resource. The bond becomes difficult mainly when it prevents you from living in the present.
A little theory · The idea of “continuing bonds” was developed by Dennis Klass, Phyllis Silverman and Steven Nickman (1996). Several studies also show that making sense of the loss (understanding what happened, integrating it into your own story) is associated with calmer grief, more than finding “benefits” in it (Holland, Currier and Neimeyer, 2006).
Grief also affects the body
Tiredness, sleep and appetite problems, lowered immunity, aches and pains: grief is also a physical ordeal. Looking after your sleep, eating, moving a little and seeing your doctor if needed are all part of the support.
A little theory · A review published in The Lancet shows that bereavement is associated with a higher risk of health problems and mortality, especially in the first months after the loss (Stroebe, Schut and Stroebe, 2007).
When grief gets stuck: prolonged grief
In a minority of people, the pain doesn’t ease over time. Yearning for the person, or constant thoughts about them, remain intense and pervasive, with great suffering (difficulty accepting the death, a feeling of having lost part of oneself, anger, guilt, inability to engage with life). Recently, medical classifications have recognised prolonged grief disorder.
A little theory · The WHO’s ICD-11 speaks of prolonged grief disorder when these reactions persist for at least 6 months after the death, clearly exceed what would be expected in the person’s culture and disrupt their life; the DSM-5-TR requires at least 12 months in adults. A meta-analysis estimates that about one bereaved person in ten has it (9.8%; Lundorff et al., 2017). The risk is higher after a sudden or violent death, or the loss of a child (Shear, 2015).
A little theory · Paul Boelen’s cognitive behavioural model describes three mechanisms that keep this blockage going: the loss isn’t yet integrated into one’s own story, very negative thoughts (about oneself, the future or one’s way of reacting) and avoidance, both anxious (not thinking about the death) and depressive (no longer doing things) (Boelen et al., 2006).
Is psychological help useful?
Not necessarily for everyone. Most people get through their grief with the support of their loved ones. Psychological help is useful above all when the suffering is very strong, lasts a long time or when you ask for it.
A little theory · A large review of 61 controlled studies found a small effect for interventions offered to all bereaved people, with no clear long-term benefit; results were better in people with significant difficulties or who were seeking help (Currier et al., 2008). For prolonged grief, specific therapies, especially cognitive behavioural ones, are effective (Shear et al., 2005; Johannsen et al., 2019).
What can help
- Make room for everything you feel: sadness, anger, relief, guilt, and even moments of joy. All of it can coexist.
- Alternate: moments to remember and others to rest.
- Accept practical help and say what you need: a meal, company, someone who listens without giving advice (worksheet 49).
- Rituals matter, whether religious, family or invented: a letter, a candle, a place (worksheets 52, 108, 126).
- Look after your body: sleep, meals, a little movement.
- Be kind to yourself: anniversaries, holidays and certain places can rekindle the pain, even years later (worksheet 22).
- Don’t make big decisions too soon if you don’t have to.
When to seek help
- if, after several months, the longing or the pain are just as intense as at the beginning and stop you living;
- if you can no longer cope with daily life, work or your relationships;
- if you are drinking more or taking medication to keep going;
- if the death was sudden, violent or traumatic, or if it is the loss of a child;
- if you have thoughts of dying or of being reunited with the person: call 112, 3114 (France) or your local emergency number, without waiting.
If you live abroad, grieving a loved one who stayed in your home country brings its own difficulties: not being able to be there, lost rituals, loneliness. The guide on migratory grief and worksheets 46 and 55 can also help you.
Worksheets to practise
- 141 · My back and forth · Between moments for the loss and moments for life
- 142 · What I feel in my grief · Every emotion has its place
- 143 · The bond that continues · What I keep of the person, and how I honour them
- 144 · The letter I couldn’t give · Telling the person what was left unsaid
- 145 · The difficult dates · Preparing for anniversaries, holidays and firsts
- 146 · What has changed in my daily life · The tasks and roles to reinvent
- 147 · Guilt and the “if only”s · Looking at my self-reproaches more fairly
- 148 · What I have been avoiding since the loss · Gradually going back to places, objects and activities
- 140 · Finding meaning in a difficult situation · When I can’t change the situation
- 126 · The kind letter · Writing to myself as someone who wishes me well would
- 108 · The gratitude letter · Thanking someone who has mattered
- 52 · My rituals for leaving and arriving · Marking transitions to get through them better
- 22 · Talking to myself as I would to a friend · The self-compassion break for anxiety
- 49 · My network here and there · Mapping social support in two countries
- 55 · Far from those who stayed behind · Living with ambiguous loss: present in your heart, absent from daily life
- 46 · The map of my losses · Naming everything migration has made me lose (migratory grief)
- 15 · Slow breathing · Slow breathing to accompany anxiety
Sources
Stroebe, M. & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197-224.
Stroebe, M. & Schut, H. (2010). The dual process model of coping with bereavement: A decade on. Omega: Journal of Death and Dying, 61(4), 273-289.
Stroebe, M., Schut, H. & Stroebe, W. (2007). Health outcomes of bereavement. The Lancet, 370(9603), 1960-1973.
Stroebe, M., Schut, H. & Boerner, K. (2017). Cautioning health-care professionals: Bereaved persons are misguided through the stages of grief. Omega: Journal of Death and Dying, 74(4), 455-473.
Maciejewski, P. K., Zhang, B., Block, S. D. & Prigerson, H. G. (2007). An empirical examination of the stage theory of grief. JAMA, 297(7), 716-723.
Bonanno, G. A., Wortman, C. B., Lehman, D. R., Tweed, R. G., Haring, M., Sonnega, J., Carr, D. & Nesse, R. M. (2002). Resilience to loss and chronic grief: A prospective study from preloss to 18-months postloss. Journal of Personality and Social Psychology, 83(5), 1150-1164.
Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), 20-28.
Worden, J. W. (2018). Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (5th ed.). Springer.
Klass, D., Silverman, P. R. & Nickman, S. L. (Eds.) (1996). Continuing Bonds: New Understandings of Grief. Taylor & Francis.
Holland, J. M., Currier, J. M. & Neimeyer, R. A. (2006). Meaning reconstruction in the first two years of bereavement: The role of sense-making and benefit-finding. Omega: Journal of Death and Dying, 53(3), 175-191.
Boelen, P. A., van den Hout, M. A. & van den Bout, J. (2006). A cognitive-behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13(2), 109-128.
Shear, M. K. (2015). Complicated grief. New England Journal of Medicine, 372(2), 153-160.
Shear, K., Frank, E., Houck, P. R. & Reynolds, C. F. (2005). Treatment of complicated grief: A randomized controlled trial. JAMA, 293(21), 2601-2608.
Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., Raphael, B. et al. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121.
Lundorff, M., Holmgren, H., Zachariae, R., Farver-Vestergaard, I. & O’Connor, M. (2017). Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. Journal of Affective Disorders, 212, 138-149.
Currier, J. M., Neimeyer, R. A. & Berman, J. S. (2008). The effectiveness of psychotherapeutic interventions for bereaved persons: A comprehensive quantitative review. Psychological Bulletin, 134(5), 648-661.
Johannsen, M., Damholdt, M. F., Zachariae, R., Lundorff, M., Farver-Vestergaard, I. & O’Connor, M. (2019). Psychological interventions for grief in adults: A systematic review and meta-analysis of randomized controlled trials. Journal of Affective Disorders, 253, 69-86.
Organisation mondiale de la santé (2022). CIM-11, Classification internationale des maladies, 11e révision : 6B42 Trouble de deuil prolongé.
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR).
These worksheets do not replace therapy. If you are in distress or having suicidal thoughts, call your local emergency number (112 in Europe; 3114 in France, free, 24/7).
