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Journal of Psychology and Christianity Copyright 1999 Christian Association for Psychological Studies
1999, Vol. 18, No. 4, 309-329 ISSN 0733-4273
Grief, Loss, and Bereavement:

An Overview
Naji Abi-Hashem
The New Life Clinics
Seattle, Washington
This article presents a general view of the topic of grief by defining the common
terminology, discussing the nature and types of losses, listing the variety of grief
reactions, and describing the factors that determine the severity of bereavement.
This article also addresses the question of morbidity and mortality of grief, throws
a light on the emerging topic of traumatic grief where elements of trauma and a
devastating loss are both present, and finally reviews the steps toward healing
and grief resolution. Throughout the article, a special emphasis is given to the
communal, spiritual, and cultural aspects of mourning and, toward the end, a few
suggestions are offered to the caregivers who are involved in grief and bereave-
ment counseling.
Grief is a universal experience. It is inevitable and real. Human life is a series of

attachments and detachments, gains, and losses. Grief emotions are a natural
response to any separation or loss (White, 1999) whether it happened in the past,
is happening now in the present, or is anticipated to happen in the future. Bereave-
ment is commonly experienced and expressed by all individuals and groups,
regardless of their background, location, and beliefs. Grief is as old and ancient as
the human nature itself.
Grief is a tender subject of study and a sensitive area of the human experience.
Both as lay people and professionals, we usually approach the topic of mourning
and try to help a bereaved person not from a mere theoretical view or a purely
objective and detached attitude. Rather, we become somehow involved and, to
some degree, personally affected as we relate to the sense of loss and mourning.
Virtually no one is immune to grief. It is such a common and familiar experience to
all walks of life. Grief knows no historical or geographical boundaries. It is clearly
manifested across age, time, and culture.
What is true of grieving on an individual level is also true on familial, group, tribal,
social, and communal levels (cf. Seeley & Kajura, 1995; Williams, Zinner, & Ellis,
1999). That also applies to the national level as well. Both ancient and modern his-
tory have many examples of public and communal grieving. When there is a politi-
cal loss of a national identity, a tragic death of a national leader (Witztum &
Malkinson, 1999), or a major natural disaster (like fire, flood, or earthquake), the
whole society will collectively mourn, and quite often, for a long period of time.
Definition of Terms
Grief, bereavement, and mourning are common terms which are repeatedly
used in the literature. In an attempt to define one term, many authors employ the
other terms due to their interdependence and interconnectedness. Regardless of
their extensive use, no term or combination of terms can totally unfold, completely
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Correspondence should be addressed to Naji Abi-Hashem, Ph.D., P.O. Box 1732,
Mercer Island, WA 98040-1732, USA, or to NajiAbiHashem@gmail.com
309
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CITATION: Abi-Hashem, N. (1999). Grief, Loss, and Bereavement: An Overview. Journal of Psychology and Christianity, Vol 18 (4), pp 309-329.
explain, or fully capture the profound meaning of the encompassing phenomenon

of grief. At times, these terms are used interchangeably while, at other times, each
has a unique and assigned meaning or connotation, depending on the context and
dynamic involved.
Definitions of grief may range from the simple and short (yet profound) to the
highly complex and sophisticated. Grief can be defined as deep sorrow, heaviness
of heart, and agony of soul. It can also be understood as mental anguish and emo-
tional suffering. Although there is an aspect of grief that is universal and familiar, on
a deeper level, grief remains surprisingly unfamiliar and mysteriously strange.
Staudacher (1987) considered grief as “the stranger” (p. 3). Grief can be described
as an acute and overwhelming sense of loss. It is basically a phenomenological
experience (Osterweis, Solomon, & Green, 1984). A major loss almost always
results in a state of deprivation for the entire personality, in adults and children
alike, which may become helplessly engulfed with strong waves of emotions.
Grief is not a specific emotion but a constellation of a mixture of feelings,
thoughts, sensations, movements, and behaviors. Grief is an internal experience of
an external event of loss and the meaning the bereaved person usually assigns to
that loss. According to Wolfelt (1988), grief is both a process and an outcome. It is
a mental, emotional, and behavioral response to loss. Rando (1984) defined grief
as the process of psychological, social, and somatic reactions to the perception of
loss. Averill (1968) suggested that grief is a product of biological evolution that has
adaptive value. Mitchell and Anderson (1983) referred to grief as “the normal but
bewildering cluster of ordinary human emotions arising in response to a significant
loss, intensified and complicated by the relationship to the person or the object
lost” (p. 54).
Grief usually comes in different shapes, forms, frequency, and intensity, and lasts
for different periods of time. It is like an unpredictable stranger who comes to stay
(Staudacher, 1987). Grief is a phenomenological experience that repeatedly cap-
tures the whole mind and soul of the bereaved. Additionally, the grief process can
be conceptualized as the unfolding, the progression, and the working through of a
host of intense affect, cognition, activities, and physiological sensations until a cer-
tain degree of resolution and closure has been reached and a level of inner bal-
ance reestablished.
Another commonly used term is bereavement. Bereavement is the state of hav-
ing suffered a loss or is a state caused by loss. Bereavement is a global term that
describes the vast array of experiences, changes, and conditions that take place
after the loss (Sanders, 1989). Several types of losses can create the state of
bereavement. It reflects the experiential condition and existential position an indi-
vidual endures after realizing a significant loss has occurred in his or her world.
According to Burnell and Burnell (1989), the term bereavement has roots in the old
English language and means “to rob,” “to plunder,” or “to dispossess” (p. 29). It also
has the idea of taking away a loved one in a forceful manner leaving the survivor
struggling with the consequences of a sudden loss and separation.
On the other hand, mourning has been referred to as the external expression of
the internal experience. It is the outer manifestation and public demonstration of
grief. Mourning is bereavement shared publicly. It is the act of lamenting openly the
lost object or deceased person. The term mourning could have two meanings. The
first is derived from the psychoanalytic literature and implies a wide range of con-
scious and unconscious activities and intrapsychic processes, all triggered by the
310
event of loss (Bowlby, 1980; Rando, 1984). The second refers to the appropriate
cultural response to grief over a major loss. It is like any other reaction that is
socially regulated. Wolfelt (1988) explained:
The specific ways in which people mourn are influenced by the
customs of their culture. The mourning behavior exhibited may
or may not be in agreement with [the] true feelings of the
bereaved; however, they may incur disapproval if they do not fol-
low the prescribed social customs. (p. 1)
When a death occurs in a community, mourning therefore becomes embodied in
the set of “rituals and customs that formally and publicly express grief at death.
Though most often carried out by relatives, friends, and neighbors, they may be the
responsibility of professional mourners or burial guilds” (Smith, 1995, p. 737).
Types of Losses
The study of the nature and impact of loss has resulted in an extensive body of
literature in this century. From a psychological and psychiatric point of view, the
effect of loss was first articulated by Freud (1917) and then broadly elaborated
upon by Lindemann (1944). Much has also been written from a psychodynamic
perspective about the theories of attachment and bonding, and also about separa-
tion and loss (cf. Bowlby, 1977, 1980, 1982; Vaillant, 1985; White, 1999).
The loss of a loved one or the death of a close family member (child, spouse,
parent, best friend, grandparent, etc.), especially by sudden or tragic death, has
been uniformly identified as the most devastating type of loss and the most potent
stressor in ordinary life (Birenbaum, Robinson, Phillips, Stewart, & McCown, 1989;
Clayton, 1998; Elliott & Eisdorfer, 1982; Hamburg, Elliot, & Parron, 1982; Holmes &
Rahe; 1967; Nolen-Hoeksema & Larson, 1999; Rabkin & Streuning, 1976). How-
ever, depending on the age, gender, personality characteristics, emotional needs,
value system, and social circumstances of the survivor(s), other types of losses
can be equally painful. For example, losing a cherished place, a romantic relation-
ship, a treasured personal item, a house, a favorite pet, a rewarding career, a talent
or a mental faculty, a precious object, a part of health, etc., can all be significant
and very disturbing losses. In addition, family conflicts that result in separation and
divorce, moving and uprootedness due to old age, job placement, civil wars, natu-
ral disasters, the empty nest phenomenon, broken life-long dreams, loss of identity
or dignity or integrity, loss of childhood innocence (as being subjected to depriva-
tion, neglect, or abuse), missing a golden opportunity, retirement from a meaning-
ful work, and giving up a social role or status can also generate significant
bereavement responses and substantial mourning.
Normally, when there is a deep and meaningful attachment, there will be a deep
sense of loss. Severe separation from a special object, person, or function, and the
breaking up of a close relationship or an intimate family or social circle, will definite-
ly create a major grief response and a state of psychological bewilderment (White,
1999). Following a major loss, the bereaved survivor will need to go through a long
process of readjustment, renegotiation, reorganization, and readaptation to normal
living without what has been lost, that is, without the deceased person, the lost
object, the family role, the bodily function, the meaningful career, or the social sta-
tus (Abi-Hashem, 1999b). Attig (1996) called this process the relearning of the
world.
311
There are different kinds and types of losses. Losses can be personal or materi-
al, tangible or symbolic, sudden or gradual, specific or general, minor or major, real
or imaginary, partial or total, personal or corporate, expected or unexpected, single
or multiple, private or public, individual or communal, local or global. Existentially
speaking, a loss can also be classified as historical—happened in the past, con-
temporary—is taking place in the present, or anticipatory—is expected in the near
or far future. Each one of these time-related losses can be powerful and generate
intense or prolonged bereavement reactions. The inability to deal with previous
losses and the crippling fear of future losses could impinge on the present moment
and interfere with the psychological functioning of the person. Therefore, it is not
unreasonable to suggest, as Bowlby (1980) did already conclude, that unresolved
and complicated grief lies in the core of much psychiatric disorders and illnesses
(see also Rando, 1993; Worden, 1991, 1996).
Variety of Grief Reactions
Reactions to a major or sudden loss can include some or all of the following
responses. These are part of a normal grieving and bereavement process. They
include but are not limited to all possible grief reactions and manifestations. The
bereaved may experience them in different variations and at different times. Some
of them come like waves upon the person or like a flood of intense emotions and
memories; consequently, they engulf the whole personality with clouds of deep
sadness and strange sensations. It is important to note that they do not necessarily
occur in any specific order or expected fashion (cf. Clayton, 1998; Burnell & Bur-
nell, 1989; Lindemann, 1944; Osterweis, Solomon, & Green, 1984; Rando, 1993;
Worden, 1991, 1996). The most common reactions are: sense of shock and disbe-
lief; numbness (especially early in grieving which later turns into intense feelings of
separation); substantial sadness; irritation and anger; guilt and self reproach; vari-
ous symptoms of anxiety, including shortness of breath, hollowness in the stomach,
and tightness in the throat; all sorts of fears and apprehensions (possibly developing
into full panic attacks or phobias); bodily sensations and muscle tensions; physical
aches and pains; marked loneliness and helplessness; intense yearning; crying,
tearfulness, and sobbing; sorrowfulness; general distress and confusion; fatigue,
exhaustion, and vegetative symptoms; regressive tendencies (for both children and
adults); blaming and complaining (at times showing hostility); deep frustration; rest-
lessness; sleep and appetite disturbances; mental preoccupation, brooding, and
rumination; sensing the presence of the lost object or deceased person (seeing,
hearing, smelling, etc.); disturbing dreams; searching behaviors; clinging to familiar
objects and reminders of the lost, or completely avoiding all reminders; social with-
drawal and isolation; break of communication with others, especially early in mourn-
ing (the bereaved often refuses the comfort offered by others); preoccupation with
the images of the deceased person or lost object; changes of the usual patterns of
conduct and behavior; and at times, sense of relief, especially following a long,
painful, or terminal illness.
These reactions may occur in or out of sequence, mixed or combined, separate
or together. Some of them are short and intermittent in nature while others persist
for a long period of time. Typically, what makes a loss especially devastating is its
magnitude, finality, and irreversibility. If what has been lost was originally founda-
tional and essential to the livelihood and psychological stability of the survivor,
and if the loss is totally unredeemable or irreplaceable, then the bereavement pro-
312
cess will most likely be intense and prolonged, with potential clinical implications
in the future.
Areas of Human Functioning Affected by Loss
Losses can profoundly affect many areas of the human functioning and impact
the bereaved and on different levels (cf. Abi-Hashem, 1992; Burnell & Burnell,
1989; Clayton, 1998; Clayton, Desmarais, & Winokur, 1968; Elliott & Eisdorfer,
1982; Kopelman, 1994; Nolen-Hoeksema & Larson, 1999; Osterweis, Solomon, &
Green, 1984; Rabkin & Streuning, 1976; Rando, 1993; Rogers & Reich, 1988;
Worden, 1991, 1996; Zisook, 1994). What is true on a personal level is also true on
a familial, group, and even communal level. Following a significant loss, or a series
of multiple losses, bereaved people are most likely to experience troubles in one or
more areas of their psychosocial functioning. Commonly, bereaved people repeat
statements like these: “Soon after I experienced that major loss in my life, I felt like
I was not the same person anymore,” “My life has been completely shattered,” “My
mind is constantly in a fog,” “Since the death of my spouse I have been sick all the
time,” “It is awkward for me to be alone or to be with other people,” “I find myself
constantly apprehensive and in fear,” “I am angry at the unfairness of life,” “We
have been fighting in our family and attacking each other … that’s something new
… we’ve never had so much tension and conflict in our family,” “I am surprised how
much I have changed … I have not been myself since the loss,” “I have never felt
such heaviness and deep sadness … it seems there is no end to the pain.”
Disturbances usually vary in nature, intensity, frequency, and duration. Some of
the following domains may be affected more than others. As time progresses, the
impact of loss shifts and the internal experience of grief changes as mourning
takes different shapes, forms, and venues: On the emotional-affective level, symp-
toms of anxiety and depression are usually present. It is common for bereaved
people to frequently experience fluctuations of mood, deep anguish, intense loneli-
ness, feelings of guilt and anger, waves of sadness, high irritation, crying spells,
multiple fears, disturbing dreams, helplessness, and being constantly drained.
On the mental-intellectual level, there will usually be occasional confusion, some
disorientation, poor concentration, states of mental fog, periods of spacing out,
poor school or job performance, doubts and bewilderment, loss of intellectual
sharpness, mental preoccupation with the lost, seeing visions of the deceased,
and “feeling like going crazy.” On the physical-biological level, there are often
changes in several health-related habits and physiological functioning. The
bereaved is most likely to develop new aches and pains and certain somatic distur-
bances which did not exist before the loss (e.g., high blood pressure, diabetes,
severe headaches, ulcers, joints or respiratory problems, etc.).
On the behavioral-habitual level, following a major loss many bereaved individuals
often engage in unhealthy and compromising behaviors because, to them, life stops
having the same meaning as it once did prior to the loss. Apparently, they resign to a
point where they feel they do not care about the same values anymore. They tend to
rapidly develop unhealthy habits and practice destructive behaviors like excessive
drinking, eating, working, smoking, or playing. They may start gambling, using drugs,
or engage in any activity that seems to soothe their pain or help them cope with the
harsh reality of loss. Some bereaved people temporarily lose the desire for any pro-
ductive work and tend to stop their normal routine and regular life activities.
On the social-interpersonal level, there may be disruption of meaningful relation-
313
ships, break of long term alliances, increase in marital conflicts and separations,
and even divorce. On the other hand, some bereaved tend to become overdepen-
dent on or enmeshed with each other to a certain degree. They will cling to the
remaining survivor(s) for comfort and emotional support hoping to fill in the major
void created by the loss; like a child clinging to the mother, father, grandparent, or
sibling, and a parent clinging to the youngest child, as often happens. At times,
children try to protect the surviving parent or other grieving family members by
stepping up and assuming major responsibilities around the household.
On the spiritual-existential level, there will often be serious doubts, crises of faith,
and vacillations between hopefulness and hopelessness. Extreme reactions are
common, like the tendency to overspiritualizing and activating one’s spiritual faith
versus underspiritualizing and distancing oneself from the spiritual life, religious
activities, and the community of faith. It is very common for the bereaved to go
through phases of blaming oneself and other family members or feeling very angry
toward society, life, and God in general.
The majority of these signs, changes, or symptoms are part of normal grieving
patterns. However, grief can remain unresolved, unfinished, delayed, or masked for
an extremely long period of time (cf. Worden, 1991). When the disturbances
become chronic or increase in time, then the bereaved may develop serious psy-
chological conditions and will qualify for a psychiatric diagnosis, like major clinical
depression, psychosomatic illnesses, or anxiety and panic disorders. In this case,
bereavement is referred to as complicated or pathological bereavement.
What Determines the Severity of Responses?
There are a number of factors that determine the severity of grief reactions.
These factors basically determine the nature and intensity of bereavement and
eventually the outcome of the whole mourning process (cf. Abi-Hashem, 1992;
Burnell & Burnell, 1989; Coleman & Coleman, 1985; Nolen-Hoeksema & Larson,
1999; Osterweis, Solomon, & Green, 1984; Rando, 1993; Worden, 1991, 1996).
The following are among the most prominent factors: (a) the timing and magni-
tude of loss, (b) any pre-existing psychological conditions of the survivor(s), (c) the
circumstances of loss or death (sudden or expected), (d) the nature of relationship
with and the degree of attachment to the lost object or deceased person (the
stronger the attachment, the more intense the grief), (e) the experience of handling
previous losses (successful or still unresolved), (f) the availability of a meaningful
support system before, during, and after the loss (lack of support and emotional
isolation can be very harmful), (g) the emotional stability and personality traits of
the survivor(s) (emotional instability and characteriological predisposition would
certainly result in greater risks for psychological disturbances and physical morbidi-
ty), (h) the socioeconomic status of the grieving individual, family, or group
(whether they have enough means to care for themselves or financially survive
after the loss or death in their family), (i) the turn of events after the loss, (j) the
existential hope and spiritual faith of the survivors (the more active and mature is
the faith, the higher is the resiliency, and the better is the outcome), and finally, (k)
the cultural background, personal heritage, and set of traditions, norms, and cus-
toms of the bereaved (those certainly shape and regulate the mourning process).
Most people in Eastern and African societies, in developing countries, and in
less fortunate communities around the world have a more natural tendency to
accept hardships, tolerate pain, and accommodate to losses. To them, suffering is
314
a vital part of life. Some even have learned to expect pain and manage to live with
adversities much better than most Western people who live in more affluent, pre-
dictable, and comfortable societies. Similarly, people’s view of death is shaped by
their socio-cultural and religious-philosophical background. To some, death is an
intruder, a stranger, and an enemy of life that must be fought, reduced, and con-
quered at any price. To others, death is an integral part of life. They have devel-
oped an intrinsic and existential ability to reconcile dying with living, and therefore,
to them death gives meaning to life (Abi-Hashem, 1999d, 1999e).
Traumatic Grief
The term traumatic grief has been recently emerging in the literature. However,
its concept and phenomenon are as old as the human suffering and the experi-
ence of tragedy and loss itself. Several researchers from Europe, South Africa,
Australia, and the United States have looked into the connection between trauma
and grief and have studied the impact of bereavement in the context of trauma
(Figley, Bride, & Mazza, 1997; Hart, 1994; Prigerson, Shear, Friank, & Beery, 1997;
Raphael, 1997; Simpson, 1997; Stroebe, Schut, & Stroebe, 1998; Trolley, 1993-
94). They found that there are many patterns of resemblance and a clear overlap
between the two phenomena. Apparently, the symptoms of traumatic stress and
bereavement responses intensify when both are present as they can significantly
impair the mourning process (Nader, 1997).
In addition, there are current attempts by a group of theorists to make the syn-
drome of traumatic grief a unique and separate psychological category (Horowitz
et al., 1997; Prigerson et al., 1999; Prigerson & Jacobs, in press). They have been
trying to conceptualize traumatic grief as a special clinical entity and diagnostic cri-
teria. Virtually, there is considerable merit to this attempt since too many cases of
unresolved grief and complicated bereavement go unnoticed among caregivers
and remain misdiagnosed among therapists and healthcare professionals (cf. Abi-
Hashem, 1998a, 1999a; Lindemann, 1944; Rando, 1993; Worden, 1991; Zisook &
Lyons, 1989).
This syndrome or new diagnosis is designed to highlight the interplay between
trauma and grief, that is, the connection between suffering a major loss or experi-
encing a death of a loved one during a traumatic event and the subsequent psy-
chological distress and psychiatric disorder resulting from that experience.
Evidently, when a significant loss occurs as the result of a severe trauma, violence,
tragedy, accident, or natural disaster, the survivor’s reaction tends to be an amal-
gam of symptoms. Depending on the situation, the pre-existing conditions, and the
nature of the traumatic event, the cluster of symptoms experienced by the trauma-
tized bereaved includes usually elements of post traumatic stress disorder, clinical
depression, acute stress disorder, generalized anxiety, panic disorder, and compli-
cated bereavement reactions.
During any traumatic event, the survivors naturally experience a set of psycho-
logical responses and become highly vulnerable to serious symptomatology. Trau-
ma usually involves an actual or perceived threat of death, severe injuries, and a
serious threat to the safety, identity, and integrity of the individual or group of peo-
ple. Trauma could also result in intense fears, marked helplessness, and a persis-
tent sense of horror (Abi-Hashem, 1999c; Meichenbaum, 1994). However, when
the trauma is coupled with a major loss (personal or communal; see also Williams,
Zinner, & Ellis, 1999) or a horrifying and violent death of a loved one (Exline, Dorri-
315
ty, & Wortman, 1996; Rando, 1996), the grieving individual, who may be already
highly traumatized, becomes at greater risk of developing potentially complicated
bereavement and pathological mourning (Figley, Bride, & Mazza, 1997; Raphael &
Martinek, 1997). Furthermore, recent investigators have drawn useful comparison
and contrast between grief reactions and trauma responses for both children and
adults (Nader, 1997; Pynoos & Nader, 1990; Raphael & Martinek, 1997). Treat-
ment and interventions must target the twin goals of trauma mastery and grief res-
olution (Meichenbaum, 1994; Rando, 1996). Stroebe et al. (1998) suggested “the
dual process model of coping” where therapy approaches address both the stress
from the traumatic event and the manifestations of grief from the major loss.
Horowitz et al. (1997) have introduced the idea of Complicated Grief Disorder
while Prigerson et al. (1999) have introduced the idea of Traumatic Grief. Others,
like Sable (1992), have referred to Disordered Mourning and discussed ways that
certain psychological theories and therapies can apply to disordered mourning.
According to Jacobs (1999), traumatic grief is a disorder that occurs after a devas-
tating death of a significant other. A wide range of disabling symptoms is likely to
be present. Major features from different disorders would be overlapping in this
case. The survivor’s condition will be marked by (a) a traumatic reaction, and (b) a
separation reaction. While separation anxiety disorder is well documented among
children, it is not so among adults, especially as related to grief. Ollendick, Lease,
and Cooper (1993) and Manicavasagar and Silove (1997) have tried to clinically
detect and document such cases among adults. It would seem only reasonable to
conclude that, following a devastating loss, bereaved adults would also display fea-
tures of separation anxiety. Jacobs (1999) noted that, “Most commonly and con-
spicuously, adults experience separation anxiety after the death of an intimate.
Separation anxiety occasioned by a death is made up of two components: the
pang of grief and searching behavior” (p. 5). The acutely bereaved person usually
experiences frequent “waves of episodic distress” (p. 6). Lindemann (1944) origi-
nally described these waves as pangs of grief. They are mostly characterized by
excessive mental preoccupation and “intense yearning” (p. 6) for the lost object or
deceased person.
With this background, Jacobs (1999) concluded “it is conceivable that adult Sep-
aration Anxiety Disorder is a nosologic concept that will develop more over the next
few years. It is also conceivable that Traumatic Grief will ultimately be viewed as an
adult form of Separation Anxiety Disorder and the name of the disorder might be
changed accordingly” (p. 23).
Morbidity and Mortality of Grief
Can grief cause a serious illness? Can someone die from a broken heart? Origi-
nally, it has been established that severe and prolonged stress has negative
impacts on the physical and mental health of people (Strean, 1996). In a provoca-
tive article, Engel (1961) challenged the healthcare profession by asking, is grief a
disease? Engel argued that the loss of a loved one can result in a psychological
wound similar to the physical injury or physiological illness, which mainly consti-
tutes a departure from a state of health. Due to mourning, the full function can be
impaired. According to Engel, the terms health and pathology can be equally
applied to the bereavement process. As physical recovery and healing are neces-
sary following a bodily injury or physiobiological disease, so recovery and healing
are necessary following a major loss. Adequate time is needed for mourning in
316
order to allow the bereaved to gradually return to a homeostatic balance and a

state of equilibrium. Otherwise, functioning will remain impaired and healing inade-
quate (Engel, 1961).
There are a number of researchers who referred to the impact of grief on morbid-
ity—being subject to disease, and mortality—being subject to death (Clayton,
1998; Kaprio, Koshenvuo, & Rita, 1987; Kopelman, 1994; Osterweis, Solomon, &
Green, 1984; Rando, 1993; Rogers & Reich, 1988; Worden, 1991, 1996; Zisook,
1994). Naturally, grief can exacerbate not only the physical but also the psychologi-
cal morbidity. However, regarding the question of mortality, the findings are incon-
sistent. Rogers and Reich (1988) explored the early versus late effects of
bereavement on the mortality of survivors. The authors argued that when grief
exceeds a critical threshold it may become pathogenic. Stroebe et al. (1981-82)
examined the connection between bereavement and mortality in West Germany
and found it inconclusive. Stroebe et al. recommended further longitudinal studies
to clarify any positive relationship between the two. In a later work, Stroebe (1994)
explored again this relationship in order to find who among the bereaved are most
vulnerable to such consequences. Stroebe found, among other factors, what distin-
guished survivors from non-survivors was lack of contact with others during
bereavement, intense loneliness and social isolation, lack of support and little inte-
gration with others, and no instances of remarriage. Thus, the primary effects of
mourning and the secondary effects of related living stressors have basically
underlied the bereavement-mortality relationship which, in other words, is the bro-
ken heart phenomenon (Stroebe, 1994).
Certain studies suggested that young adults who suffered a spousal loss had
more physical complaints and took more drugs for symptom relief than their non-
bereaved married counterparts (Clayton, 1974). While most widow(er)s suffer from
emotional distress and depressive symptoms during the first year of bereavement,
those bereaved at a younger age apparently have more somatic complaints and
physical distress (Bowlby, 1980; Clayton, 1979). When intense grieving over the
major loss of a spouse, for example, is coupled with social alienation and poor liv-
ing conditions, it is not unusual for the bereaved, especially the elderly, to die fol-
lowing such loss. Clayton (1979) found that the mortality rate among women did
not increase during the first year of bereavement following spousal loss. However,
for men, Clayton suggested that there may have been an increase in mortality,
especially for older men, even during the first six months of bereavement.
While there is little disagreement over the possible negative consequences of
complicated bereavement and pathological grief, Kopelman (1994) raised the
question whether normal grief should be considered bad or a disease. Kopelman
argued that there is more reason to believe that normal grief, despite its distress
and pain, is rather adaptive, good, and healthy for it is eventually associated with
empathy, creativity, and the capacity to overcome. Although basic grief experience,
as a normal reaction to life’s developmental changes, detachments, and losses, is
not an illness or disorder by itself (Exline, Dorrity, & Wortman, 1996; Kopelman,
1994; Rando, 1993; Worden, 1991), long term, masked, delayed, unresolved, or
exaggerated grief over serious or multiple losses can create a disordered condition
on any or all levels of functioning, especially for those individuals who are already
vulnerable and at risk (Burnell & Burnell, 1989; Lindemann, 1944; Rando, 1993;
Worden, 1991; Zisook, 1994; Zisook & Lyons, 1989). Many investigators have
focused on normal as well as pathological grief reactions and have tried to com-
317
pare the outcomes of both (cf. Clayton et al., 1968; Clayton, 1972; Osterweis,
Solomon, & Green, 1984; Parkes & Weiss, 1983; Rando, 1993; Worden, 1991,
1996).
Evidently, increased isolation and lack of meaningful communications and per-
sonal connections among the grieving population are major contributors to the
morbidity and mortality of bereavement (Lynch, 1990; Stroebe, 1994). In extreme
cases like life-imprisonment or permanent exile, the psychological conditions
become rather amplified and exaggerated. Ancient and modern history is full of
examples of individuals who died in exile. They were denied access to their land or
heritage, were removed from their role or occupation, were forced into complete
separation and detachment from their loved ones, were not allowed to practice
their cherished gifts, talents, or passions, and were utterly helpless in the face of
injustice and oppression toward their own people. Consequently, they died in
severe anguish and brokenness of heart. According to Hart (1994), in exile the
mourning process is usually disturbed and the impact of bereavement is intensified
because both the internal and external realities of the bereaved are heavily disrupt-
ed. An example is found in the historical records of the great American Indians
concerning Chief Joseph who, along with some of his people, was sent to exile. “In
1901, [Chief] Joseph told an interviewer: ‘My home is in the Wallowa Valley, and I
want to go back there to live. My father and mother are buried there. If the govern-
ment would only give me a small piece of land for my people … that is all I would
ask’” (Great Chiefs, 1975, p. 183). However, his repeated pleas were denied, and
on September 21, 1904, “while he sat by the fire in his tibi, he suddenly pitched for-
ward on his face. The reservation doctor commented, ‘Joseph died of a broken
heart’ ” (p. 183).
Steps Toward Grief Resolution
Many bereavement theorists have conceptualized the progression and resolution
of grieving in terms of stages, phases, tasks, or mediators (cf. Burnell & Burnell,
1989; Osterweis, Solomon, & Green, 1984; Rando, 1993, 1996; Worden, 1991,
1996). Each of these terms has its own usefulness and strength yet also its own
limitations and level of ambiguity. No single term could fully reveal or precisely
reflect the depth of the grieving experience. Maybe it is useful to add to this reper-
toire of terms two more, steps and procedures.
Stage may imply a fixed or concrete period of time, and people tend to fit the
bereaved into one stage or another. Bereaved people tend to label themselves in
terms of stages as well, and box their own experience into one or another stage
(e.g., stages of development). Phase may imply a period that is unconnected to
another phase of life and may pass for good without return. Task may give the
impression that additional work needs to be done. The grieving person is likely to
perceive the concept as a new burden with a sense of duty and responsibility.
Already bereaved people are loaded with heavy burdens and are emotionally
drained, so they may dread facing grief recovery as additional painful work they
must do.
Steps and Procedures, as suggested here, not in a mechanical sense (as in a
list or numerical order) but in a phenomenological sense, are similar to the concept
of Mediators used by Worden (1996). Steps and procedures could fill in some of
the gaps and basically complement the other concepts. The bereaved can take
necessary steps toward healing, alone or guided, at his or her own pace and
318
according to his or her own style. He or she can follow certain procedures (or psy-
chosocial protocols) in order to face the pain, release the internal agonies, and
reach some resolution and inner peace. The steps can be repeated as needed,
and the procedures can be done over and over as well. It is like walking in the val-
ley of the shadow of death, through the desert of grief, loss, and tears, and into a
fruitful field. So, any term or concept should reflect grief as a movement and as a
journey. This is why it is recommended to conduct grief therapy in intense and
extended sessions. Once the floodgates are open, the mourning fountains are
flowing, and the grief waves are rolling, it is more therapeutic and productive for the
bereaved to “ride the waves” and “go with the flow” rather than to fight or swim
against them. Afterwards, most bereaved people find themselves landing safely on
new shores, which eventually gives them a sense of relief, resolution, and renewal
(almost as a fresh beginning).
Those terms are broad concepts, not rigid in nature but flexible and fluid like the
nature of grief itself. They simply are guidelines, principles, or blueprints. Thus, it is
essential to understand and remember the unsystematic and multidimensional
character of grief. Regardless of the terminology used, grief should not be concep-
tualized as a linear process but rather as a phenomenological experience (cf.
Osterweis, Solomon, & Green, 1984). For grief cannot adequately fit into any previ-
ously shaped mode, concrete frame, or rigid period of time.
There have been constant attempts to refine the existing interventions and treat-
ment approaches to grief, and to find new effective ways to help the bereaved cope
and heal well. Although there are commonalties of bereavement responses and
universalities in mourning patterns, a review of the current treatment modalities
would suggest that perhaps the best intervention is the one specifically designed
for the needs and tailored for the particular situation of the grieving individual or
family (cf. Exline, Dorrity, & Wortman, 1996). “The typical treatment of grief often
includes such elements as a psychoeducational component designed to clarify the
nature of grief, opportunities for emotional expression, exposure to the death, and
relaxation strategies” (Exline et al., 1996, p. 15). Generally, there is some consen-
sus that mourning has the greatest chance to be resolved if the following therapeu-
tic factors are present: “a safe haven that facilitates the expression of grief;
reassurance that feelings and responses are normal; sufficient time for grieving;
monitoring the risk of suicide and coping failure; and appropriate medical attention
and medication when symptoms warrant this” (p. 15).
A successful grief counseling process consists of the following steps or proce-
dures (cf. Abi-Hashem, 1999a; Burnell & Burnell, 1989; Rando, 1993; Roach &
Nieto, 1997; Worden, 1991, 1996; Zonnebelt-Smeenge & De Vries, 1998):
A. Helping the bereaved to admit that the loss has taken place and it is final.
For many survivors, that is a difficult place to reach. Accepting the finality of loss is
a crucial part in grief recovery. This will reverse the defense strategy of denial.
Most survivors accept the facts of loss merely on an intellectual level. Resistance
to accept any drastic changes or to accommodate any sudden losses is a natural
intrapsychic response that usually stems from the core of the human self. It is an
act of refusal to any change of normality and an objection to any loss of familiarity
in life, especially if these normalities and familiarities have been long established
and were consistently meeting the deep emotional needs of the survivor. Through
helping bereaved people face the reality of their altered lives or shattered worlds,
they gradually begin to lower their resistance and soften their refusal as they
319
embrace life slowly again, this time without the lost object or loved person.
B. Helping the bereaved to experience and express all range of emotions,
deep feelings, and private thoughts, including the pleasant and the unpleas-
ant ones, as related to the loss. This will eventually stop the coping mechanism
of suppression. Experiential activities and exercises, like the empty chair technique
(which can be powerful and needs adequate training to conduct), where the thera-
pist carefully suggests a visit or introduces a dialogue with the lost object or
deceased person in order to facilitate expression and establish long-desired emo-
tional contact, realizing that the image or representation of the lost is still carried
within the survivor. These exercises may include revisiting important places and
events, reliving special moments or scenes, recalling warm or sad memories, and
reflecting on the history of the relationship and its emotional investment. Generally,
it is assumed that the nature of relationship was positive and the major emotional
expression of grief is the feeling of sorrow and sadness. However, in many cases,
the relationship with the lost was ambivalent or conflictual and, consequently, the
survivors struggle with a mixture a feelings. They vacillate between anger, relief,
guilt, and sadness. Their sorrow is usually coupled with resentment. They grieve
also “what they have endured” and “what could have been” rather than “what they
actually had” (as in the case of abandonment, mistreatment, or abuse). Assigning
homework to bereaved people is an important part of their grief recovery as a tan-
gible way of mourning, e.g., reading, writing, drawing (especially for children), play-
ing musical instruments, physical exercise, going through mourning rituals,
establishing memorials (like a photo album), keeping a journal, visiting special sites
(grave, school, childhood home), and, at some point along the way, sponsoring
another grieving person.
C. Helping the bereaved to release the lost object or deceased person by let-
ting go, setting free, and saying good-bye. This will undo the dynamic of cling-
ing. First, by focusing on what the bereaved misses about the lost object or
deceased person, and by helping the bereaved treasure fond memories and good
moments from their history together. Then, grief counseling should help the
bereaved face the other side of reality by gradually focusing on what he or she does
not actually miss about the lost person, function, or object. With the encouragement
and probing of the therapist, this approach will make the bereaved confront the full
reality of the loss, correct any exaggerated attitudes, and clear any distorted per-
spectives he or she has created. Certainly, this will help de-idealize the loss and
reconcile opposite emotional polarities, especially if the pe-existing relationship with
the lost has been conflictual, painful, or tense. It is usually a turning point in counsel-
ing when the survivor realizes that the lost object or person was not perfect or ideal
and, in fact, that there are aspects about the lost that the bereaved did not really like
or appreciate then and, consequently, does not miss right now. Preparing the griev-
ing clients to say “good-bye for now” after each session is an important exercise
toward the final goal of saying “good-bye for good” when they are almost ready.
D. Helping the bereaved to reinvest the mental and emotional energy con-
sumed earlier in unsuccessful resolution of grief in new relationships,
endeavors, people, and projects. Encouraging bereaved clients to branch out,
be involved in the community, develop new interests, make new friends, practice
old talents or forsaken skills, engage in productive activities or public service, focus
on their dreams, and set new goals and aspirations. This will hopefully help them
320
break the condition of stagnation and transform their pain into purpose and their
mourning into mission.
With time, and by repeatedly walking through these steps and following these
recovery principles, the intensity and frequency of grief begin to decrease, and the
bereaved’s sense of inner congruency, peace of mind, and emotional cohesive-
ness begin to increase. Grief recovery has been described as finding the way back
to self and as reconstructing one’s own world. One sign that healing and resolution
are taking place is when the grieving person becomes able to see reminders of the
deceased, talk about intimate aspects and memories of the lost, and go visit cer-
tain places and sites that have special meaning, without being completely dis-
turbed or overwhelmed by a flood of grief emotions.
The goal of grief counseling, whether it is taking place in a clinic, church, or
school, is to help the bereaved—child, adolescent, or adult—to accommodate the
loss, complete the mourning process, receive adequate nurture and support, make
necessary adjustments, and return to a certain degree of normal functioning.
Eventually, the goal is not to sever the connection between the survivors and the
lost, neither to help them totally forget, detach, or distance themselves from what
they have lost. Rather, the goal is to help the bereaved transform, reshape,
reframe, and reinterpret the former relationship by giving the loss a new value,
place, and meaning. In addition, the purpose of grief counseling is not to bring the
bereaved to a griefless state. That is not actually possible. Grieflessness is not a
human condition. Therefore, it is essential to allow the bereaved to move through
the mourning process at their own pace and in their own style. That is true for indi-
viduals, families, and groups alike. Special attention and consideration should be
given when the helper and the bereaved largely differ in their sociocultural back-
ground, value system, and spiritual beliefs.
Is grieving necessary? The answer is definitely yes. For as long as there are deep
and meaningful attachments in life, and as long as there are losses thereafter, griev-
ing is natural and necessary. How long does the mourning last? Will bereavement
be smooth or interrupted? When will grieving actually be finished? There is no easy
or ready answer to these questions. It all depends on the individual differences and
personal style, on the severity of loss, on the presence and influence of any compli-
cating factors, and on the circumstances surrounding the survivors (cf. Burnell &
Burnell, 1989; Sanders, 1989; Rando, 1993; Worden, 1991).
Loss has both a personal and a social dimension. According to Larsen (1999),
grief is a social event that cannot be resolved in isolation. Unresolved grief can
cause serious emotional, mental, behavioral, physical, spiritual, and social disrup-
tions. Often bereaved individuals become highly sensitized to any potential loss,
whether real or imaginary, in their immediate or distant future. Unless they receive
in-depth therapy for their interrupted mourning, they probably will continue to live
and function in a compartmentalized world. “Therefore, missing grief precipitators
will cause counseling to merely focus on other related matters. Such interventions,
including psychiatric medications, succeed temporarily in alleviating the severe
bereavement symptoms only to discover they they will reoccur again” (Abi-
Hashem, 1999a, p. 523).
Preparedness in facing grief and bereavement is important. However, it is not
possible to be totally prepared to face a significant loss or a sudden death of a
loved one. Some people have suffered multiple losses since the early years of their
childhood. Others were spared major losses until mid-or-late adulthood. Eventually,
321
everyone will become a bereaved person at some point along their journey in life.
Even after a good degree of closure and resolution, the bereaved person will con-
tinue to carry a certain residual or shadow of grief which emerges every now and
then, especially around anniversaries, holidays, birthdays, and some unique or
awkward reminders. However, the intensity and duration of these recurring grief
moments are rather smaller and shorter compared to the original grief reactions or
basic symptoms of an unfinished grief or chronic bereavement.
Spiritual and Cultural Aspects of Mourning
The spiritual aspects of grief are broad, rich, and profound. The existential strug-
gles for some bereaved people during their mourning season can be very intense.
However, spiritual crises in such grieving times are natural and common. People’s
internal and external reactions to a major loss (or series of losses) depend largely
on their religious background, spiritual faith, cultural tradition, set of ideals and
beliefs, social norms and expectations, family heritage, and personal worldview (cf.
Kutscher & Kutscher, 1972). Their concept of God and the supernatural, their view
of life and death, their interpretation of good and evil, and their tolerance of suffer-
ing and pain all play a major role in how they initially react and subsequently pro-
ceed with their grief and bereavement. Eventually, several of these factors end up
either facilitating or complicating the mourning process.
Some bereaved people, depending on their religious tradition, cultural back-
ground, and their particular season of life, readily accept the loss and accommo-
date themselves to living without the lost object or person. They consider the loss
as their fate or divine destiny (like certain Christian, Muslim, and Druze branches).
Their life is mostly guided by key philosophical concepts and spiritual premises
which enable them to navigate through the major dilemmas and losses of life. For
example, in the Middle East there are common phrases people use in time of loss,
such as: “As God wills” (Ma Sha’a Allah), or “What can we do? That’s our fate”
(Kadar). About the deceased they may say, “That’s his destiny” (Maaseer), or
“That’s her portion of life” (Naseeb). Other statements reflect more of a determinis-
tic view: “That is what’s written for him or her” (Maktoob). The concept of fate and
destiny (Al-Kadaa wal-Kadar) is especially highlighted in the theology of both the
Druze and the Muslims. It is not merely a passive faith or an act of mental resigna-
tion (which it can be at times); rather, it appears to be a complete submission to
the will and desire of Allah (God) who is in control of all aspects of this life, all gains
and losses, all births and deaths, and, ultimately, all aspects of the other life (here
on earth as in reincarnation—Druze belief) and the afterlife (as in eternal life for the
immortal soul—Christian belief).
For many people, a major loss can cause a serious mental struggle and a spiri-
tual crisis which eventually could result in resentment and alienation from the faith,
God, and the spiritual community. They go through an existential dilemma that
makes them question everything about the sovereignty of God, the meaning of life,
and their own role, identity, and personal value. Undoubtedly, all bereaved people
do experience a certain degree of faith crisis regardless of their spiritual history,
psychological strength, or emotional maturity. Under such grieving circumstances,
it is rather normal to doubt, wonder, and question one’s own beliefs, purpose, and
meaning of life. It is also normal to complain and repeatedly ask, silently or loudly:
“Why?” “How come?” “Why us?” (or “Why me?”), “Why now?” and “What is going
to happen next?” It is all part of the disbelief, confusion, and disorientation, and,
322
moreover, of the resistance and ambivalence bereaved people experience as they

struggle to accept what happened and how it happened. At some point, the
bereaved may need help in reframing their reality, reconstructing their philosophical
view, and reaffirming their faith. These foundations are all seriously challenged and
perhaps disturbed by a major loss or unexpected death. According to Grollman
(1996), reconstructing one’s faith in the face of a sudden loss is not simply the task
of clergy or spiritual advisors but, rather, is a shared task of all types of caregivers.
The psychological issues and struggles just discussed are existential in nature,
and, furthermore, most existential issues are spiritual in nature (cf. Benner, 1999).
Fundamentally, these are interwoven together. Therefore, it is quite reasonable to
conclude that what is psychological is ultimately spiritual in core and nature. Care-
givers and psychological professionals have to consider these spiritual matters
seriously, and adequately address them in a comprehensive and global way,
because the human nature is a unified nature and human beings are inherently
total beings. Unfortunately, due to the increase in the fields of study and the
branching out of countless academic disciplines, there is a strong tendency to
divide and fragment the body of knowledge, and therefore compartmentalize the
human nature and function (Abi-Hashem, 1998b).
Across cultures, people differ in their understanding of death and in their coping
with severe losses. Even within one particular culture or society, there are varia-
tions in coping styles depending on the customs of that local group or subculture.
Therefore, trying to help a bereaved individual or family across cultural boundaries
requires that the therapist or caregiver set aside his or her own personal assump-
tions and presuppositions. What is unhealthy and abnormal in one culture may be
quite healthy and normal in another (cf. Abi-Hashem, 1999e). For example, using
categories and diagnoses based on North American standards to classify mental
health and illnesses, including responses to grief and bereavement may, in a differ-
ent cultural setting, or in other parts of the world, be inappropriate, superficial, and
completely irrelevant (cf. Rosenblatt, 1994). Although there are certain commonal-
ties and universalities to grief, each culture approaches personal and social
bereavement differently. That includes “defining the relationship between the dead
and the living, describing the nature of life after death, and enabling the social
reconstruction of the ruptured relationships within family and community” (Shapiro,
1994, p. 220). Therapists and healthcare professionals are naturally immersed in
their own lifestyle, values, sociocultural setting, and worldview from which they try
to analyze the bereavement experiences of others. However, “the field of cultural
anthropology has an extensive literature that challenges our own culturally embed-
ded point of view of the grief experience. The sociological and cross-cultural per-
spective on bereavement can give those of us who work with families a much
needed widening of our cultural-bound assumptions about bereavement” (p. 222).
In fact, some authors have argued that the medical and mental health industries, in
themselves, represent certain subcultures with particular norms and expectations
about mourning that bereaved people from different backgrounds usually
encounter and struggle with when seeking help from established clinics or institu-
tions (Stephenson, 1985).
Cultural, religious, and ethnic factors greatly shape the bereavement responses,
and regulate the mourning patterns of people (Kutscher & Kutscher, 1972; Oster-
weis, Solomon, & Green, 1984). Differences in beliefs, values, and practices among
people groups continue to exist in spite of recent globalization and social integration.
323
Even within what appears to be a homogeneous society, there are still cultural differ-
ences and diversities which are naturally manifested in a variety of bereavement
responses and a wide range of mourning styles (cf. McGoldrick, 1989; McGoldrick
et al., 1991). Furthermore, Murray (1994) observed,
General areas in which differences exist include variation in (a)
the extent of ritual (e.g., the importance of attending funerals,
types of acceptable emotional displays, and the degree to which
these affairs should be costly); (b) the need to see the dying
[family member or] relative; (c) openness and type of display of
emotion; (d) emphasis on verbal expression of feelings and pub-
lic versus private (namely, solitary or family) expression of grief;
(e) appropriate length of mourning; (f) the [social and spiritual]
importance of anniversary events; (g) roles of men and women;
(h) role of the extended family; (i) beliefs about what happens
after death, particularly related to the ideas of suffering, fate,
and destiny; (j) whether certain deaths are stigmatized.
(McGoldrick et al., 1991, p. 182)
The type of socio-religious rituals depends mostly on the degree of cultural
immersion and spiritual commitment of the bereaved and on the communal identity
(belongingness) and social expectations where the loss occurs. For example, in
many Near Eastern countries, grieving women wear black fully and confine them-
selves to the home for weeks or even months. Some women continue to wear
black or dark color clothes in public for years (or for life, depending on the age and
social status of the deceased). Men refrain from working and social entertainment
and children stop attending school for the whole period of mourning. The house
would always be open for people to come and present their consolation. Some
close neighbors, friends, and relatives stay with the bereaved family all the time as
they try to help, support, and share the sorrow.
In biblical times, all members of the community would join in grieving and open
mourning. Weeping aloud (wailing), sitting on the ground, sprinkling dust or ashes
on the head, and tearing of one’s robes were some of the mourning gestures
expressed in public (cf. Genesis 23, 37, 50, & Job 2). Similar rituals are still prac-
ticed today in many traditional and intimate communities around the world. Evi-
dently, some Western and industrialized societies have lost that sense of freedom
and open expression of grief due to the strong emphasis on privacy, composure,
self-reliance, and individuality. Displaying sad emotions in public, has been discour-
aged and depreciated, especially among men. Unfortunately, this kind of psycho-
logical reservation and cultural inhibition have resulted in many cases of unfinished
grief and unresolved mourning.
In counseling and psychotherapy, and especially in the early phases of griev-
ing, it is important to avoid correcting the ideology and theology of the bereaved
person, or to engage in an intellectual-doctrinal debate about the nature of God
and the necessity of exercising true faith or hope (cf. Abi-Hashem, 1999b).
Instead, it is more therapeutic to dwell on the emotional tones of grieving, and
help the bereaved express all burning feelings, stirred emotions, flooded memo-
ries, deep thoughts, intense sadness and fears, and mental confusion, including
major doubts about God and anger toward the unfairness of life as related to the
devastating loss; all must take place in a safe, warm, and accepting (non-judg-
324
mental) environment. Later on, the bereaved individuals gradually begin to dis-
cover that God was not the direct cause of their pain or agony. Rather, God was
closely present with them and actually grieving with them during the whole event
of their terrible loss. In fact, as part of their healing, some survivors begin to look
back and reflect on how God was carrying them compassionately throughout the
grieving process. They realize that God is able to face their own loss; therefore,
they will begin to face it themselves as well. They eventually become able to
receive God’s comfort and utilize the available resources of their community of
faith (cf. Arbuckle, 1991). Grief appears to have a transcendent function and can
enhance the spiritual growth of bereaved people as it awakens them to the exis-
tential and spiritual essence of life (Chen, 1997). Many bereaved individuals
begin to reach out to other grieving friends in a marvelous way, and graciously
offer support, care, empathy, and comfort. Virtually, they will be able to identify
themselves with Christ’s mission, heart, healing presence, and the Sermon on
the Mount’s beatitude, “Blessed are those who mourn for they will be comforted”
(Matthew 5:4).
Grief counselors and ministers who work with bereaved individuals of all ages
and backgrounds find the experience quite rewarding, delicately tender, and
immensely rich. Such service is both a privilege and a responsibility. By helping
and ministering to the needs of the grieving, caregivers are actually touching the
very spiritual depths of people (Haugk, 1984) as if they are entering into a secret
garden or standing on holy ground. However, such work can also be consuming,
stressful, draining for all parties involved. According to Exline et al. (1996),
“There is a widespread agreement among clinicians and researchers alike that
the feelings evoked in therapists who work with the bereaved must be acknowl-
edged and processed” (p. 18). Counselors usually take a constant risk when
exposing themselves to the pain of others (Larsen, 1999). Therefore, caregivers
need to practice good self-care, remain in touch with each other for ongoing sup-
port, open communications, emotional expression, exchange of ideas, and con-
tinual learning (cf. Larson, 1993; McCall, 1999). Otherwise, the burden of
caregiving for the bereaved can, at times, deplete the counselors’ inner
resources and “lead to emotional numbing, demoralization, and ultimately,
burnout. The stress of such caregiving can also result in maladaptive attempts at
self-soothing” (Exline et al., 1996, p. 18) behaviors, unhealthy lifestyle, and
diminished effectiveness as people-helpers (see also Burness & Burnell, 1989;
Rando, 1993; Vachon, 1987; Worden, 1991). Thus, grief counselors need not
lose the capacity and joy of facilitating the resolution of mourning, watching the
cleansing effects of grief and, virtually, contributing to the emotional recovery,
restoration of inner peace, and personal growth of bereaved people.
References
Abi-Hashem, N. (1992). The reactions of children and adolescents to the death of a par-
ent. Unpublished doctoral dissertation, Biola University, California.
Abi-Hashem, N. (speaker). (1998a). Grief therapy for normal and complicated bereave-
ment. (Cassette Recording No. ITEC 980327A28). Chattanooga, TN: Christian Associa-
tion for Psychological Studies.
Abi-Hashem, N. (1998b). Returning to the fountains. American Psychologist, 53, pp. 63-
64.
Abi-Hashem, N. (1999a). Grief therapy. In D. G. Benner & P. C. Hill (Eds.), Baker ency-
clopedia of psychology and counseling (2nd ed., pp. 521-523). Grand Rapids, MI: Baker
325
Book House.
Abi-Hashem, N. (1999b). Loss of function. In D. G. Benner & P. C. Hill (Eds.). Baker
encyclopedia of psychology and counseling (2nd ed., p. 705). Grand Rapids, MI: Baker
Book House.
Abi-Hashem, N. (1999c). Trauma. In D. G. Benner & P. C. Hill (Eds.), Baker encyclope-
dia of psychology and counseling (2nd ed., pp. 1229-1230). Grand Rapids, MI: Baker
Book House.
Abi-Hashem, N. (1999d). Dying, pastoral care of. In D. G. Benner & P. C. Hill (Eds.),
Baker encyclopedia of psychology and counseling (2nd ed., pp. 373-375). Grand Rapids,
MI: Baker Book House.
Abi-Hashem, N. (1999e). Cross-cultural psychology. In D. G. Benner & P. C. Hill (Eds.),
Baker encyclopedia of psychology and counseling (2nd ed., pp. 294-298). Grand Rapids,
MI: Baker Book House.
Arbuckle, G. A. (1991). Change, grief, and renewal in the church: A spirituality for a
new era. Westminster, MD: Christian Classics.
Attig, T. (1996). How we grieve: Relearning the world. New York: Oxford University
Press.
Averill, J. R. (1968). Grief: Its nature and significance. Psychological Bulletin, 70,
721-748.
Benner, D. G. (1999). Care of souls: Revisioning Christian nurture and counsel. Grand
Rapids, MI: Baker Book House.
Birenbaum, L. K., Robinson, M. A., Phillips, D. S., Stewart, D. J., & McCown, D. E.
(1989). The response of children to the dying and death of a sibling. Omega: Journal of
Death and Dying, 20, 213-228.
Bowlby, J. (1977). The making and breaking of affectional bonds, Parts I & II. British
Journal of Psychiatry, 130, 201-210, 421-431.
Bowlby, J. (1980). Attachment and loss: Vol. III. Loss, sadness, and depression. New
York: Basic Books.
Bowlby, J. (1982). Attachment and loss: Retrospect and prospect. American Journal of
Orthopsychiatry 52, 664-678.
Burnell, G. M., & Burnell, A. L. (1989). Clinical management of bereavement: A hand-
book for healthcare professionals. New York: Human Sciences.
Chen, Li-chu, (1997). Grief as a transcendent function and teacher of spiritual growth.
Pastoral Psychology, 46, 79-84.
Clayton, P. J. (1972). The depression of widowhood. British Journal of Psychiatry, 120,
71-78.
Clayton, P. J. (1974). Mortality and morbidity in the first year of widowhood. Archives of
General Psychiatry, 30, 747-750.
Clayton, P. J. (1979). The sequelae and nonsequelae of conjugal bereavement. Psy-
chiatry, 136, 1530-1534.
Clayton, P. J. (1998). The model of stress: The bereavement reaction. In B. P. Dohren-
wend (Ed.), Adversity, stress, and psychopathology (pp. 96-110). New York: Oxford Uni-
versity Press.
Clayton, P. J., Desmarais, L., & Winokur, G. (1968). A study of normal bereavement.
American Journal of Psychiatry, 125, 168-178.
Coleman, F. W., & Coleman, W. S. (1985). Helping siblings and other peers cope with
dying. Issues in Comprehensive Pediatric Nursing, 8, 129-150.
Elliott, G. R., & Eisdorfer, C. (Eds.). (1982). Stress and human health: A study by the
Institute of Medicine, National Academy of Science. New York: Springer.
Engel, G. L. (1961). Is grief a disease? A challenge to the medical research. Psycho-
somatic Medicine, 23, 18-22.
Exline, J. J., Dorrity, K., & Wortman, C. B. (1996). Coping with bereavement: A research
review for clinicians. In Session: Psychotherapy in Practice, 2, 3-19.
Figley, C. R., Bride, B. E., & Mazza, N. (Eds.). (1997). Death and trauma: The trauma-
tology of grieving. Washington, DC: Taylor & Francis.
326
Freud, S. (1917). Mourning and melancholia. In J. Strachey (Ed. and Trans.), The stan-
dard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp. 237-
258). London: Hogarth. (Original work published 1961)
Grollman, E. A. (1996). Spiritual support after sudden loss. In K. J. Doka (Ed.), Living
with grief after sudden loss: Suicide, homicide, accident, heart attack, stroke (pp. 185-
188). Washington, DC: Taylor & Francis.
Hamburg, D., Elliott, G. R., & Parron, D. (1982). Health and behavior: Frontiers of
research in the biobehavioral sciences: A report of the Institute of Medicine. Washington,
DC: National Academy.
Hart, B. (1994). Exile and bereavement. Psychoanalytic Psychotherapy, 8, 227-241.
Haugk, K. C. (1984). Christian caregiving: A way of life. Minneapolis, MN: Augsburg.
Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of
Psychosomatic Research, 11, 213-218.
Horowitz, M. J., Siegel, B., Holen, A., Bonnano, G. A., Milbrath, C., & Stinson, C. H.
(1997). Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry,
154, 904-910.
Jacobs, S. C. (1999). Traumatic grief: Diagnosis, treatment, and prevention [Series in
trauma and loss]. Philadelphia: Brunner/Mazel.
Kaprio, J., Koshenvuo, M., & Rita, H. (1987). Mortality after bereavement: A prospective
study of 95,647 widowed persons. American Journal of Public Health, 77, 283-287.
Kopelman, L. M. (1994). Normal grief: Good or bad? Health or disease? Philosophy,
Psychiatry, and Psychology, 1, 209-220.
Kutscher, A. H., & Kutscher, L. G. (Eds.). (1972). Religion and bereavement. New York:
Health Sciences.
Larsen, J. A. (1999). Grief. In D. G. Benner & P. C. Hill (Eds.), Baker encyclopedia of
psychology and counseling (2nd ed., pp. 529-520). Grand Rapids, MI: Baker Book House.
Larson, D. G. (1993). The helper’s journey: Working with people facing grief, loss, and
life-threatening illness. Champaign, IL: Research Press.
Lindemann, E. (1944). The symptomatology and management of acute grief. American
Journal of Psychiatry, 101, 144-149.
Lynch, J. (1990). The broken heart: The psychobiology of human contact. In R. E. Orn-
stein and C. Swencionis (Eds.), The healing brain: A scientific reader (pp. 75-87). New
York: Guilford Press.
Manicavasagar, V., & Silove, D. (1997). Is there an adult form of separation anxiety dis-
order? A brief clinical report. Australian and New Zealand Journal of Psychiatry, 31, 299-
303.
McCall, J. B. (1999). Grief education for caregivers of the elderly. New York: Haworth
Pastoral Press.
McGoldrick, M. (1989). Ethnicity and the family life cycle. In B. Carter & M. McGoldrick
(Eds.), The changing family life cycle (2nd ed., pp. 69-90). Boston: Allyn & Bacon.
McGoldrick, M., Almedia, R., Hines, P. M., Garcia-Preto, N., Rosen, E., & Lee, E.
(1991). Mourning in different cultures. In F. Walsh & M. McGoldrick (Eds.), Living beyond
loss (pp. 176-206). New York: Norton.
Meichenbaum, D. (1994). A clinical handbook/practical therapist manual for assessing
and treating adults with PTSD. Waterloo, Ontario: Institute Press.
Mitchell, K. R., & Anderson, H. (1983). All our losses, all our griefs: Resources for pas-
toral care. Philadelphia: Westminster.
Murray, C. I. (1994). Death, dying, and bereavement. In P. C. McKenry & S. J. Price
(Eds.), Families and change: Coping with stressful events (pp. 173-194). Thousand Oaks,
CA: Sage.
Nader, K. O. (1997). Childhood traumatic loss: The interaction of trauma and grief. In C.
R. Figley, B. E. Bride, & N. Mazza (Eds.), Death and trauma: The traumatology of griev-
ing (pp. 17-41). Washington, DC: Taylor & Francis.
Nolen-Hoeksema, S., & Larson, J. (1999). Coping with loss. Mahwah, NJ: Lawrence
Erlbaum.
327
Ollendick, T. H., Lease, C. A., & Cooper, C. (1993). Separation anxiety in young adults:
A preliminary examination. Journal of Anxiety Disorders, 7, 293-305.
Osterweis, M., Solomon, F., & Green, M. (1984). Bereavement: Reactions, conse-
quences, and care. Washington, DC: National Academy Press.
Parkes, C. M., & Weiss, R. S. (1983). Recovery from bereavement. New York: Basic
Books.
Prigerson, H. G., & Jacobs, S. C. (in press). Diagnostic criteria for traumatic grief: Con-
ceptual issues, critical appraisal, and an empirical test. In M. S. Stroebe, W. Stroebe, & R.
O. Hansson (Eds.), New handbook of bereavement: Consequences, coping, and care.
Washington, DC: American Psychological Association Press.
Prigerson, H. G., Shear, M. K., Friank, E., & Beery, L. C. (1997). Traumatic grief: A case
of loss-induced trauma. American Journal of Psychiatry, 154, 1003-1009.
Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F., Maciejewski, P. K., Pilko-
nis, P., Wortman, C., Williams, J. B. W., Widiger, T. A., Davidson, J., Frank, E., Kupfer, D.
J., & Zisook, S. (1999). Consensus criteria for traumatic grief: A preliminary empirical test.
British Journal of Psychiatry, 174, 67-73.
Pynoos, R. S., & Nader, K. (1990). Children’s exposure to violence and traumatic death.
Psychiatric Annals, 20, 334-344.
Rabkin, J. G., & Streuning, E. L. (1976). Life events, stress, and illness. Science, 194,
1013-1020.
Rando, T. A. (1984). Grief, dying, and death: Clinical interventions for caregivers.
Champaign, IL: Research Press.
Rando, T. A. (1993). Treatment of complicated mourning. Champaign, IL: Research
Press.
Rando, T. A. (1996). On treating those bereaved by sudden, unanticipated death. In
Session: Psychotherapy in Practice, 2, 49-71.
Raphael, B. (1997). The interaction of trauma and grief. In D. Black & M. Newman
(Eds.), Psychological trauma: A developmental approach (pp. 31-43). London: UK:
Gaskell/Royal College of Psychiatrists.
Raphael, B., & Martinek, N. (1997). Assessing traumatic bereavement and post-trau-
matic stress disorder. In J. P. Wilson, & T. M. Keane (Eds.), Assessing psychological trau-
ma and PTSD (pp. 374-395). New York: Guilford Press.
Roach, S. S., & Nieto, B. C. (1997). Healing and the grief process. Albany, NY: Delmar.
Rogers, M. P., & Reich, P. (1988). On the health consequences of bereavement. New
England Journal of Medicine, 319, 510-512.
Rosenblatt, P. C. (1994). Cross-cultural variation in the experience and expression of
grief. In D. P. Irish, K. F. Lundquist, & V. J. Nelsen (Eds.), Ethnic variations in dying,
death, and grief: Diversity in universality (pp. 13-19). Washington, DC: Taylor & Francis.
Sable, P. (1992). Attachment, loss of a spouse, and disordered mourning. Families in
Society, 73, 266-273.
Sanders, C. M. (1989). Grief: The mourning after: Dealing with adult bereavement. New
York: John Wiley.
Seeley, J., & Kajura, E. B. (1995). Grief and the community. In L. Sherr (Ed.), Grief and
aids (pp. 73-85). Chichester, England: John Wiley & Sons.
Shapiro, E. R. (1994). Grief as a family process: A developmental approach to clinical
practice. New York: Guilford Press.
Simpson, M. A. (1997). Traumatic bereavements and death-related PTSD. In C. R.
Figley & B. E. Bride (Eds.), Death and trauma: The traumatology of grieving (pp. 3-16).
Washington, DC: Taylor & Francis.
Smith, J. Z. (Ed.). (1995). Mourning. The HarperCollins dictionary of religion (p. 737).
San Francisco: HarperCollins.
Staudacher, C. (1987). Beyond grief: A guide for recovery from the death of a loved
one. Oakland, CA: New Harbinger.
Stephenson, J. (1985). Death, grief and mourning: Individual and social realities. New
York: Free Press.
328
Strean, H. S. (1996). Mending the broken heart: A psychological perspective on pre-

venting and treating heart disease. Northvale, NJ: Jason Aronson.
Stroebe, M. S. (1994). The broken heart phenomenon: An examination of the mortality
of bereavement. Journal of Community & Applied Social Psychology, 4, 47-61.
Stroebe, M. S., Schut, H., & Stroebe, W. (1998). Trauma and grief: A comparative anal-
ysis. In J. H. Harvey (Ed.), Perspectives on Loss: A sourcebook (pp. 81-96). Philadelphia:
Brunner/Mazel.
Stroebe, M. S., Stroebe, W., Gergen, K. J., & Gergen, M. (1981-1982). The broken
heart: Reality or myth? Omega: Journal of Death and Dying, 12, 87-106.
The great chiefs. (1975). Alexandria, VA: Time-Life Books.
Trolley, B. C. (1993-1994). A bridge between traumatic life events and losses by death.
Omega: Journal of Death and Dying, 28, 285-300.
Vachon, M. L. S. (1987). Occupational stress in the care of the critically ill, the dying,
and the bereaved. Washington, DC: Hemisphere.
Vaillant, G. E. (1985). Loss as a metaphor for attachment. American Journal of Psy-
choanalysis, 42, 59-67.
White, F. J. (1999). Loss and separation. In D. G. Benner & P. C. Hill (Eds.), Baker
encyclopedia of psychology and counseling (2nd ed., pp. 699-705). Grand Rapids, MI:
Baker Book House.
Williams, M. B., Zinner, E. S., & Ellis, R. R. (1999). The connection between grief and
trauma: An overview. In S. E. Zinner & M. B. Williams (Eds.), When a community weeps:
Case studies in group survivorship (pp. 3-17). Philadelphia: Brunner/Mazel.
Witztum, E., & Malkinson, R. (1999). Death of a leader: The social construction of
bereavement. In S. E. Zinner & M. B. Williams (Eds.), When a community weeps: Case
studies in group survivorship (pp. 118-137). Philadelphia: Brunner/Mazel.
Wolfelt, A. D. (1988). Death and grief: A guide for clergy. Muncie, IN: Accelerated Devel-
opment.
Worden, J. W. (1991). Grief counseling and grief therapy: A handbook for the mental
health practitioner (2nd ed.). New York: Springer.
Worden, J. W. (Ed.). (1996). Dealing with grief [Special issue]. In Session: Psychother-
apy in Practice, 2(4).
Zisook, S. (1994). Bereavement, depression, and immune function. Psychiatry
Research, 52, 1-10.
Zisook, S., & Lyons, L. (1989). Bereavement and unresolved grief in psychiatric outpa-
tients. Omega: Journal of Death and Dying, 20, 307-322.
Zonnebelt-Smeenge, S. J., & De Vries, R. C. (1998). Getting to the other side of grief:
Overcoming the loss of a spouse. Grand Rapids, MI: Baker Book House.
Author
Naji Abi-Hashem, M.Div., M.A., Ph.D. (Rosemead Graduate School of Psychology,
1992; DABPS, Diplomate, American Board of Psychological Specialties, 1998) is a
Lebanese-American clinical and cultural psychologist (licensed, 1995), and an ordained
minister, currently based in Seattle, Washington. He is involved in international service,
missionary work, writing, editing, teaching, and consultation. Special areas of interest are
relating the Christian faith to clinical practice, pastoral care and counseling, Middle East-
ern and cultural studies, political and peace psychology, existential philosophy, and con-
templative spirituality.
329
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" Grief, Loss, and Bereavement: An Overview "

Article · December 1999

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Grief, Loss, and Bereavement:

Grief is a universal experience. It is inevitable and real. Human life is a series of

explain, or fully capture the profound meaning of the encompassing phenomenon

order to allow the bereaved to gradually return to a homeostatic balance and a

moreover, of the resistance and ambivalence bereaved people experience as they

Strean, H. S. (1996). Mending the broken heart: A psychological perspective on pre-

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