Guia Duelo Adulto ENGLISH

ADULT GRIEF GUIDE
For socio-healthcare professionals

ADULT GRIEF GUIDE
For socio-healthcare professionals
By Sara Losantos
With the collaboration of Patricia Díaz and Pilar Pastor
Illustrations by Malagón
INDEX
INTRODUCTION................................................................................................................7
CHAPTER 1: Justification: Why the need for a guide on grief?.........................9

1.1 Reflections regarding grief.
1.2 Why is a guide on grief necessary for socio-healthcare professionals?
CHAPTER 2: The most frequent questions made by

grievers and their social circle........................................................19
2.1 What certainties do we have regarding grief?
2.2 Is what is happening to me normal?
2.3 How long does grief last?
2.4 Why am I not hopeful?
2.5 When is grief therapy necessary?
2.6 Who can provide grief therapy?
2.7 What types of therapy are there?
2.8 When and where is it necessary to refer?
2.9 Why is it necessary to understand the process of grief?
2.10 Questions without answers.
CHAPTER 3: Grief intervention levels......................................................................31

3.1 How can I provide basic psychological help?
3.2 Who is able to help with grief?
3.3 How can we measure grief?
3.4 What role do the different social agents play?
3.5 What does a grief patient seek at the doctor.

CHAPTER 4: Definition of grief...........................................................................................47
4.1 Grief: Definition.
4.2 What is grief and what is not grief?
4.3 How does grief work.
CHAPTER 5: Irrational or erroneous ideas regarding

grief: Inadequate feedback.........................................................................55
CHAPTER 6: What does the grief process consist

of and how do we understand it?..............................................................60
6.1 First task: Assume the reality of the loss.
6.2 Second task: Elaborate emotions related to grief.
6.3 Third task: Learn to live in a world where the departed is no longer present.
6.4 Fourth task: Emotionally relocate the departed and continue living.
CHAPTER 7: Anticipatory grief versus delayed grief...................................................90
CHAPTER 8: Grief and psychosomatics...........................................................................95
CHAPTER 9: Grief versus depression..............................................................................99
CHAPTER 10: Grief due to a loss by suicide...................................................................103
CHAPTER 11: Grief due to a traumatic death..................................................................107

CHAPTER 12: Grief due to a disappearance....................................................................112
CHAPTER 13: Gestational or perinatal grief....................................................................117
CHAPTER 14: Grief and faith.................................................................................................123
APPENDIX: CLINICAL CASES...............................................................................................130
o What always works in grief.
o Examples of answers and keys to grief. A study of ten cases.
o Common elements connected to all questions.
EPILOGUE...................................................................................................................................137
o Letter to a recent Psychology graduate.

o The pros on practising grief therapy.
o The emotional cost for the grief expert.
BIBLIOGRAPHY.........................................................................................................................140
INTRODUCTION
Three years after the launch of the first edition of the Adult Grief Guide, we
felt the need to review and modify a substantial amount of its contents. When
we decided to write this guide back in 2015, our focus was set on the socio-
healthcare professional. At that time, we perceived that there was a knowledge
gap in this area that was important to fill. Our aim was to enable Primary Care
workers to identify patients with complicated grief from those with a healthy
grief who, therefore, did not require therapy. That was our main motivation.
In this new edition, we wish to incorporate the main questions that

grievers ask when they assist the Mario Losantos del Campo Foundation’s
psychotherapy service, aiming for the professionals themselves to be the
ones who answer these questions. Only when in direct contact with grieving
fathers, mothers, children, and siblings can we identify the questions
that resonate in the heart of a person who has just suffered a loss.
Throughout this guide we want to reply to all those questions that we

have been asked about in therapy. Answering these questions has been
proven to ease the pain of the bereaved, so it could be argued that
the ultimate goal of this book is to exponentially increase the number
of people we can help. It is thus a tool aimed to guide and help.
It is an enormous responsibility for us to develop a guide that provides

guidance and brings comfort and relief to people who have recently suffered
a loss. In writing this guide we have tried to express everything we know
about grief with the aim of making it more accessible. The conclusions
we reach in this guide are not intended to be rigid, nor do we pretend
to lecture, we only seek to shed some light on such a complex process.
7
Grief is a universal experience that affects all of us. The fact that death is
universal makes this an issue with which we are all very sensitised and one we
tend to discuss with a certain levity. Hence, when a death occurs, frequently
people from the bereaved’s sphere tend to offer their opinion over what is
right or wrong regarding grief. This happens because each individual has
their own subjective idea on grief: on how long it should last, what the most
common reactions are, which ones are adaptive and which ones are not.
In my experience, these “ideas” based on our own beliefs, on general

culture or on the experiences of close relatives do not usually adjust to
each person’s real experience. When a person goes through grief, they
discover that everything they theoretically believed they knew about this
process is insufficient to explain and manage it, especially concerning the
idea that there are rights and wrongs. During an experience as intense
as that of grief, all these beliefs are challenged and have thus to be
questioned and adapted to the reality that each individual goes through.
During the first moments that follow a loss and those that come after,
each person acts as best they can in order to adapt to what is happening;
hence, it is not fair to establish Manichean categories that classify
these reactions as good or bad. Each bereaver does what they consider
appropriate to respond to the demands of the situation. Therefore, when
someone - in good faith – offers advice regarding our grief, it is worth
placing them on a standstill and bearing in mind that these comments
do not innate from a technical or objective knowledge of that reality,
but rather from a subjective experience. And since in grief there are no
universally valid answers, neither is there any universally valid advice
It is important to distinguish a professional opinion from a personal one.

A technician’s advice is not the same as the advice coming from a friend.
In these circumstances, a technician’s advice is always more reliable and,
in fact, there are grief “technicians”; that is to say, psychologists who are
experts in grief therapy who, although they are not infallible, do have
a more founded and intricate opinion on the process and its approach.
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CHAPTER 1
WHY A GUIDE ON GRIEF?
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CHAPTER 1
Generally, a person going through a grieving process visits the social-health

professional feeling vulnerable, disorientated, hurt... with many doubts about
the process, about the pain and, sometimes, with a blocked or masked grief.
How can we act correctly, from the vocation of wanting to help, in the face of
this increasingly frequent demand?
It is an increasingly generalized perception that in our society death is not well

seen: it is hidden, medicalized and transformed into a technical process. This
technification becomes a defence, a buffer of pain and reality. In advanced
industrialized societies, it is ever more difficult to accept or live with the mere
idea of death (Gala, Lupiani, Raja, Guillén, González, Villaverde et al., 2002).
However, death is the most absolute of all certainties. And, even if we avoid
thinking about it, the patient’s relative, the palliative patient, the bereaved...
all continue to need help, support, understanding and space to grieve.
In the past, family and community networks, which used to be more extensive,
used to cover this basic need and offer the bereaved the necessary support.
However, currently, society tends to distract, avoid or deny this space; that
is to say, it tends to “protect itself” from pain, so it is increasingly common
for the bereaved to choose to resort to health professionals (Gil-Juliá, Bellver
& Ballester, 2008). Presumably, this trend will continue to grow naturally,
hence, social-health professionals in contact with grievers will need to know
the grieving path in order to offer them adequate help.
1.1 Reflections regarding grief
Talking about grief necessarily implies talking about loss. This may seem
obvious, but it is not. Only those who suffer a loss will grieve, those who have
nothing, lose nothing. Grief takes place when we lose something or someone
whom we have greatly loved. Losing it implies having had it, having enjoyed
it. Some find comfort in the idea that grief is the price we pay for having loved.
In order to discuss grief, it is essential to reflect on the human being’s need

to bond and connect. The bond is the starting point of any grieving process.
Frequently, the way in which we have vitally bonded ourselves to a person and
the type of attachment we have developed with that particular loved one can
predict the type of response we will endure during the grieving process when
they pass away.
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JUSTIFICATION: WHY THE NEED FOR A GUIDE ON GRIEF?
Another almost philosophical issue to reflect upon is the tolerance level that
each person has towards absence. Even whilst being in a relationship, there
are “spaces” that seem unconquerable and that are not susceptible to merging
with the “other”. Even in the closest of relationships there is a space that still
only belongs to the individual, beyond the couple’s or the friendship’s sphere.
In that sense, there are moments or experiences in which we find ourselves

alone. We all have to face that feeling of emptiness at some point. There
are those who welcome that space, and even conquer and defend it, and
there are those who are greatly afraid of it. Those of us who are committed
to accompanying people in grief must have previously gone through this
experience successfully in order to be able to reflect on it with our patients.
“Void” is not an easy term to explain or manage. Irving Yalom, an existentialist

psychologist, addresses it in a masterly way in the film “Yalom’s Cure” (2014):
in it, he raises the need to expose oneself to that “void” or that intimate space
that is only accessible to each individual person. It can be a place where we
can cultivate our talents or our hobbies -something similar to our private
niche-, or it can be a space in which we feel, with all its rawness, the abyss of
loneliness with which every human being is born and dies.
Overcoming this void in order to transform it into a space for recreation and
enjoyment is a challenge. That is the goal all therapies should aim towards.
However, this will not be possible if the therapy conductor has not succeeded
in doing so first. The therapeutic space thus becomes the rehearsal for this
reality. This is the reason as to why grief therapy sessions need to be on a
weekly basis (in order to conquer the gap formed between sessions).
With the revision of the Adult Grief Guide, we wish to answer those questions
that our patients have been asking us over the last few years. They are
real questions that arise from experience, from close contact with grief as
an experience, as absence or emptiness. The Greek philosopher Socrates
considered knowledge as a form of birth and conceived the idea of learning
from dialogues through questions and answers. This new edition aims to
formulate the right questions in order to find the meaning to the most common
answers, because grieving is full of unsolved questions and because, both for
the bereaved and for those around them, it is essential to put those unknows
into words.
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Sometimes, the answers are universally valid and, on other occasions, each
person will find their own answers. These questions come from those raised
by the people we have seen during evaluations, throughout individual or
group therapies; the professionals we have trained; or simply those who have
approached us with their doubts via Internet, by phone or in person. This is
the reason as to why this guide was conceived as fundamentally a practical
one.
We have gathered all the thoughts that have arisen over the almost fifteen
years that we have been working as grief experts. Our sessions consist of
accompanying people who are grieving, by listening to their questions and
concerns. Together we establish a dialogue in which we reflect on everything
that is happening to them and the meaning this has. Thus, we try to make them
understand what they are experiencing, but at the same time, we manage
and approach a reality that is painful, giving it a space that releases the force
of all those emotions that grief contains.
There are grievers who are relieved by dialogue because of its intellectual
side, as they require working with the most rational part of the process. There
are also those who use therapy to verify that there is a space where their
grief does not generate rejection or produce more pain, but one where it
rather dissolves or evaporates. Grief requires for us to give it a space, that
we give it a name, and we do so through dialogue. It is in the course of our
conversations that these questions and their answers arise.
1.2 Why is a guide on grief necessary for socio-healthcare

professionals?
Recent studies have revealed that a third of the cases seen in Primary Care
consultations have a psychological origin. Out of all these cases, a quarter are
identified as the result of some type of loss (Bayes, 2001).
On another hand, bereavement is considered as a cause of morbidity and

mortality and hyperfrequency in Primary Care (Lacasta and De Luis, 2002)
and it is thought that the average annual rate of visits to the healthcare centre
is 80% higher among grievers (García, Landa, Trigueros and Gaminde, 2005).
Various studies, many of which have already become classics, confirm these
data (Prigerson, 1997), (Martikainen and Walkonene, 1996) and (Parkes,
1964). All these statistics expose, on one hand, that the bereaved turn to the
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socio-health professional for help and, on the other hand, that grief can have
complications on a psychological, physical and social level.
Among the possible physical complications compiled in multiple studies, we

found that the risk of depression in widows is multiplied by four during the
first year (Zisook and Shuchter, 1991), while almost half of them present
generalized anxiety or panic attacks (Jacobs, Hansen, Kasl, Ostfeld, Berkman
et al., 1990); alcohol abuse increases (Madison and Viola, 1968) and 50% of
widows use a psychoactive drug during the first 18 months (Parkes, 1964).
Furthermore, between 10-34% of grievers develop pathological grief (Jacobs,
1999) and the risk of death increases (mainly due to cardiac events and
suicide). In fact, widowers are 50% more prone to die prematurely during the
first year of widowhood (Kaprio, Koskenvuo, and Rita, 1987).
These are some of the possible complexities grief can have on a physical level,
perhaps the most serious ones, but in my experience it is also common for the
bereaved to express various somatic complaints: physical sensations similar
to those experienced by the deceased, fear of illness, or feelings of exhaustion
and shortness of breath.
Grief is a social process and as such, feeling support, as well as being able to
verbalize and share the experience, is essential for its resolution. However,
today’s society can exert its influence in the opposite direction, (Tizón, JL. Loss,
grief, bereavement. Paidós, Barcelona 2004) that is, by forcing the bereaved
to recover immediately, to be distracted, to avoid contact with pain or tears,
thus causing the process to be inhibited, as well as complicating it.
In summary, a correct elaboration of grief is essential for an individual’s good

physical and mental health (Portillo, Martin and Alberto, 2002).
As we have already mentioned, our society feels more and more blocked in
the face of disease, pain and death. Socio-health professionals, as participants
in society, are not alien to this trend. Various studies reveal certain attitudes
that occur within the hospital professional environment: not wanting to
name death, incongruities and dissonances between verbal and non-verbal
communication or an increase in technological attention to the detriment of
empathic-affective communication (Gala et al., 2002). Behind these attitudes
lies the socio-health professionals fear, the reflection of their own worries and
their concern in avoid causing the patient a harmful emotional.
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Socio-healthcare professionals who assist people in situations of pain, grief or

illness, face greatly emotionally intense experiences, which can involve a high
degree of stress and uncertainty, (Rothschild, 2009). In an attempt to briefly
relieve the bereaved person of this searing pain, the health professional can
easily fall into the error of prompting attitudes that avoid pain (e.g., over-
medication, etc.). Frequently, they tend to seek a solution that magically
alleviates and resolves the patient’s pain, becoming frustrated if they perceive
that it does not improve from one encounter to another, or after a “reasonable”
period of time. A professional’s lack of knowledge on the path of grief can lead
them to demand practically unattainable goals from themself and from the
bereaved.
While the socio-health professional deals in their interior with these confusing
and contradictory tendencies, this attitude can lead the bereaved to endure -as
seen in my clinical experience- a feeling of abandonment, as well as greater
loneliness and confusion.
On another hand, data from recent studies have shown how effective therapeutic
intervention reduces hopelessness, depression and anxiety. Likewise, there is
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evidence of the importance psychological support from healthcare professionals

has on patients during the last moments of the disease and its effect in the
subsequent evolution of the family’s grief. The intervention made by the socio-
health professional in any of the phases of the death process will directly
influence the subsequent evolution of grief.
By providing the socio-health professional with training on how to cope with

grief and how to handle pain and death, we will provide them with the tools
to cope -arising from their vocation to help- with these situations of great
emotional intensity. In addition, these resources constitute a fundamental
support for the professionals, since they often help to prevent healthcare
stress by improving treatment with the patient and the family.
Although the use of technology or protocols is essential (in the case of other
professions within the healthcare field), this is insufficient if we intend to
offer an effective, beneficial and efficient response to crisis situations. In this
context, Chochinov (2009) coined the term “Patient-centred care”, in which
communication and emotional approach in helping relationships are enhanced.
All these aspects support the need to provide greater training around grief,
both at an accompaniment level as well as regarding therapy. With this guide
we aim to respond to a need present both in society and within the socio-
healthcare field of professionals, who must face situations involving death,
pain and illness in their day-to-day lives. The more prepared the professional
is, the more capable they will be in accompanying the patient and the patient’s
family throughout the process of illness, loss and grief (Gómez, 2000).
Throughout this book we are going to embark on the path of grief; a very
personal process wich involves many curves, obstacles and slopes. Therefore,
the professional who approaches this world needs to have a few certainties
about what grieving is like in order to be able to accompany the bereaved in a
satisfactory way, giving them freedom of movement so that they can choose
to resolve the process in their own way.
We aim for this guide to be useful at any level of intervention: whether it is

during accompaniment, counselling or therapy (Worden, 2013). The differences
between each level are as follows:
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• Therapy: Therapy’s goal is to identify and resolve the conflicts that prevent
those whose grief does not appear, is delayed, excessive, or prolonged
from completing the tasks of grief. That is to say: they suffer what we refer
to as complicated grief. Therapy will be carried out by an experienced grief
psychologist.
• Counselling: The purpose of counselling is to aid the person in the

resolution of the tasks of a recent grief, so that the process is successfully
fulfilled. It is carried out by socio-healthcare professionals trained in grief,
although there are also places where this function can be performed by
volunteers who have gone through similar circumstances.
• Accompaniment: The aim of accompaniment is to be by the side of a

person who experiences pain due the recent loss of a loved one, listen to
their pain and validate it: give them time for emotional expression. This is
accomplished by professionals who are in ongoing contact with people who
are experiencing acute grief situations, such as funeral service workers or
emergency room professionals.
Whatever stage of the intervention level the professional is in, the appropriate
general intervention framework for the experience of grief is counselling
(Gómez, 2000). The professional who works following this framework
undertakes the responsibility of knowing how to listen to themselves -their
behaviour reflects their inner state-, of understanding others without judging
them, of opening up to another person’s experience, accepting them and
enabling them to communicate with themselves. Counselling offers a very
favourable framework of openness, understanding and acceptance that allows
the bereaved to freely embark on their own path of grief.
According to William Worden (1997), the general grief intervention objectives

are:
• Aid the person to come to terms with the reality of the loss.
• Aid the person address the emotions and the pain that loss entails.
• Aid the bereaved to adapt to the world now that the deceased is gone.
• And, finally, help them to psycho-emotionally relocate the deceased.
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To achieve these objectives, we suggest a series of general principles that can

guide the intervention:
• Talking about death (and everything related to it) helps and relieves.
• Each grief is unique, not one is the same as another. Only our conscientious
listening will help us to discover the keys to each process.
• Encourage the expression of emotions and pain.
• Explaining, in general terms, what the grieving process consists of makes

it easier for the person to get involved in it and for them to not feel so lost.
• Help them in answering the questions they may have.
• Encourage the reconstruction of the personal world of meanings after the

loss (values, beliefs, one’s own identity, etc.). Grief provides us with the
opportunity to update or rebuild our inner world.
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All these principles have the purpose of updating certain concepts, modifying
others and incorporating some new ones. And experience has taught us
that those who approach FMLC seeking help are, fundamentally, searching
for answers to rational and not so rational questions.
We aim for the Primary Care physician, the nurse, the social worker -all
those professionals who detect grief at the first level- to be able to provide
them with a correct and sufficient response, which initially serves as a
comfort to their patients. This may dramatically reduce the need for clinical
grief care. And, in case that is not enough, we hope that you will find in this
guide useful tools to identify those cases that need specific attention and,
thus, be able to adeuqately refer them.
This new edition of the Adult Grief Guide has the novelty that it is more
concrete and practical, because each of the words it contains are aimed
at relieving the pain of those enduring grief, taking our clinical experience
as the only starting point.
This guide does not end on the last page, but rather continues through
the reflections that we hope to sow in all its readers. It is a living guide.
Certainly, the questions it contains do not exert all knowledge of grief, but
neither does it purport to do so. Hopefully the answers and reflections
that we propose in this guide will be of use as a relief and a guide.
REMEMBER:
• Grief is the natural process that occurs when we

lose something or someone we have deeply loved.
• A third of the cases that are attended in the
Primary Care consults have a psychological origin.
• In order to be able to address and accompany
the griever in a satisfactory way, the healthcare
professional needs to have several certainties
about this process that we will try to answer in this
guide.
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CHAPTER 2
THE MOST FREQUENT QUESTIONS MADE BY GRIEVERS AND THEIR
SOCIAL CIRCLE
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CHAPTER 2
A well-known Mario Benedetti quote reads: “When we thought we had all the
answers, suddenly, all the questions changed”. This is the phenomenon that
takes place whilst we are grieving.
Answers do not exhaust the need human beings have to understand, but
rather help produce the inertia that propels us into reflection and introspection.
Each question generates a new one, in a succession that leads to a deeper
understanding of grief and of oneself.
Below, we have tried to enumerate the main questions that we have had to
answer throughout all these years:
2.1 What certainties do we have regarding grief?
There are few certainties regarding the grieving process. One of them is that
it involves pain. The Spanish word for grieving “duelo”, comes from the Latin
“dolus”, which means pain. This is significant, as pain is an essential aspect
in this process. If it does not involve pain, we know it is not grief. Almost all
reactions towards pain are adaptive, and the shape this pain adopts in each
person can vary considerably.
Another certainty that we have is that there are no universalities surrounding

grief. There are some generalities that can guide us, but there is not one
given factor that is universally valid. Consequently, it is necessary to analyse
grief case by case, given that what is valid for one person may not be so for
another one. Knowing that there are no universalities in grief is tremendously
liberating for the bereaved, as this means that they do not have to adjust to a
particular experience or specific reaction that others consider to be valid, but
rather leaves space for nearly any reaction.
2.2 Is what is happening to me normal?
If the questions raised by grievers had to be ordered in terms of importance,

this would be the first one. The main concern of a person going through grief
is knowing if what is happening to them is normal. Pain in the face of loss is so
intense that sometimes the bereaved may come to think that they are going
crazy. Part of the therapeutic work will consist in validating and legitimizing
the reactions that a grieving person may go through as they confront the
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THE MOST FREQUENT QUESTIONS MADE BY GRIEVERS AND THEIR SOCIAL CIRCLE
death of a loved one. In my experience, the range of reactions that are normal
in the face of pain is very ample.
Deep down, this concern is linked to the perception of “doing it right or wrong”.
We begin with the false belief that there is a right or wrong approach towards
the elaboration of grief. However, the truth is that each person does as best
as they can, each individual reacts with the resources they have available.
Patients who reach out to us show a great interest in addressing the process
correctly, in not adding more distress or a pathology to the pain they already
feel. Therefore, knowing that what is happening to them is normal is a source
of reassurance and comfort for them.
However, normality is a purely statistical matter. There is no normality in

objective terms, but only in relation to a society or an environment, always in
comparison with something. This piece of information is important in therapy,
as well as in this type of consultations that make us redefine the concept of
normality. The reason behind this is that if we stick to the statistical criteria,
some grief reactions that seem atypical or strident are normal if we explain
them or place them in a specific context. For example: a person suffering
from foot pain, in abstract, this may be strange or pathological, but if they
have previously banged their foot or something has fallen on top of it, the pain
is perfectly normal. This does not imply that this pain has to be neglected, but
it does normalise it.
If we take the experience of grief as an example, the reactions of each person

must be analysed taking into account their context. That is to say: if a person
is extremely shy, they will undergo a shy grief process and this will be normal;
whereas, if they are a tremendously melancholic person, they will endure a
particularly melancholic grief process. The characteristics and reactions of
grief cannot be analysed separately from the individual. Grief is an added part
of what a person already is, in such a way that previous experiences or the
personality of the bereaved will mark and define the “normal” way in which
each one faces grief. Our job is to depathologize the reactions to grief: firstly,
because almost all of them are normal and, secondly, because many of those
that are not statistically normal are normal when framed in their own context.
The first task of the grief “companion” must be to soothe and normalize. In
order to do this, it is essential to believe it. We cannot say something if we
do not believe it ourselves. Additionally, we also have to distinguish between
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normal and non-normal reactions and be able to explain and understand each
reaction in a given context.
The first task of the grief “companion” must be to soothe and normalize. In
order to do this, it is essential to believe it. We cannot say something if we
do not believe it ourselves. Additionally, we also have to distinguish between
normal and non-normal reactions and be able to explain and understand each
reaction in a given context.
If the context allows the reaction to be explained, then the reaction is normal.
If the context does not make any sense of it, then it is not normal.
2.3 How long does grief last?
This is one of the questions that causes most concern among grievers. There is
a widespread belief, according to which grieving lasts a year and any process
that lasts longer than that is considered to have pathological overtones. But,
in reality, there is no specific deadline in which to elaborate grief, each person
requires a different time span, thus by trying to frame grief in an exact period
of time only serves to add pressure to the process.
Most probably, this ingrained belief that establishes that the duration of grief
lasts for one year is connected to a period of time when widowed women
mourned their loved ones at the beginning of the 20th century. Once the
obligation of mourning disappears, the process is left without rules that
establish a framework or a time limit.
Time is one of the fundamental components of grief. However, this is not

the equation’s essential ingredient, but rather only part of it. Actually, what
determines whether grief is overcome or not is what each person does with
their time.
Throughout the entire grieving process there are numerous micro-decisions

that the grieving person must make:
• Go to therapy?
• Try to allow the grief process to flow or encapsulate it?
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• Ask their social circle for help?
• Request a medical leave?
Grief is an active process. For this reason, placing pain at the mercy of the
passing of time unprotects the bereaved and leaves them without resources
or options to manage the process, as they merely limit themselves to wait
for time to go by. If grief resolution were that simple, psychiatrists would
prescribe time instead of medication. But the only thing that time does is
set distance between a pain. If the bereaved simply awaits, grief will remain
unresolved and the pain will not disappear.
When a loved one dies, we frequently hear those around the bereaved say
the phrase: “Time heals everything”, but this is utterly false. Time serves as a
buffer, but it does not cure anything. The passage of time only makes us older.
One of the basic concepts that we know about grief is that, when portrayed
graphically, the process depicts a Gaussian Bell Curve. This is a graph that
contains two axes: one represents the level of pain and the other, the passage
of time (Parkes, 1964).
Generally, the pain level is lower during the first moments of grief -coinciding
with the need to reduce the impact produced by death- and it grows as time
passes and the person begins to realise everything that the loss of their loved
one implies. Usually, peak level occurs around six or seven months after the
death and this is what we call, acute grief (Parkes, 1964).
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2.4 Why am I not hopeful?
Many grievers become afraid when they perceive that they do not feel hopeful
about anything, they are apathetic. However, this is completely normal, as
pain is incompatible with hope. As long as the grieving process lasts, it will be
normal for hope not to exist and any attempt at it from the griever’s part of
will cause a lot of frustration.
Pain and hope have an inversely proportional relationship (Emilio Duró, 1998):
the more pain, the less hope and vice versa. Frequently, the griever’s social
circle seeks to alleviate their pain by encouraging them to carry out enjoyable
activities, but more often these will not bring about an authentic connection
with hope, as they are incompatible.
What we can do is offer relief in order to try to reduce the level of pain.
2.5 When is it necessary to go to grief therapy?
For me, one of the keys that signal the need for therapy is the fact that the
process is not progressing, that the sensations have not varied in duration
or intensity for four or five months. The changes indicate that the process is
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alive, while the absence of these indicates that there is a blockage that must
be addressed in therapy.
Sometimes therapy serves the griever to mitigate or alleviate unbearable

anguish, or to vent and empty out when he cannot talk about his emotions
with his family and surroundings. It is also useful when you want to look for a
deep meaning to the loss, give meaning to life or when the beliefs on which it
was based have been devastated by the death of the loved one.
Even under these circumstances, the decision to go to therapy is something

subjective that each griever must find within themselves. You do not have
to go to therapy based on the “recommendation of” someone, but because
you feel you require it. The recognition of that need, real or false, marks the
beginning of the process.
When one attends therapy without being convinced, recommended by a doctor

or a friend, the motivation to continue going is minor and, in the face of any
setback, the patient will abandon the therapy, misemploying a resource that
in other circumstances could have been useful.
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The start of therapy has to occur at the right time, once the bereaved feels
ready, since each person requires their own moment to begin a therapeutic
process.
2.6 Who can provide grief therapy?
Grief therapy as such should only be practised by a grief expert, be it a clinical

psychologist or a medical therapist.
Other than this, there are certain levels of assistance that can be provided in
a timely manner. For example, a Primary Care physician may offer treatment
to control “flowery” symptoms during the grieving process; or a psychiatrist
can offer pharmacological support when the process becomes complicated.
The latter is usually used as a temporary assistance, in order to reduce anxiety

levels and prompt sleep and rest.
2.7 What types of therapies are there?
There are many valid therapeutic offers to help to manage grief. On one hand,
we have the medical-psychiatric option, which controls the most physical part
of the process and can be complemented with conventional therapy. Also,
within conventional therapy, therapy can be carried out individually or in group
format.
Group therapy is very powerful, since all the group’s energy is attached to
the power of the therapy itself. In turn, individual therapy is aimed at people
who do not want to participate in group sessions, either because of shyness,
modesty, or because the person feels quite invaded and needs to work on
some personal aspects or grief itself before being able to continue with group
therapy, among other reasons. An example would be traumatic grief, which is
easier to work on in individual therapy rather than in group therapy.
Each of the different psychological orientations offer the griever something

different and all of them promote the elaboration of grief. Each professional
or patient must choose the one who best suits their needs. In my opinion,
the most appropriate one is a person-centred therapy, the efficacy of which is
supported by numerous studies.
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I believe that the desire to help is in the human being’s DNA and each individual
does so from where their point of expertise. What I have discovered is that
non-scientific techniques such as yoga, meditation, acupuncture, homeopathy
or hypnosis, to which many grievers resort to and which I do not dare to
downplay since they seem to work. Each person will find their path.
2.8 When and where to refer?
It is important to have a list of professionals to whom to refer a patient when

necessary. Each socio-healthcare professional is responsible for “generating”
that list, in order to refer cases to other professionals they trust and with
whom they can establish collaborations and work in a network.
2.9 Why is it necessary to know the grieving process?
According to statistics, each death can affect up to ten people and it is

estimated that around 10% of grievers will endure a complicated grief, with
severe implications for their physical and psychological health (Prigerson,
Vanderwerker & Maciejewski, 2007).
In 2017, a total of 424,053 inhabitants died in Spain. Out of this number, it is

estimated that in 2017 alone there were around four million people grieving,
of which around 420,000 would be going through a complicated grief process.
This places before us a substantial number of people in need of help.
Recent studies have revealed that a third of the cases seen in Primary Care
consultations have a psychological origin. Of these cases, a quarter are
identified as the result of some type of loss (Bayes, 2001). Bereavement
is considered a cause of morbidity and mortality and hyperfrequency in
Primary Care (Lacasta and De Luis, 2002) and it has been calculated that the
average annual rate of health care visits is 80% higher in grievers (García,
Landa, Trigueros and Gaminde, 2005). Various studies, many of them already
considered as classics, confirm these statistics (Prigerson, 1997); (Martikainen
and Walkonene, 1996) and (Parkes, 1964).
All these data prove that the bereaved reach out to social-health professionals
for help and, furthermore, that grief can have complications on a psychological,
physical and social level.
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Among the possible physical complications collected in multiple studies, we

found that the risk of depression in widows multiplies by four during the
first year (Zisook and Shuchter, 1991), while almost half of them present
generalized anxiety or panic attacks (Jacobs, Hansen, Kasl, Ostfeld, Berkman
et al., 1990); alcohol abuse increases (Madison and Viola, 1968) and 50%
of widows use a psychoactive drug during the first eighteen months (Parkes,
1964). Furthermore, between 10% and 34% of grievers develop pathological
grief (Jacobs, 1999) and the risk of death increases (mainly due to cardiac
events and suicide). In fact, widowers are 50% more likely to die prematurely
in the first year (Kaprio, Koskenvuo, and Rita, 1987).
These are some of the possible complications on a physical level, perhaps the
most serious, but it is also common for the griever to express various somatic
complaints: physical sensations similar to those experienced by the deceased,
fear of illness, feelings of exhaustion and suffocation.
Although grief is a normal adaptive process, it is sometimes psychologically

complicated, causing pain to be delayed, inhibited, or masked (Rando T.A.,
Treatment of complicated mourning, Champaign, IL, Research Press, 1993).
In these cases, normal reactions such as feeling depressed or feeling anxious
can transform into despair, a feeling of helplessness in life, clinical depression
and disorders derived from anxiety, such as phobic attitudes and obsessive
thoughts.
Grief is a social process and, as such, the fact of feeling support and being
able to verbalize and share the experience will be essential for its resolution.
However, today’s society can exert its influence in the opposite direction, that
is, forcing the bereaved to be well right away, to be distracted, to avoid contact
with pain or tears, causing the process to be inhibited and complicated.
In summary, a correct elaboration of grief is essential for the good physical

and mental health of the individual (Portillo, Martín and Alberto, 2002).
We have already justified the importance of the grieving process. But to

elaborate this process properly it is very useful to have a theory that provides
the professional with a deeper understanding of the process that the patient
is going through and, at the same time, provides the bereaved with a greater
sense of control over what is happening to them, as well as a hanger on which
to organise their feelings and give them meaning.
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2.10 Questions without answers
One of the great concerns of human beings is to answer the questions about
death. However, there are answers that no one has, so these questions are
also an invitation to begin a deeper understanding of loss, its meaning, of
love...
The attempt to give a concrete answer to that search will not be able to
quench the thirst for knowledge, because there are questions for which there
is no answer.
For this exact reason, when a patient formulates one of these questions, we
must carefully accompany the need behind the posed question and let the
patient themself find their own answer.
We have to be conscious that neither ourselves nor anyone else has the
answers to all questions. On the contrary, the desire of been seen by the rest
as infallible experts can break the intuitions born from these concerns.
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REMEMBER:
• Pain is a fundamental aspect of grief and the form it adopts

on each person can vary greatly.
• There is no “correct” or “normal” way of elaborating grief,
the range of reactions towards this process is immense.
• Grief does not have a determined duration; each griever
requires different periods of time. The fundamental issue
is what each individual does with their time.
• Therapy is necessary when a stagnation of the process is
perceived and we see that it does not progress, being able
to help the bereaved in multiple ways.
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GRIEF INTERVENTION LEVELS
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CHAPTER 3 CHAPTER 3
The most powerful tools against pain are the love and compassion that come
from other human beings, whilst there are essentially two main reactions
towards pain: withdrawal or approach. This is an almost obvious statement,
as only these two possibilities exist.
These positions are maintained according to the attitude that each person
keeps towards this reality. When the pain of others frightens, a withdrawal
occurs: people who adopt this position change the subject so as not to talk
about death in front of the bereaved, they avoid delving into the meaning of
the emotions and sensations of the other, they do not know how to comfort
or how to accompany the pain and feel overwhelmed by reactions that are
usually normal and even healthy in this process. On the opposite side are
those who are not so afraid of the pain of others and want to help.
The most common outtake is that both a group as the other side have good
intentions, but few resources to face such complex situations. Pain can only
be approached by those who do not fear their reactions and firmly believe that
it can be overcome. Those who do not have this conviction will approach grief
from paternalistic and overprotective attitudes, transmitting the idea that this
process is something that must be protected and moved away, because it is
difficult to overcome.
3.1 How can I provide basic psychological aid?
There is no single way to help someone who has suffered a recent loss.
Everyone reacts as best they can to a situation that is often disconcerting
and very intense. Hence, when a person with a recent or immediate grief
comes before us, it is useful to have a series of general guidelines that we can
adjust to the needs of each suffering person, since knowing them allows us to
provide support and comfort with a greater sense of security.
There are at least three ingredients that are essential in that “shaker” to
relieve pain:
Symptom control and attention to the more physical aspects of grief
This point relates to the most common symptoms or reactions to the grief of
loss. We refer to reactions such as headaches, dizziness, fatigue, difficulty
falling asleep or lack of appetite, among others.
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Grief is a process that has a huge impact on the human being and requires a
large number of resources to achieve the balance that is lost with the death of
the loved one. This emotional impact has a physical correlation (Gendlin, 1967)
with a great diversity of different sensations that accompany the process.
Grief is a first-rate stressor for the individual. This stress maintained continuously
over time is what explains, at least in part, the physical correlation. In a
first instance, taking care of the more biological part calms the bereaver and
restores a certain sense of control over the grief.
The best prepared person to address these symptoms during the first moments
is the family doctor. He/she is the one who will be able to supervise and,
where appropriate, prescribe any medication that allows adjusting the sleep
and rest cycles if necessary, as well as regulating previous medications or, for
example, illnesses that have been neglected during the deceased’s illness. or
during much of the grieving process.
It is essential to properly regulate the diet and rest of the bereaver. Grief requires
a lot of energy and, to be able to go through it, it is important to properly
monitor these two aspects.
Any type of help aimed at meeting these needs will help to mitigate the most
visible physical symptoms.
Closeness
In general, grief is a process that you go through alone, without a clear guide
or instructions. In this sense, the loss of a loved one sometimes brings with it
other losses: the loss of contact with friends or acquaintances, with neighbours,
with the social circle. This occurs because the social environment is usually
not prepared to meet the needs of a bereaved person, nor to “bear” the pain
of others, since pain can produce fear and even rejection.
The isolation caused by not feeling understood or validated can intensify the
bereaved’s grief over the loss of a loved one. Usually, people tend to move away
from what causes pain or suffering and closer to what gives them pleasure.
During grieving this paradigm is fulfilled. The social circle is often frightened
by the bereaved’s reactions and does not have the capacity to take charge of
the griever’s pain.
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When this happens, the help offered to the bereaved by their closest circle
may be inadequate, by prescribing what they really need themselves: that
there is no pain, something that is impossible throughout grieving, because
its mere name means pain and withdrawal to this emotion is impossible.
Other times, although the environment is prepared to deal with the suffering
of the bereaved, the perception that he has of the help is that it is insufficient
or does not suit his most pressing needs. In this context, it may happen that
the bereaved is perceived as a burden or as inadequate, causing a distancing
from his or her closest circle.
In the end, this detachment is prompted by two situations:
• The bereaved feels misunderstood and does not know how to make their
social sphere understand what they need.
• The social sphere does not know how to manage their pain or how to help
them.
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These two situations have a meeting point in communication: open

communication between both parties can help to put on the table what
each one is willing to do and what the other needs. This direct and honest
communication will help the sufferer to get closer to the people around them
and to release his pain, because what each person needs is different.
In these disconcerting moments of grieving, one of the things most valued by

the bereaved is the closeness of another person: without invading, without
overprotecting, simply being available, making concrete offers, validating and
normalising the feeling that loss produces in each one. Only another human
being can calm the pain of a person who hurts, because we are social beings.
It is also important to handle the closeness / distance duality, because when

the closeness is excessive, it can become pernicious. We all need a space
to assimilate what has happened, to feel without pressure. When closeness
becomes suffocating, it is no longer useful. This is why it is essential to pay
attention to the rhythm of each suffering person without pressuring them: to
allow and encourage them to take care of what they can. The difficult balance
involved in this dance makes it sometimes difficult to meet the needs of a
grieving person, largely due to the limitations that each one carries.
An aspect that is not often considered within the grieve accompaniment is

the perception that each subject has of the help they are receiving. This is
fundamental, because what matters is what the bereaved perceives and not
so much the real situation. It may be the case of people who, being very
accompanied, feel alone and others who, despite having little or no support,
feel that they have received more than enough. That is the difference between
the real support received and the perceived, you have to attend to the second,
not the first.
Hope
It is extremely difficult to cope with pain if what we have in mind is that it

will last forever. For this reason, it is absolutely essential to instil hope in the
grieving patient: a real hope that the grieving will be overcome, that the pain
will be undone. You have to support that message with objective data. The
reason is that you cannot live without hope, since pain wears down a lot and
we cannot ask a grieving person in any other way to live with their pain, to
leave space or not to reject it.
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In my clinical experience, there are at least three arguments that allow us to

affirm that the human being is biologically prepared to overcome pain:
1. Throughout our history, we have lived and endured millions of losses and
we have overcome them. In spite of everything, we are still on earth as a
species and we have not become extinct.
2. According to the World Health Organization (WHO), 90% of people who

suffer the death of a loved one go through a healthy grief. Healthy grief,
logically, hurts. But the pain lasts for a shorter period of time and, moreover,
it remits almost spontaneously, without making any effort. It is a type of
grief that does not require therapeutic, psychological or medical attention.
There are those who need more time to get over it and those who need
less, but the vast majority of people get through grief. The percentage
of people who require help to overcome it is very small compared to the
number of people who do not.
3. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-V) includes a novelty in the annex relating to conditions that require
further study: resistant complex grief disorder. This describes in a fairly
detailed way a type of disorder that globally affects the individual in his life
and that therefore requires psychological and / or medical attention. It is
important to note that the prevalence of this disorder is between 2.4 and
4.8%, which implies that the vast majority of people who experience a loss
will be able to overcome it almost spontaneously and a “small” percentage
of Cases will require therapeutic help, but both will overcome it. There is
a percentage - barely close to 1% - where unfortunately and for different
reasons we have to speak of therapeutic failure. For these cases there is
not purely “curative” therapy, but there would be the possibility of making
an emotional accompaniment to relieve the sufferer and combine it with a
pharmacological therapy to control the most intense symptoms of anxiety
or anguish. For all these reasons, based on statistical criteria and facts, we
can categorically affirm that grief can be overcome, with or without help
and / or more time.
Messages that can offer hope:
• “Pain does not last forever”.
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• “No matter how long or dark your night, a new dawn will break”.
• “This too shall go away”.
• “You are doing everything in your power, now just trust”.
• “You are not alone with your pain, you can ask for help for whatever you
may need. Wherever you may not be able to reach, I will”.
• “Others prior to you got over this, and so will you”.
• “Be kind and compassionate to yourself, and the rest will come by itself”.
What not to do:
When faced with a person’s grief, we should not take anything for granted,
as if all griefs were the same. This, in addition to being false, diminishes the
importance of the experience itself. Each experience is unique and each pain
is different.
Do not minimize the pain of others, or say lightly that “it will pass.” Nor should
we downplay the death of the loved one to reduce the drama of the tragedy,
with phrases such as: “At least he no longer suffers”, “It is the best thing that
could have happened to him/her”, “Nothing could be done for him anymore.
“,” You are young, you can fall in love again “,” You can still have another
child “... These phrases so widespread and heard at funerals often produce
discomfort, a sense of incomprehension and anger in most of the grievers.
Do not use topical phrases (from movies, customs, social milestones) such as:
• “I share your feelings”.
• “I’m here for whatever you may need”.
• “Don’t worry, time heals everything”.
• “Only the good guys die”.
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It is difficult to avoid topics, because they are comfortable and allow you not
to think much. They are social conventions that seek to alleviate the pain
when a loved one dies, whatever the circumstances. However, the final effect
of the topics is that they convey indifference, they equate all experiences.
They do not express a specific real feeling (what this specific death generates
for me, in relation to this specific person) but they are set phrases that, by
dint of repeating them, have lost their meaning. What a griever values most
at this time is the proximity of a specific message, one that is born from the
heart and that seeks to shelter, comfort or at least have an honest and real
communication in the face of the pain and tragedy that death has caused.
3.2 Who can provide help during grief?
We could say that almost anyone can accompany or bring comfort to a person
who suffers: pain needs witnesses. But it is important to distinguish help from
quackery and not to abandon oneself to the “siren song” that is sometimes
offered with good intentions.
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With this term we do not refer to homeopathy, acupuncture or reiki, but to

techniques that produce iatrogenic effects, that normalize or enhance signs of
grief that are not healthy, for example, groups that seek unorthodox spiritual
contacts or in the beyond.
Intervention Levels
The fact that grief is a universal experience also contributes to the existence of
different levels of intervention. From the most basic to the most professional,
the levels would be:
• Unprofessional help. It is the one that can provide the closest social
circle: friends, family, neighbours... supporting, accompanying, taking care
of the well-being of the grieving person at specific levels, such as providing
food, housework, etc.
• Non-specialized professional help. We talk about the help that the

Primary Care doctor can provide to the sufferer. It is not a specific aid
to attend to grief, but it can attend to certain common symptoms of the
process, such as anguish, insomnia or anxiety. At this level, the social
worker or the nurse is also relevant, as they may have knowledge about
the approach to grief due to their more frequent contact with patients and
closer follow-up.
• Specialized professional help. We speak of specialized help when a

person goes to a service in order to receive specific help for the discomfort
caused by grief and receives it from professionals who have been trained
to attend this process. At this level we can already speak of grief therapy
taught by expert psychologists. They will be the ones who deliver the
therapy, either individually or in groups, depending on the needs of each
patient.
3.3 How can we measure grief?
The grieving process is difficult to measure. It cannot be evaluated exactly

- as if it were an X-ray - in order to see where the process is, that is: if it is
progressing or blocked, how much and what is left to finish. But it is important
that a part of the therapy be devoted to evaluating it, because this information
acts as an external motivator.
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If we do not give the bereaver an estimate of their evolution, the process may
seem infinite in time. However, there is no standard method that allows the
professional to accurately discern where a person is at during the process. Part
of this difficulty has to do with what the fact of ending the grieving process
implies for each subject and, above all, when to end it.
In the previous edition of this guide, we incorporated the Revised Texas

Inventory, (Faschinbaguer et al, 1977, 1981) better known by its acronym
ITRD. This inventory consists of twenty-one items and is self-administered. The
average administration time is ten minutes. However, in this new edition, we
have not included the questionnaire, because we consider that it overdiagnosed
complicated grief. Furthermore, grievers are usually not motivated to fill in
the scales and Primary Care physicians do not have time in consultation to
address this issue in depth.
Even so, there are subjective measures that make it possible to roughly
estimate where each bereaver is in the process, what they have achieved and
what they are lacking. Normally in my professional practice I use what I call
“the measuring table”, which is nothing more than my worktable. At a point in
therapy, I ask the patient to imagine that one end of the table is the beginning
of the grieving process and the other end is the end. Next, I ask them to pick
a point between the two that represents how far they have come and how
far they have to go. Clinical experience has shown me that patients almost
always agree with my own assessment of their condition.
Another way to appreciate the progress of grief is to observe the patient’s

changes in therapy: from one week to another things change, what is verbalised
is different, the sensations are different... this tells us that the process is not
blocked, because pain varies in intensity, duration and frequency. If the pain
begins to manifest itself in waves that last less, or that are less frequent or
less intense, that speaks of a positive change.
Other positive signs are that the person talks more about themself than the
deceased, that they worry about everyday things, that they talk more as
compraed to if they barely talked before, that they more focused compared to
before, that they are more aware of what occurs and name their emotions ...
even the patient’s own perception of reality. Sometimes it’s the subtle details
that show us progress in the course of grief.
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At other intervals it seems that the patient is not moving forward and that the
process has stalled. In those cases, what happens is that perhaps we have
gone very deep into the process and it is moving towards greater awareness,
towards greater introspection, “inward” rather than “forward”. But that should
also be recorded as progress: the ability to tolerate pain or to speak openly
about what happened.
3.4 What role do the different social agents play?
The human being lives in society and elaborates grief in society. Thus, each
of us has a role and a way of influencing the grieving process of the people
around us. The griever is not alone, they live immersed in a specific culture
and time. Our culture is hedonistic and seeks immediate pleasure - perhaps
that is why it is difficult for it to meet the demands of the bereaved who need
care and time to grieve - but we all play a role in it.
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For this reason, it is not society in the abstract that must change to favour
contact with the reality of grieving and suffering, but each one of us, with small
gestures, being receptive, informing ourselves about grieving, by speaking
openly about death and pain… Each person has their own “niche” from which
to influence and improve their knowledge of grief or the care of pain.
The role of the media
The media have a key role in facilitating this process and their power of
influence is expressed in many different ways:
• Giving spaces in written and audiovisual media that make it possible to

speak normally about grief, death or suffering.
• Disseminating rigorous information about grief and giving voice to well-

known experts on issues of loss, trauma and grief.
• Following the guidelines recommended by mental health experts when

transmitting news likely to impact the population, such as attacks, accidents,
natural disasters...
When a major media disaster or tragedy occurs, the guidelines that trauma
experts advise are:
• Avoid the dissemination of traumatic or potentially traumatic images.
• Offer objective data, but avoid speculation.
• Intersperse other information and do not focus only on the tragedy.
• Launch messages of hope and flee from “devastating prophecies”.
• Find out about what can benefit and what can harm listeners.
• Provide information about the process that is being lived, caring towards
the emotional needs of those affected and where help can be received.
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The role of doctors and healthcare workers
Doctors and health workers have a priority role, because they are often the
ones who detect whether a grief is complicated or pathological. Many people go
to the doctor, nurse or social worker with complaints, or with a discomfort that
hides a neglected grieving process. Therefore, this primary care is essential.
Socio-healthcare professionals have to know how to identify when they

are facing a complicated case of grief and when it is a healthy grief. Faced
with the latter, they must normalise the reactions, validate them, provide
support and closeness. Faced with complicated grief, they should refer each
case to the psychiatrist, if medication is required, or to the grief expert if no
pharmacological regimen is required.
From this it can be deduced the essential need for social and health professionals
to know a theory of grief that allows them to answer the main questions of
a bereaved, in addition to facilitating the differentiation of one case from
another. It is essential that they do not “prescribe” a specific period of time to
elaborate grief, that they do not pressure the patient or transmit topics such
as: “What you have to do is not think about it”, “Get to work so as not to have
so much free time”, etc.
3.5 What does the grieving patient seek in a doctor?
In today’s society, the institutionalisation of death and grieving has brought

complications for grievers. Faced with the way in which mourning was lived as
in the past - more natural, with rituals in which the neighbourhood, the social
sphere and the entire society participated - a more solitary or individual way
of living this process has been imposed.
These factors have contributed towards the limits of grief becoming more
diffuse, pushing patients to look towards the health professional for the “rule”
that distinguishes normal from pathological. By stripping grieving from the
“official” rites that give it meaning, and appointing a beginning and an end,
the need arises to institutionalise the treatment of this same process.
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The healthcare professional in grief
1. The grieving process involves enormous stress for the body, causing
physical wear and tear that sometimes leads to the development of various
symptoms that add anxiety and suffering to the bereaved.
2. Sometimes, during the period of illness prior to the death of the loved one,
the bereaved may abandon the medical treatments or processes that he
or she was following before the loss. This loss generates in the bereaved
a real awareness of physical death and it is then that fear and the need to
take care of and check themselves arises.
3. The difficulty of the social environment to contain the pain of the bereaver
and respond to the unknowns generated by death and grief lead them to
consider the socio-health professional as the only valid speaker.
● What does the griever seek in a doctor
The griever seeks different things from the Primary Care professional:
• To check their physical condition after grieving the loss of a family member.
• A review of their medications and medical processes that have been

interrupted by the illness or death of their loved one.
• Advice and guidance regarding whether or not their grief is being a healthy
process.
• Advice on practical issues, such as medication in case of anxiety, or

receiveing guidelines to help them feel better.
• Consolation. The griever seeks words of encouragement, as well as another

person who acts as a witness and accompanies them in their pain.
• Something different from what their social environment already offers

them. If what they need (understanding, affection and guidance) is found
in their social environment, they probably do not have as much need to go
to the doctor. They look for something different from what their close ones
offer them in the hope of finding themself better.
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• Hope. The griever trusts that the professional knows how to manage and
reduce the discomfort and pain of grief.
Ultimately, what the griever is looking for in the doctor is an answer to the
questions that he/she must face after the loss. They require guidance in a
generally quite confusing process, where there are no clear boundaries
between what can be considered as normal and what is not.
The demands of the griever will require the doctor has a greater training in
grief and specific training in listening skills, as ultimately what a griever is
lsearching for is another human being to comfort them.
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REMEMBER:
• Grief is a major stressor and can cause physical symptoms
that need to be addressed. Self-care is vital during the first
moments of this process.
• An open and close communication between the bereaved
and their social circle is crucial to prevent them from
feeling misunderstood and in order to avoid their tendency
of isolating themselves.
• It is essential to convey hope to the bereaved in the notion
that they will get over the loss, as well as confidence in that
they are capable of achieving so.
• There are different levels of intervention in grief, going
from no professional intervention to that of a specialised
professional.
• Doctors and health workers play an important role, as they
are often the ones to detect if a grief process is complicated
or pathological.
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DEFINITION OF GRIEF
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We live in a society in which talking about grief, pain or death is uncommon.

We live keeping our backs turned away from this reality for as long as we
can and only turn to face it once it is inevitable. Ignorance causes us to
react towards grief in an intuitive way, which quite often is not the most
appropriate one.
Comprehending the keys of the grieving process is essential if we intend to

help people who are going through one: not only in order to differentiate
normal reactions from pathological ones, but also because bereavers need
to know a theory that helps them understand in a simple way what is
happening to them. This in itself is already therapeutic.
If we thoroughly review the literature that exists surrounding this topic, we

will discover that there is not merely one, but rather many definitions of grief.
Each of them constitutes an attempt to understand it as a phenomenon, as
well as a step forward in its description. The truth is that there is no single
way to define grief, just as there is no single way to explain or experience
grief.
4.1 Grief: Definition
We know that in Spanish, the word “dolor” (grief) comes from the Latin
term “dolus” and it means “pain”. Therefore, based on its etymology, we
should not be surprised that bereavers feel pain and have a hard time. As
Doug Manning used to say, “Grief is as natural as crying when you’re hurt,
sleeping when you’re tired, eating when you’re hungry, and sneezing when
your nose itches. It is Nature’s way of healing a broken heart“.
One of the most widely accepted definitions of grief is that “it is the normal
process that follows the loss of a loved one”. This definition is heir to the
different nuances that different authors such as Bowlby, Tizon, Parkes or
Freud have incorporated into this definition.
The grieving process has been detected in numerous animal species, not
only in humans. An example can be the case of oysters. When one of the
members in an oyster pair dies, the surviving partner secretes a substance
which is chemically very similar to human tears.
Thus, grief is a behaviour that is installed in the human being at an almost

biological level and one which takes place after any loss in general: ie., the
loss of a job, a relationship, an object to which we were especially linked, a
loved one, or the expectations of having a healthy child. Throughout this
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guide, we will focus on grief as the normal process that takes place
after losing a loved one who has passed away.
Although we accept this definition as the one that comes closest to our
understanding or explanation of grief, it could be said that not a single
grief is the same as another one. This is because grief is an addition
to everything else that a person is and, since there is no single person
equal to another, there cannot be two equal grief processes. It is as if grief
were a transparency that is superimposed on the personal characteristics of
each human being: each of these peculiarities will modulate grief, making it
unique. Or which is the same as saying: it would be necessary to subtract
from grief that which a person already is, in order to adjust the treatment
to the expectations. This means that grief must be evaluated in its own
context, taking into account the individual characteristics of each person.
The death of a loved one will not turn someone into a more active,
sweeter, more sensitive, or more responsible person. If a person is very
sensitive, they will remain as such during grief, and if thye are very rigid,
they will handle their grief in a rigid style. It should not be assumed
that everyone will behave in the same way during grief, nor can it be
presumed that the expectations regarding its resolution will be the same.
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4.2 What is grief and what is not grief?
It is essential to differentiate grief from other similar processes. Grief can

frequently be mixed up with other mood disorders, such as major depressive
disorder. The DSM-V guide, (Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition, APA, 2013) is not of great help when carrying out
a differential diagnosis, as it centres all the responsibility in the clinician’s
opinion, who thus has to use their own experience in order to reach one
decision or another.
Often, the FMLC psychotherapy service is referred to by a psychiatric

service in the area regarding cases that have been diagnosed as recurrent
depression or as persistent grief. What I have found is that:
• Major depressive disorder and grief share most of the same symptoms,
especially if we are facing a complicated or pathological grief.
• When it comes to a grieving process, no significant improvements are
reported with the use of antidepressant medication, while in the case of
depressive disorder, the improvement is evident.
• Usually depressive disorder causes the loss of self-esteem, while in grief
this does not necessarily occur.
• A major depressive disorder and grief can coexist, but one of the
processes is almost always more urgent than the other and work on
both cannot be undertaken at the same time.
However, this distinction, which simplifies and clarifies a lot at a pedagogical

level, is not so simple to carry out at a practical level. Therefore, it is up
to the clinician to determine what decision to make in each specific case.
We usually establish a hypothesis and test it. And, if it does not work, we
conceive another one.
Likewise, we can establish differences between a healthy grief and a

complicated or pathological one. One of these differences involves the
intensity of the symptoms: at first, it is normal to have intense feelings of
pain, sadness, anger or others, but when that intensity persists over time
we are talking about to a pathological grief.
Another aspect that allows us to differentiate normal grief from a pathological

one, is the moment when symptoms first appear: if they come out when
the loved one dies, or after a few days, we are talking about normal grief.
However, if the symptoms crop up weeks or months later, or do not emerge,
we are talking about a pathological grief. This makes sense in that, when
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DEFINITION OF GRIEF
death occurs, the social support the bereaved recieves is prolongued for
some time, weeks, or even months. Yet, when it comes to a time-delayed
grief, social support is no longer present.
Finally, there are characteristics that allow us to differentiate a complicated

grief from a normal one: denial of death is one of the main signs of
pathological grief. Denial is a very primitive and typically psychotic defense
mechanism, as well as complex and structured hallucinations in which the
griever can see or even hear the deceased person.
Above all, we see a cultural perspective and, in that sense, what is

considered “normal” within one culture may not be so in another:
culturally normal behaviours related to the deceased are part of a healthy
grieving; while those that are not, are part of a complicated grief. Denial
that is upheld over time is part of a complicated grief, while if it only
occurs during the first moments, it is solely a protective mechanism.
In general, we can say that sadness in grief is associated with the loss of
a loved one and not with life in general. Through the grieving process, the
world is what seems amiss, not oneself or one’s own image. Moreover,
through a healthy grief, sadness emerges in the form of waves, it is
not constant and often coexists with moments of joy and feelings of
gratitude or admiration for the loved one who is no longer there, this is
something that does not occur throughout a complicated grief process.
There is no single criterion when it comes to correctly identifying

whether or not a person is going through a complicated grief.
Hence, it could be useful to use an inventory or scale that allows us
to define the needs of the person who asks us for help, as well as to
determine which treatment is the most appropriate one for them.
In order to accurately identify complicated grief, there are two inventories.

The first one, is the Inventory of Grief Experiences, created by Katherine
Sanders in 1977, which consists of 135 dichotomous items and is divided into
18 scales. This inventory is adapted into Spanish and is self-administered.
The average administration time is an estimated twenty minutes.
The second inventory we have is the Texas Revised Grief Inventory.

Better known by its acronym TRIG, this questionnaire was prepared by
Faschinbaguer in 1981 and consists of 21 items, divided into two scales. It
has also been adapted into Spanish and is self-administered. Its average
administration time is approximately ten minutes.
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The importance of achieving a correct diagnosis lies in the fact that normal
grief does not require therapy, whilst pathological grief does. Avoiding the
psychological treatment of people undergoing a healthy grief process would
provide important expense savings to the Spanish Public Healthcare System.
Health problems derived from bereavement could also be prevented, as
shown by the abundant medical studies on the matter, which indicate a
higher mortality rate arising from cardiac events and suicides, as well as
a greater use of healthcare resources by those undergoing complicated
griefs.
As we have already pointed out, it is especially important to measure the

degree of grief intensity, as this element makes the difference between a
normal process and a pathological one. In the first edition of this guide, we
included the Texas Revised Inventory of Grief, as it is an objective measuring
instrument. However, we consider that this instrument overdiagnoses
complicated grief and, furthermore, cannot be applied in Primary Care
consultations due to the limited time professionals have available to tend
for their patients. Additionally, we find that patients lack motivation to fill
out these forms and grievers, quite often, get tired of answering it and
abandon self-administration.
In order to replace it, we have included a series of questions that professionals

can ask their patients and can help in guiding them in their diagnosis:
1. Does the patient have physical symptoms that are not organically based?
2. Does the patient have depressive disorder symptoms (such as dysthymia,
lack of enthusiasm for activities that they previously enjoyed...) - that
do not subside with medication?
3. Are there any unresolved grieving experiences in the patient’s history?
4. Does the patient have the feeling that the world has become a dark or
dangerous place since the death of their loved one?
These questions should serve as a guide for healthcare professionals. If the

answer to these questions is affirmative, it would be appropiate to refer the
patient to a specialised grief treatment service that allows them to delve
into this possibility.
4.3 How does grief work
Grief is a normal process that most people resolve without the need for
therapeutic intervention. Nonetheless, what are the keys that solve the
grief of those who require psychological attention or need guidelines?
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Two types of measurements:
In this epigraph, we will address how grief works in general, respecting the
fact that each grief is unique, as not one is the same as another. There are
many things that can be done to relieve or sooth the pain caused by grief:
• Medication, to which we can turn to in order to treat the most acute

symptoms, reduce anxiety levels, bolster sleep or any other disorder
related to the damage and emotional wear that this process implies.
• Time. It is imperative that time goes by to be able to work on the

loss. However, we are not talking about a specific period of time, three
months or a year, as each person will need a different amount of time.
Also, time is not the only component involved in this process. Time only
sets distance away from a painful event and, in that sense, can appease
it. Yet by itself, the course of time does not cure anything.
• Pain treatment. Pain caused by grief requires for it to be seen,

recognised in all its nuances, legitimised and normalised. That calms
the pain. Therapy can help us in doing so, but if someone does so by
themselves they will achieve the same effect. The therapist conveys
the assurance that grief can be overcome, offers hope and normalises
grief’s reactions, inviting the patient to confront these reactions,
whatever they may be, in order to be able to live with them. And
they do so by speaking about these feelings from their own core: by
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accompanying them, acknowleging them, allowing them to unravel, thus

rewriting what happened and what is happening to them since then.
When we pay attention to pain, it dissolves, not immediately, but it does in
the medium or long term. If, instead, we distract it, the pain is postponed,
it freezes and accumulates.
On another hand, grief is a process that is perfectly regulated. It manifests

itself as a diffuse discomfort concentrated in the centre of the chest and it
thus, greatly distorts the diagnosis. If it is addressed, sorrow or a feeling of
emptiness or absence emerges, which is why crying frequently appears. When
we cry out long enough, it generates a kind of sedation, as tears have a chemical
component very similar to the main ingredient present in any benzodiazepine.
SUGGESTIONS:
• Stay calm.
• Normalise reactions, always within common sense.
• Do not strive too hard.
• Do not try to force or organise the grieving process.
• Be compassionate towards yourself.
• Follow your intuition.
• Get plenty of rest.
• Keep up the hope that grief can be resolved.
• Do not pretend, do not rely solely on the course of time and, above all, do
not return to life as if nothing had happened.
• Do not fight against grief’s reality and emotions, because there is a lot of
suffering in denial: what you resist, persists and what you allow yourself to
feel, flows.
REMEMBER:
• Grief is the normal process that takes place after
any loss. There is no grief without loss.
• Each grief is unique from the rest.
• Anyone can accompany or bring comfort to a
grieving person: pain needs witnesses.
• Some keys in offering basic help: pay close
attention to the physical aspects of grief, provide
hope and closeness.
• Grief differs from depression in that it is not a
disorder and that it is solved without medication.
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IRRATIONAL OR ERRONEOUS IDEAS REGARDING GRIEF: INADEQUATE FEEDBACK
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The expectations around how grief works, how long it lasts, whether it
comes to an end or not and how this occurs… This is to say, the theories
that each individual person establishes regarding this process, decisively
influence their evolution. In our society, there are many irrational ideas
about grief which people consider to be valid. Learning to demystify grief
and offering an alternative theory is a key factor in its resolution.
We have all heard, at some point or another -either through a relative or

an acquaintance- inadequate phrases that make us uncomfortable. Many
people find it difficult to remain silent when a death occurs in their social
circle. In their attempt to fill the void of silence caused by the pain and
sorrow for the loss, they may make comments that may seem inadequate
or awkward. However, sometimes during these situations, the most
appropriate phrase is: “I do not know what to say, I doubt there are any
words that can relieve your pain”.
Below, we shall elaborate on the most common and widespread

misconceptions regarding grief:
”Time heals everything”
This statement speaks of a passive person, one who expects things to occur
as if they had no control over what happens around them. This generates
a significant sense of loss of control and presents a panorama whereby one
can only wait for the pain to disappear, almost as if by magic. But, in reality,
time actually sets real distance with the death of our loved one, allowing us
to look at it with another perspective. In any case, we can strongly affirm
that what leads to the resolution of the grieving process is not time, but
rather what one does with their time.
“He/she would not want you to suffer”
This idea induces us into thinking that the deceased person were still alive,
an assumption that can block the bereaver’s acceptance of the death and,
at the same time, propel them to censor certain reactions for fear of being
seen from the afterlife and disregard their loved one. This idea must be
counteracted with the reasoning that when people die, they stop thinking
and feeling. Hence, if a person suffers or does not complete their grief
process, the only thing that occurs is that they do not get over the death
of their loved one.
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“It’s worst if you think about it”
Sometimes, when we do not know what to say to a grieving person, we

try to avoid the subject, as we consider it to be “delicate” or “thorny”.
However, when a person tries to solve their grief, they need to assimilate
and think about it in order to find some sense to it. Everything we resist,
persists and what we let be, dissolves.
“What you ought to do is to distract yourself”
This idea is especially widespread and refers to the need to hide or distract
pain, as it considers that suffering in itself is something pathological. Out
of all the irrational ideas we can come across, this is one of the most
harmful ones, because it blocks an emotional flow that is in itself a natural
healing source. Blocking, distracting or disguising pain only contributes to
complicate grief.
“You have to be strong”
This idea is often repeated and refers to two erroneous approaches:

the impossibility that expressing pain is a sign of strength and that the
expression of emotions is bad for one’s health. In general, these ideas
are deeply rooted in an individual’s personality, and are very difficult to
confront and change. Applied in a rigorous manner, the assumption that
“you have to be strong”, inevitably leads to an emotional blockage that can
end up pathologising grief.
“If you do not overcome it, you are not allowing the deceased to
rest”
This idea follows the same principal as the previous: “He would not want
you to suffer”. Dying implies to stop seeing, thinking and feeling. A person
who is dead -by definition- does not rest, as their vital functions and senses
no longer exist. If a person does not overcome grief, they will have a hard
time and may suffer more than necessary, but that does not imply that
they have to bear the guilt of preventing the deceased from resting.
“Those of us who are here, need you to be well”
Those closest to the bereaved express all these ideas with a single
intention: to relieve, comfort and avoid pain. The only problem is that
pain cannot always be averted. In the words of Jorge Bucay: “Grieving
hurts and nothing can be done to avoid it”. Therefore, although our
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social sphere says this with the best of intentions, these ideas only push
the bereaved to encapsulate, prolong or defer their pain over time.
We live with our backs turned, denying the truth about death for as long as
we can. Hence, when death strikes us closely, we feel frail and defeated,
not knowing how to reposition ourselves. We do not know how to handle
pain, so we resort to those strategies that we have always used and found
helpful. The problem with this is that, when circumstances change, the
strategies that are to be used must also change. What was once of use
to us, now no longer works, so we must implement new tools in our daily
lives.
Our social circle may not be very capable in comforting or accompanying us

in the face of loss. Quite often, the loss of a loved one brings with it other
losses, in this case, those of social relationships that we once enjoyed.
An explanation to this phenomenon could be the distance that originates
between the circle and the bereaved, a detachment that is bidirectional and
based on fear: the distress the social circle has of harming the bereaved
or of being infected by their pain; and the concern the bereaved has of
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exhausting the patience of their social sphere or the dread of being hurt
by them.
Inadequate expressions that hinder authentic communication and

can be upsetting:
• “This way he/she no longer suffers...”
• “It must have been a relief...”
• “At least you have more children...”
• “You can still have more children”. (In the case of early losses).
• “How old was he/she?”. (As though if the deceased was an elderly
person, the death could be justified or, in the case of children, as if
the pain would be greater based on the years they had lived).
• “A partner can be replaced, a child cannot”.
REMEMBER:
• In our society there are many irrational ideas about
grief that people consider to be valid, however they are
actually only harmful to the bereaved.
• Idioms such as “You have to be strong”, “He/She would
not want you to suffer” or “We need you to be well” are
inappropriate or awkward.
• In these cases, the most appropriate phrase to say is:
“I don’t know what to say, I don’t think there are any
words that can relieve your pain”.
• It is more useful to be present and limit yourself
to listen, than speaking: a look, a gesture may be
considerably more helpful than any word.
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WHAT DOES THE GRIEVING PROCESS CONSIST OF AND HOW DO
WE UNDERSTAND IT?
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WHAT DOES THE GRIEVING PROCESS CONSIST OF AND HOW DO WE UNDERSTAND IT?
Occasionally, grief -acknowledged as the normal process that takes place after the
loss of a loved one and as an adaptive period in which the person uses all of their
resources to overcome it- can get blocked, come to a halt or become complex.
There are at least two social factors capable of hindering the smooth running of
this process, which could be resolved in a natural way without complications.
One of them is the act of turning one’s back on grief: it is omitted, hidden
and is often avoided by society, as if wanting to avoid pain or prevent
suffering. An attitude that constitutes one of the biggest traps in this process.
The second factor that can hamper grief is trying to regulate pain, ie.
by classifying it. Pain is different for each person, regardless of the loss
they have suffered: there is no single way to experience affliction. The
stages or phases are ways of apprehending a reality in order to be able
to work and understand it. However, certain realities -such as grief-
are difficult to transfer to a clinical aspect, as each individual has their
own pace, their own strategies and their own way of processing grief.
Beyond any theory, the main key to grief is that any attempt to stop
or resist pain will increase and perpetuate it; while keeping a confident
attitude, allowing pain to flow, will gradually dissolve it. This explanation
is easy to understand and difficult to put into practise. A professional’s
job is to build trust in order to allow the patient to be in contact with
their own pain. It is a delicate task, one that is undertaken gradually,
by trying to progressively amplify the pain tolerance threshold.
The psychologist and researcher William Worden defines the tasks of grief as
those which the bereaver has to solve in order to be able to properly process
their grief. In so doing, he offers a simple and pedagogical explanation to
understand this process. He uses the term tasks instead of phases (according
to the theory of Colin Murray Parkes) or stages (according to the theories
of Elizabeth Kübler-Ross, 1973). The explanation is quite simple: when
talking about tasks, we give the subject the possibility of carrying out an
action in an active way, thus helping to relieve that feeling of helplessness,
of “What can I do for myself to be better?”. On the other hand, it places
the subject in an active place of grief, not a passive one (ie. suffering).
Specifically, Worden refers to four tasks of grieving:

• Accept the reality of the loss. Intrinsically related to this task is
the question of what to do with the deceased’s belongings. Both the
decision to get rid of them immediately and to keep them as if the
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deceased were to return, speak of a total or partial blockage of the

bereaved on this first task.
• Process the emotions associated with grief. As we have already
pointed out, Bucay says: “Grief hurts and there is nothing you can do
to avoid this”. Family members who try to “distract” the bereaved, or
people who “occupy” all of their time in trying not to feel, interfere or
interrupt this second task.
• Learn to live in a world in which the deceased is no longer
present. This is related to our own identity: I am no longer the
husband or wife of the deceased, but his widow or her widower.
This task refers to the roles that each one played, with accepting
assignments and different tasks from those that we previously
performed, but it also has to do with making the decision of what you
want to do with your life now, what do you need, what can they offer
you and what can you offer yourself.
• Emotionally relocate the deceased and continue living. This
is connected to the idea of “keeping” the deceased in a place that is
only ours, without constructing a shrine or denying their memories. It
consists of establishing new relationships, regaining hope, living and
not merely surviving.
These four tasks do not have to be carried out in a specific order, nor
are they successive; that is to say, completing each of the tasks is not
required before proceeding to move on to the next.
REMEMBER:
• The theory of the tasks of grieving helps the

bereaved to have an active attitude towards this
process, granting them a certain sense of control.
• There are four tasks and they are not successive,
nor is it necessary to finish one to begin another.
Sometimes they run simultaneously.
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6.1 First task: Accept the reality of the loss
The first task, “Accepting the reality of death”, is quite complex because it
not only consists of being aware at a rational level that the loved one has
died, but also requires assimilating all that this implies on an emotional
level: what it means to be dead, specifically defining what has been lost.
This invites the griver to walk a path that leads them to define who they
were to that person and who that person was to them. In doing so, we
delve into the meaning of loss.
Today we live with our backs turned to death for as long as we can.
Therefore, when we face the death of a loved one directly, it becomes an
unreal situation for us. We live with the false feeling that only the elderly
die or that only “others” have accidents. This is why, processing this task is
sometimes so difficult that it gets blocked or, at least, it gets complicated.
Sometimes the loss is so painful and so difficult to bear for the bereaved,
that the organism rations out the pain, causing an oscillation between
acceptance - in which the bereaved feels all the pain that it entails - and
non-acceptance, which causes the bereaver to have the “strange” feeling
that the deceased person has not died, but is on vacation or working,
despite rationally knowing that it has happened. In these cases, acceptance
should not be forced upon: one must wait until the bereaved is ready and
refrain from contradicting or confronting them. Each person requires their
own set time.
● How can this task become blocked or complicated?
We can detect that a person has partially or totally blocked the first task
of grief when, for example, they talk about their deceased loved one in the
present tense and not in the past tense.
Another way to detect if this task is blocked is to enquire after what the
griever has done with the deceased’s belongings. In the event that they
have kept all of their things (“I keep his /her room as he/she left it”) they
may be denying death through a mummification process (Worden, 1991)
as if the deceased person were to return. On the contrary, if you remove
everything that belonged to the deceased as if it never existed, you are
denying death through a process of minimisation.
Sometimes, denial acts in the form of a question, the bereaved ask

themselves: “What would have happened if...?” in an attempt to imagine
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different outcomes and, while they are imagining them, the person is alive,
if only in their mind and for a fleeting moment. This mechanism, which
is usually an unconscious one, causes the process to start all over again
several times a day, which is a huge waste of energy for the bereaved.
The death of a loved one pushes us to accept that death is a reality, that we
all die. That is a certainty that governs the world and the sooner we accept
it the better, since it is an immovable rule that works the same way for
everyone. In general, the idea of our own death or that of others generates
so much anguish that we need to deny it at least for some time, until we
are able to accept it.
Another extreme form of denial occurs in people who claim to see, hear or
feel in some way the loved one who has died, in a kind of “hallucination.”
It is a very primitive way of denying the loss and, if maintained over time,
these perceptions - which can be normal in the first moments or weeks
after the death of the loved one - can turn into something pathological.
In this context, everything that has to do with clairvoyance or paranormal

resources poses a special problem, as it maintains the idea that the deceased
person is “alive”. Since there is no scientific evidence to confirm whether
there is life beyond death, we cannot categorically state that it does not
exist. But it is clear that parapsychology can generate a lot of confusion in
the first moments after a loss and, furthermore, it is not scientific, while
psychology is.
In recent decades, the popularisation of clairvoyance, tarot and

parapsychology in general through certain television programmes has
favoured many people placing great hopes in a séance, which is why it
is increasingly urgent to unify positions in regards to this topic. When a
person dies we do not know if their spirit remains alive in the form of
energy or another type of matter, but it is evident that that person no
longer exists in the same way as they did before, that is, they no longer
have corporeity. Therefore, as we are unable to imagine how a spirit lives
or exists, we imagine it as it was when it lived physically.
In principle, our recommendation is to be cautious. Each person must make

their own decisions and the temptation to communicate with the loved
one in this way is understandable. However, this can be tremendously
expensive, being able to find a huge scam at the end of the road, or favour
the induction of hallucinations in cases of psychotic vulnerability.
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The theme of the afterlife links to another important element in the grieving
process: faith. It is a very powerful resource for those who are believers
and can turn to it. However, it is necessary to watch out for some harmful
messages that occur within the framework of religion, such as:
- “He/she would not like to see you suffer”. This message is inappropriate
for several reasons: First, because it blocks the pain, which can end up
complicating grief. As we have explained previously, grief involves affliction
and a fundamental part of overcoming it is working through and draining
that pain. Secondly, the message is incorrect because the deceased person
can no longer see us. That is precisely what physical death implies: that
the senses no longer function. If a person suffers from grief, that is the
only thing that occurs: he/she is afflicted by grief. But this does not affect
anyone else, nor does it harm the deceased, because - for better or for
worse - that person no longer feels, suffers, or enjoys life.
- “God took him/her because he/she was good, only the best die”.
This message is often repeated a lot in therapy sessions, as an expression
of feeling of profound injustice caused by the death of a loved one. Faced
with this kind of message, the answer we usually offer our patients is that
we all die, but only the deaths of good people, who are honoured and
remembered more, hurt. However, we do not publicly mourn the deaths
of people we consider “bad” and, perhaps because of this, we feel that the
best people are the only ones who die.
How can you help to process this task?
In order to work on this task, the bereaved person is gently asked to tell bit
by bit what happened, how their loved one died, describing in great detail
what occured at each given moment and reviewing what he/she was doing
at each instant. It is about collecting real data that allows the bereaver to
assimilate what happened and, at the same time, counteract the fantasy
that their loved one has not died.
Always respecting the faith and beliefs of each individual, it must be clear
that when a loved one dies their life - as we conceive life - is over: their
vital functions stop, their senses (hearing, sight, touch, smell and taste) no
longer work. In short, that is what it means to be dead. If there is another
way of living, whether it be in the form of a spirit or soul, that is up to each
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one of us, but without a doubt, it is an existence different from the one we
know and one hard to imagine.
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REMEMBER:
The first task in grief is to ACCEPT THE REALITY OF THE

DEATH, both emotionlly and rationally.
Blocks during this task can come about in different ways:
o Talking about the deceased using the present tense.
o Keeping the room as they left it, as if the deceased
were going to return.
o Removing everything from the room as if it had never
existed.
o Trying to communicate with the deceased through
mediums, spiritism, etc.
o Imagining different endings by asking questions like
“What would have happened if…?”.
The way to work around the first task is by asking the
bereaver to tell us how their loved one died, so that they
collect real data related to the loss.
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6.2 Second task: elaborate the emotions related to grief
The second task in grief is to work out the emotions and pain of the loss.
Not all of us feel pain in the same way, or with the same intensity. In
Worden’s words: “It is impossible to lose someone with whom we have
been closely linked without feeling a certain level of pain”. What we feel
and how we feel it will be part of each person’s individual process.
Encouraging emotional expression is one of the fundamental principles of

both accompaniment and grief therapy. It is equally important to know
the nuances of that expression: what those tears are made of, who is that
anger aimed at or what lies behind that guilt. It is not only important to
place emotions in words, but we must help the bereaved to elaborate the
particular and deep meaning.
One of the few certainties we have regarding grief is that it hurts, so the
way to overcome it is through feeling and facing that pain. We know that
the emotions regarding grief struggle to come out and that, sooner or
later, they surface in order to be addressed. Knowing these emotions and
naming them stops them from being perceived as threatening or potentially
destructive. Welcoming them helps the bereaved make sense out of the
experience, as well as knowing the information they provide about their
own needs. Only by expressing them will we know their meaning and can
will be able to satisfy them.
A key aspect of grieving is meeting the needs that are generated throughout
the process. When a need appears at the forefront - for example, being heard
- it remains activated until we attend it. Once taken care of, it disappears
and is replaced by another need that was previously in the background. As
we address these needs, the process moves forward.
We can often identify the needs that are hidden behind an emotion. Emotions
function like needs, as they are taken care of and legitimised they are
undone, but, if they are repressed, they are perpetuated over time. As with
needs, when an emotion is taken care of, it dissolves and another appears,
advancing the grief process.
The range of emotions, thoughts, and behaviours that occur in grief is very
wide. It is normal to feel sad, empty, sad, or angry after a loss. However,
in caring for grief, it is essential to listen and payimg attention to the
particular nuances of each person’s emotions.
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Modern conceptions regarding bereaving define it as a unique process

in which the bereaver builds their way. It is not conceived as a passive
agent whereby emotions pass, but as an active agent that decides and
gives its particular meaning to the experience. Understanding bereaving
from this conception turns the healthcare agent into a companion
alongside the griever’s path.
The healthcare worker knows some certainties regarding this path, but
knows that the nuances are different in each person and accompanies the
debtor always keeping this distinction in mind:
● Pain defines the emotional experience after injury and is defining grief. It is a
complex experience, made up of a multitude of feelings and personal meanings.
Pain is not only felt on an emotional level, but also on a physical and cognitive
level. It is a global experience. It is hardly definable in their experience.
Therefore, to be able to name it, set limits and locate it, it is very helpful to use
metaphors, images, colours and even pinpoint where we feel it in our body.
● All emotions are adaptive and necessary. Thus, sadness and grief
invite one to be with oneself, to review memories and the experience
of death, crying or encountering different emotions, favouring both
the assimilation of loss and emotional processing. That is the hidden
need behind the emotion. For this reason, pain and what comes with
it, is necessary at first. Later, when emotions are more conscious and
processed, finding the balance between doing and feeling will help
adaptation on the day to day life without the deceased. It often happens
that, following some time after death, the bereaved feels worse than at
first, sadder. The fact that he/she feels this way is a sign of progress,
as that sadness indicates that the bereaver really realises what he/she
has lost. Noting that it is progress in grief and explaining the meaning of
this sadness can be of great help to clarify the process. It also helps the
bereaver to feel more comfortable with their feeling and not try to avoid it.
● Feeling of emptiness. Generally the emptiness is felt when the grieving

person is working out the first task, related to the acceptance of death. It is the
physical sensation that implies the certainty of the absence of the loved one.
● Anger. Worden (1997) states that if anger is not properly recognised it

can lead to a complicated grief. Anger can be directed against the deceased
(“Why have you left me alone?”); be a means of expressing rebellion in
the face of the feeling of injustice caused by loss (interpreting death as a
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punishment); or as an emotional expression of the denial of the reality of

death. The blockage of this emotion can show itself in retroflexion, that
is, when the bereaver directs anger towards themself. Helping the grieving
person to control this anger and express it in an adequate manner will
contribute in advancing with this task.
● Guilt. After loss, bereavers often experience a sense of guilt, with ideas
such as: “I could have done more” or “What we did was not enough”.
The unreal guilt –that is, the one that has no real foundation- ends up
being blurred with the dialogue and the contrast with reality. However,
although as psychologists we detect that this guilt may have an unreal
basis, we must allow the bereaver to express it, because probably the
people around them will already be trying to prevent them from thinking
about it, or be telling them that “that is nonsense”. That is why it is
necessary to offer them a space where they can express and cry their
guilt. We will take care of the unreal part of it later through dialogue.
Guilt can also be used by the bereaved as a control mechanism. It is a way

of making life predictable and controllable. Ideas such as “He died because
of me” contain a painful message, but one that allows the bereaver to
answer a question that often does not have an answer.“Why has he died?” or
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“Why him?” are questions that are difficult to answer, as they place us
before a reality full of uncertainty. But the truth is that death is not under
our control: the fact that the bereaver feels guilty without being guilty is a
mechanism that offers them a sense of control over death and, in addition,
allows them to answer those questions with tangible realities.
We may face cases where the guilt is real. To work with this kind of guilt,
tools such as the empty chair, letters that are not sent, etc., are helpful,
that is, techniques that allow the bereaved to express their guilt both to the
deceased and to themself. It is also useful to ask the griever some questions
to help them place into context the decisions they made: “Why did you decide
to make that choice or say such a thing?”; “How were you during that vital
moment?”; “What was your relationship with him/her like at that time?”.
● Anxiety. This emotion is related to the feeling of abandonment, of being

lost, of helplessness and fear of life. It is linked to the inability of the
bereaved to adapt again to life without the deceased. When someone close
to you dies, death becomes a reality and the fact of living it so closely makes
the bereaver aware of their own death, a feeling that can cause anxiety.
● Desire to die. When working with the bereaved it is important to assess the
suicidal ideation and whether or there is a plan. It may be that their wish to die
is linked to the need to reunite or see the deceased again, and that it is a distant
wish that the bereaver recognises as a fantasy, but it must always be explored.
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In therapeutic practice with the bereaved, it is common to observe

how many experiences of loss have been set as traumatic. The fact
that the experience is fixed in this way may be due, on one hand, to
physiology: there are high levels of neuronal activations associated
with the moment of the death experience. The cause may also be that
such experience has invalidated the basic schemes with which the
bereaver understands and “arranges” the world. These schemes are
the axioms that, within our thought system, help us to simplify reality.
In this case, the experience of the reality of near death collides with the sense
of security, justice, prediction or optimism that the bereaver had (Neimeyer,
2002). Helping the bereaved to make sense of the loss and to reconstruct
these schemes by integrating death into them will help them to adapt to the
loss, as well as allow them to work on the traumatic component of death.
In other cases, it occurs that the bereaver is afraid of their own emotions:
fear that these will overwhelm them, that they will invade them.
Accompanying the bereaver in these feelings allows them to understand
that sometimes one ends up exploding due to repressing an emotion for
a long time. When it is repressed, the emotion grows and thus, when it
comes out, it does so in an explosive way and that is what really scares
them. It is an essential job to teach them how the cycle of emotions works.
The factor that may block this task is not allowing yourself to feel, or
hindering exclusively in one of the emotions. Other possible ways for the
griever to block this task are:
- Focusing only on the positive memories of the deceased, which

leads the bereaver to idealise them and, therefore, not allow all emotions
and cognitions to be expressed, only the positive part, leaving another part
of the experience hidden and unexplored.
- Focusing only on the negative memories of the deceased. This causes

the bereaver to be impregnated with the emotion that these memories
produce and cannot move forward. Sometimes it has to be treated as post-
traumatic stress disorder.
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- Avoiding all contact with emotion, memories or thoughts about

the person who has died, in an attempt to distract the pain and all
experiences related to the loss through continuous activity.
In addition to the emotional coping of the bereaver, blocking the second

task is also influenced by the concept of how grief should be lived in the
society to which the patient belongs. We are social beings, we live as a
family, in a community and, therefore, the influence we receive from it is
decisive. Western society tends to push the bereaved towards distraction
from pain, pressures them to stop crying or thinking about the deceased,
interfering in the elaboration of grief.
All the sensations and feelings described are normal and frequent within
the grieving process. Some authors argue that what happens on an
emotional level during the first three months after the death of a loved
one falls within normalcy. Blocking the second task, as well as the grieving
process, can cause normal feelings of sadness, anxiety or emptiness to
escalate into more serious emotions such as despair, isolation, major
depression or complications related to anxiety (phobias, fear of illness, etc.)
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It is advisable to take into account the reactions of the griever regarding

certain calendar dates, such as anniversaries. Calendar dates are
important: both those that are meaningful to the family (birthdays,
wedding anniversaries, death anniversaries) and the holidays (Christmas,
All Saints’ Day). It is normal for emotional reactions like sadness or
pain to appear as these significant dates approach. Studies indicate that
reactions to anniversaries are normal even up to ten years after the loss.
Sometimes, exploring the proximity of significant dates on the calendar

can shed light on the emotional experience of the bereaved, discovering
what lies behind surprising reactions of pain or sadness or ones whose
origin are not understood. Preparing for important dates in advance can
be helpful, planning how and with whom you want to spend those days.
The assistance in elaborating this task begins with the observation

of the bereaver: how they express the emotion, how they cope with
it, if they identify what is happening to them, if they are aware of the
sensations that appear and accept them, how they express it... All
these data is important, because it will let us kmow how the bereaver
is managing their feelings and if they have blocked any emotions.
Based on this observation, the help will be aimed at solving the needs of the
bereaver: helping them to identify the emotions, name them and express
them; or legitimise by listening to what they are feeling and offer a space for this.
Physical sensations are also a great emotional indicator: how the body
expresses the emotion, if there is pain, a suffocating feeling... It is convenient
to make a stop at these feelings and see how the bereaver experiences
them. Approaching them will also help clarification.
As a tool for developing this task, it may be helpful to ask the following
questions:
What do you miss the most and what do you miss the least:
This question allows us to encourage the exploration of all the feelings
connected to the deceased.
- Empty chair: This technique is used to work on emotions and issues

that may have been incomplete.
- Working with photos and memories: Talking about the relationship

that existed between the bereaved and the deceased, through photos
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and objects that symbolise special memories, brings us closer to the

emotions of the bereaved and helps us to explore the totality of the
experience with them.
- Drawing. We ask the griever how they would draw their grief, pain,
anger... This is a way of approaching intense emotions.
- ‘Focusing’ can greatly help the griever to stay close to their feelings
and to approach them in another way.
In the end, it is about helping the bereaver stay with their feelings
-whatever they may be- so that they dissolve, so that they trust that
grief can be overcome and they can “live” with those emotions. When
this is put into practice, the emotion dissolves. Of course, it must be
borne in mind that in order to “be” with those uncomfortable emotions,
one must keep a certain distance away with those same feelings.
REMEMBER:
The second task is TO ELABORATE THE EMOTIONS RELATED TO
GRIEF, such as pain, sadness, anger, anxiety or guilt.
This task can be blocked if the griever does not allow themselves
to feel the emotions or is excessively blocked in one of them by
excess or by default. Other forms of blockage are:
• Focus only on the positive memories of the

deceased.
• Avoid all contact with emotions, memories or thoughts

related to the deceased.
The conception that may exist regarding grief is a key element

in this task’s blocakage, as well as how the bereaved’s society
considers it should be experienced.
The aid to carry out this task out will start by observing the
bereaved, after which we will resolve their needs, helping them to
identify their emotions and legitimise them by listening to them.
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WHAT DOES THE GRIEVING PROCESS CONSIST OF AND GRIEF
HOW DOINTERVENTION
WE UNDERSTAND
LEVELS
IT?
6.3 Third task: Learn to live in a world in which the deceased is

no longer present
The third task of grief refers to the adaptation that the bereaver needs to
undertake with regards to all the changes that the death of their loved one
implies.
In order to begin this task, the bereaved person needs to be aware of the
roles that the deceased played. This is where the first problem occurs:
normally, people are not aware of the role that the other person played until
sometime after their loss, since we live naturally assuming the functioning
of our lives.
For this very reason, it is necessary to carry out a first phase which involves
identifying the tasks that the bereaved will have to carry out, either in the
present or in the future, as well as those changes that the death implies in
terms of the roles they played and day-to-day activities.
A problem related to the identification of roles is that, while some are obvious,
others are not. This can happen either because they are exceptional -that
is, they do not occur regularly-, or because other family members willing to
help assume that burden and prevent the bereaved from becoming aware
that these roles exist, since at no time do they feel the need to respond to
the demand that these imply.
Some examples of these roles could be: the economic administration of

the home and banking procedures, the completion and presentation of the
income statement, procedures related to home insurance, the enrolment of
children in school or their extracurricular activities, relationship with school
tutors, etc. These are roles that are often assumed in a timely manner, and
therefore many of the people who come to therapy are not aware of these
roles until they are imminent.
When referring to this issue, among the bereavers it is common to hear

complaints such as:
“Never in my life have I made the income statement; I don’t even know
where all the papers are”.
“My wife was in charge of that kind of thing, I don’t know how to do it”.
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In order to be able to identify the roles that the deceased assumed, we can
ask the bereaved what new tasks they have learned to do, what things the
other person was in charge of, or in what practical aspects of their life the
deceased person is missing. From there we can help them to incorporate
new roles or tasks.
These roles not only refer to the execution of practical tasks, but also
to the need to acquire certain identities or even to reformulate personal
identity. Work with the bereaved on their new status or role. Here are some
examples of role / identity change that take place after the death of a loved
one:
• A widow ceases to be the X’s wife and becomes the X’s widow, or she
will only use her name.
• A father or a mother who loses their child can stop being even a father,
to be an accomplice with their deceased child.
• A daughter who loses her father is no longer daddy’s little girl.
• A child who loses a sibling can become the oldest child, or stop being the
middle child, or become an only child.
• When one of the parents dies, they go from being a child to an orphan.
• You can stop being a large family due to the loss of a child.
• You stop having a best friend.
• You go from being accompanied at home to being alone.
It must be clarified that the bereavers have great problems to overcome

this task, since it requires them to redefine all the core elements on
which they rely to define themselves. This is especially common in
women who base their role on caring and relationships with others.
There are many grievers who experience an inmense feeling of helplessness

and inability, believing that due to their life history they will not know
how to carry out these tasks successfully. This causes a deterioration in
their self-esteem and generates in great feelings of disappointment. These
people think that changes are due to chance and that they have no power
to change or take charge of such situations. If we do manage to do a good
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job during this task, the image of the bereaved can be strengthened and
their self-esteem will greatly improve.
From what has been explained above, it can be deduced that, even if the
grieving person feels powerless, they will often have to assume many
functions that they did not perform before, but not for pleasure, but
rather because they have no other choice. Here are some of the simpler
tasks they Objects may have to tackle:
● Pay certain bank receipts that were previously not their responsibility.
● Make adjustments in the family economy.
● Cook, when you had not done so before.
● Take charge of the care of young children.
● Change a flat registry and place it under their name.
● Get their driving license in order to use the family car.
● Make home repairs.
● Enroll in college or any other type of education.
● Go on the school bus route or by bus to school because they do not

have someone to take them.
● Pick up the clothes up and arrange them in the wardrove.
● Study alone.
● Get up using an alarm clock.
Although at the beginning the fact of carrying out these activities can cause
problems and feelings of inability or failure, later on the achievement of
objectives - no matter how small - provides great satisfaction to the bereaved
and also, bit by bit, a feeling of ability and control. As they advance with
this task, many patients comment on how surprised they are to be able to
take on activities that were previously unthinkable.
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People who block this third task of grief do not adapt to life: they are
immersed in a world that has been paralysed, without evolving. The
bereaver is not able to develop coping skills, or else misses opportunities
to incorporate new learnings, isolates themself and avoids answering the
demands of life in many ways. These people tend to become dependent,
given their inability to cope with the simplest and most everyday obligations.
However, it should be noted that some (albeit small) changes always occur
during this task. But this only happens because they are forced to cover
their most immediate needs.
Solving the third task allows the bereaved to grow and even gain autonomy.
On the contrary, if they decide to not solve the task, they will be trapped in
a life that they can hardly fully enjoy. Part of our work as psychologists will
be to analyse the aspects that the grieving person must take care of and
the roles that they must assume.
In order to return those things that you must take care of, we can analyse
and plan the procedures in a more concrete way with the patient who is in
therapy. We can also plan and arrange pending activities from the simplest
to the most complex. As the griever progresses with this task, they will
gain confidence and it will no longer be necessary to plan the steps to
follow with them.
As the patient tells us about small changes, we must reinforce the fact that
they realised they are necessary, as well as any approach towards the task
or tasks that they have carried out by themselves and that they did not use
to do before.
In short, it is about caring for the needs that appear almost spontaneously.
When each of them is addressed or resolved, it dissolves and another one
appears. Both the fact of detecting the needs of each one and of satisfying
them is a journey that guides the individual process of each griever in a
unique way. If the needs are blocked, either because we do not detect them
or because they are not satisfied, this can cause a lot of dissatisfaction in
the bereaved. Therefore, it is positive to promote a connection with each
patient and their demands, as well as the possibility of asking for help.
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REMEMBER:
● Grief’s third task consists of ADAPTING TO AN ENVIRONMENT

IN WHICH THE DECEASED IS ABSENT, with all the role changes
that this implies.
● Grievers often have several problems in overcoming this
task, as it requires them to redefine all the core elements on
which they rely to define themselves, it also involves assuming
responsibilities that the absent person was previously in charge
of and for which the bereaved are not usually prepared for.
● This task can be blocked if the person is not able to develop
coping skills, or misses opportunities to incorporate new skills,
isolating themselves and becoming dependent.
● The help in preparing for this task can be directed towards
identifying the new roles that the bereaved must assume,
gradually planning the tasks that must be carried out and
reinforcing the small advances and changes in the role that
they are assuming.
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6.4 Fourth task: To emotionally relocate the deceased and

continue living
The fourth task of grief involves emotionally relocating in our inner world
our loved one who has died.
After the death, the memories and memory of the lost person are very
present, becoming almost the protagonists of the life of the bereaved.
Elaborating the tasks of grieving, assimilating the death and facing
the emotions and the day to day imply that the relationship with the
deceased and their memory are very present in the mind of the bereaved.
As the tasks are elaborated, the memory of the deceased - even

the bond with them - takes on another form. In this period, the grief
would be like a large revolving shelf that the bereaver is rearrenging
as he/she faces, accepts and assimilates reality. Thus, with the
elaboration of the fourth task, leave room to place new things.
Elaborating the fourth task of grief does not mean forgetting the deceased.
It is common for the griever to think about this idea and it causes them a
lot of anxiety. However, relocating the deceased does not consist in denying
their memory, but in living with the past in order to live in the present.
Experience with the bereaved has shown that, in order to carry out
this task, it is necessary that the previous tasks have been well
resolved. It would be very difficult to elaborate it if death is not
really assimilated, if emotions and pain have not been faced, or if the
bereaver has not begun to adapt to the routine and to a world without
the deceased. If there is not enough road travelled in the other tasks,
facing the fourth will be a somewhat fruitless effort for the bereaved.
The fourth task of grief has to do with hope, with living and taking
risks again, getting involved again in activities and planning for the
future. Everything that is linked to the idea of not wanting to live will
be blocking this task, for example: the fact that a widower promises
herself not to fall in love again is a blocking indicator, not because
it is mandatory to fall in love again, but for living it as a prohibition.
This fourth task of grief sometimes remains unsolved. We often hear that
grief over the death of a loved one never goes away. It almost seems that
the general expectations and what is socially accepted is that the bereaver
is in pain eternally. We accept it as normal that the grieving person lives
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without hope, so that both the bereaved and their social sphere as well as the
psychologist stop making the necessary effort for that to change or evolve.
We refer to this state as the “shadow of grieving” and it is defined as a form

of chronic grieving that bereavers sometimes carry for the rest of their lives,
comparable to a shadowy pain that underlies the feelings of the person.
The path of grief is hard, painful and requires effort, determination and
perseverance, but it can have an end. Devising the fourth task leads
certain people to make a deep review of their identity, to the point of
initiating a process of personal growth. A defining feature of any personal
crisis is that the foundations that sustain the deep values of the individual
-that is, the general explanatory schemes that have been forged around
their conception of the world and their own identity- falter and crack.
Personal growth occurs when the individual affected by this crisis takes
advantage of that moment to turn on themself and concentrate their efforts and
perseverance in the re-elaboration of these schemes, as well as the deep internal
meanings that give coherence to their vision of the world and of themself.
Frequently, clinical experience shows us how the bereaver, after elaborating

the grieving process, perceive themself to be more human, more sensitive
and more understanding in regards to other people’s problems. After
suffering the loss of a loved one, priorities and the arrengement of values
often change. This can be confirmed by any professional who works in
grief therapy, as contact with the most spiritual part of the patient is very
close. I can affirm emphatically and in the first person that after having
faced a grief and having overcome it, many of the patients grow personally
and feel fuller, more compassionate, more sensitive, or more generous.
However, not everyone who suffers a loss solves it by embarking on a

path of personal growth and positive learning. Those who do, are resilient
people and those who have elaborated post-traumatic growth or flourishing.
The fact that the bereaved faces and solves the four tasks of grieving
places us in front of the following questions: “Does grieving ever end?”,
“When can we say that it is over?”
Grief is a process with a beginning and an end. Various authors consider

an indication of completion the fact that the loved one can be remembered
without pain and emotions and enthusiasm for living can be re-experienced.
But even when the bereaver has already finished the grieving process, it
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can expected form they to continue to go through ups and downs, especially
when it coincides with certain important dates.
It is necessary to emphasise that the process and the duration of grief

are alligned to a personal decision. Along this path, the bereaver makes
a multitude of decisions and, at a certain point, must also decide whether
or not to continue grieving. The result of all these decisions will be the
development and end of grief or, on the contrary, its blockage. Hence, as a
conclusion, the duration of this process is very personal.
In the fourth task of grieving, the professional’s help should be aimed at

making the bereaved decide whether they want to remain in mourning or
reencounter life. To work on the possible blockages of this task and help
the bereaver through their process, these techniques may be useful (only
for clinical therapists):
- The vital footprint: This concept is based on the various ways in which
the people in our lives influence us. We are all permeable to the people we
love and with whom we live, so that we absorb their influence in different
ways: gestures, ways of thinking, expressions, shared values, tastes, etc.
The fact that the bereaver is aware of the mark that the deceased has left on
them can be a way of paying homage to them and rebuilding the bond with
the loved one who is no longer there. Of course, not all traces are positive,
the bereaver may discover traces of the deceased’s influence on conflicting
personality traits (eg. insecurity, obsessive character, etc.). Working on
these traces will also help them to review the image of the deceased and,
therefore, to relocate them emotionally. What footprint would I like to give
up and what footprint do I want to endure? It can be a good way for the
bereaved to become aware of the “legacy” and take responsibility for it,
choosing what they want for themselves.
- Unsent letter: This tool is one of the most useful and powerful in working
through the grieving process. It consists of the bereaver writing a letter
(or letters, if we see that it is convenient during the process) where they
express everything they want, all that remained unsaid, what they need
to explain. It is an open letter, without an established script. The only
essential element is that at the end of the letter there is a farewell. It is a
very difficult process for the bereaver, so it is advisable to alternate it with
other lighter activities. The letter should be read by the bereaved in the
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context of an individual or group session. Meanwhile, the therapist or other

members of the group can write down what they hear, what has been more
emotional or significant, etc. This tool helps the griever to put to words the
words - of their grief experience - and to find a place for the deceased in
their mind and heart.
- Connection objects: Among the belongings of the deceased, there is

often an object of special importance for the bereaved, either because of
what it meant for the deceased, or because of what it represents regarding
them. The fact that the bereaver keeps this object in mind, keeps it in a
special place, or works on it in the therapeutic context, can greatly help to
address the relationship with the deceased and to rebuild the bond.
- Measure grief: This technique consists of using an object that we have

at the office (for example, a table), so that one of its ends symbolises the
death of the loved one and the other, the overcoming of the bereavement.
The bereaver must pinpoint where they feel they are between the two
points. This retrieves the patient to the moment of the path they are on,
allowing them to gain a perspective of the work they are doing and to
specify what they still have to face.
- Useful questions: What are your strengths? Who am I now? What are
your values, your vision of the world and of yourself? Asking these questions
helps the bereaver to reconstruct their meanings, as well as to reflect and
rework their value system and self-concept.
Throughout the work with the bereaved, it is important to clarify what it

means for them to elaborate grief and to work on this specific task. If they
do not understand what is involved in grieving, it may mean that there
is a block in resolving it. It is also helpful to work with the bereaved on
what their fantasy is about ending the bereavement, with questions such
as: “What would you lose at the end of the bereavement?” Working on
the answers to this question with them can help, on one hand, to correct
possible false beliefs regarding the end of grief and, on the other, to expose
possible blockages that are interfering with the completion of the process.
William Worden’s Four Task Theory sheds light on the process and is
very proactive. If we combine this theory with the one that Alba Payás
enunciates in her book “The tasks of grief. Grief psychology from an
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integrative-relational model” (2010), the understanding of the process is

further broadened.
The model that she suggests sets before the bereaver the four tasks of
grieving but, at the same time, they are also experiencing four different
phases:
1. Stun and shock.
2. Avoidance and denial.
3. Growth.
4. Transformation.
Payás states that the task she suggests the bereaver need to carry out
must be consistent with the phase in which they are in. That is to say: if
the person is in the avoidance and denial phase, we cannot suggest a task
that has to do with accepting death, because then they will fail.
Each of the grief tasks brings light to the process as a universal phenomenon.
None are complete and none are perfect, but each represents an effort to
increase an understanding of the process.
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REMEMBER:
● The fourth task of grief is to EMOTIONALLY REMOVE THE
DECEASED AND CONTINUE LIVING, without forgetting about
the loved one, but learning to live with their memory in order
to live in the present.
● This task involves recovering the hope of living. Sometimes
it remains unresolved, so the grief becomes chronic. Any
personal attitude from the bereaver that is connected to the
idea of not enjoying life again is an indicator of blockage.
● The elaboration of this task leads many people to re-
examine their identity in a profound way, starting a process
of personal growth in which the schemes and values that until
then configured their vision of the world and of themselves
are remade.
● The elaboration and length of the grieving process is
intrinsically related to the bereaver’s personal choice, who at
some point along the way will have to decide whether or not
to continue grieving. The result will be either overcoming the
process or blocking it.
● In this task, professional help will be aimed at helping the
bereaved in this choice, working out the possible blockages
with tools such as the vital trace, letters to the deceased,
objects of connection or questions aimed at reworking the
value system of the bereaved.
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ANTICIPATORY GRIEF VERSUS DELAYED GRIEF
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The concept of anticipatory grief, used in connection with delayed grief,

refers to two different moments in this process. One takes place before the
loss occurs, normally when a loved one is diagnosed with a disease that
has no cure. At this point, the family begins to come to terms with the idea
of what will take place, the acceptance of loss begins, the pain of imagining
an impending death.
It also sets up a stage characterised by what it entails to witness the physical

and emotional deterioration of a loved one, the attrition produced by long
hours in hospital, as well as changes and readjustments in schedules,
meals, and the organisation of life in general. This period requires each
member of the family to adapt their routine to be able to take care of the
relative who is ill, whether that may be at the hospital or at home. It also
encourages closeness with the loved one, in order to spend as much time
as possible with them. And at the same time hope is still maintained, in
spite of the diagnosis.
Nowadays, most authors consider that anticipatory grief is a positive adaptive

response in the face of death because it offers people the opportunity to
begin to work on the profound changes that come with loss. It is more than
apparent, that anything we may anticipate is less shocking in comparison
to a sudden or unexpected death; however, it implies witnessing the patient
undergo painful scenes, due to medical interventions or due to the suffering
caused by their ailment.
Anticipation may help grievers prepare for what lies ahead. But, as with
grief, not everyone is going to experience it in the same way, not even
within the same family. The agony and the moment that death occurs will
be especially critical and delicate for the family. The basic guidance that
professionals present at the time of death should provide family members
is mainly moral support and solutions for their specific problems.
When death finally takes place, it is common for an emotional explosion to

occur within the family. During these moments, perhaps the only help that
can be given is to offer a comforting presence: adopt a restrained attitude
of listening and affection, respect the manifestations of mourning and offer
ourselves to take care of daily tasks, no matter how simple these may be.
Anticipated grief and the period of hospitalisation itself can become more
complex due to what we know as “family surrender.” This phenomenon
consists of the inability on the part of the family to offer an adequate
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response to the multiple demands and needs of the patient, as well as the
situation in general.
How we can accompany the family
The care provided to family members who are close to losing their loved
one will be aimed at relieving their fears and solving difficult situations that
may arise:
• Offer clear, concise and realistic information to understand the disease’s

process, the symptom’s meaning and the treatement goals.
• Have the availability, understanding and support of the medical caring

team.
• Set aside time to stay with the patient.
• Intimacy for physical and emotional contact.
• Listen to the expression of their emotions: sadness, anger, grief and

fear. The patient’s family needs to be listened to and their feelings need
to be understood and accepted.
On another hand, delayed grief is the reaction that appears long after the
death of the loved one. It is an incongruous answer in time. Grief takes
time to manifest itself because there has been a previous blockage of
the process, either due to the impact caused by the loss or because the
bereaved was unable to process it at the time. It is also known as a “frozen
grief”.
Delayed grief is sometimes solved spontaneously: the person becomes

aware of the previous blockage and how they are taking charge of the new
reality. Occasionally, someone else from their circle is the one who detects
this blockage and refers the bereaved to therapy.
The difficulty that we encounter with delayed grief is that, due to the time
that has gone by since the loss, professionals sometimes have difficulty
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associating a patient’s symptoms to grief and it is diagnosed as depression.

Another difficulty stems from the fact that social support towards the
bereaved disappears over time, thus when grief “defrosts” social support
is no longer present.
REMEMBER:
• Anticipated grief takes place before death.
• There continues to be hope.
• The griever can experience a lot of depletion arising by
being aware of the deterioration and the changes that
occur in the family in order to adapt to taking care of
the patient.
• Delayed grief is the one that appears long after the
death of the loved one has occurred.
• This grief may occur because the death of the loved one
has been shocking, or because the bereaver was not
prepared to process it at that time. It is important to
detect it in order to work on it as grief and not as a
depression.
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GRIEF AND PSYCHOSOMATICS
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Psychosomatics is the study of all the physical reactions reflected in the body
that lack an organic explanation. We are talking about emotional reactions
that cause changes at a physiological level: muscle pain, headaches, rise or
fall in blood pressure... everything that leaves a sign on the body.
In this context, we may find symptoms that range from those that can be
easily explained by the emotional reaction, up to other symptoms caused
by an encapsulated emotion that -in appearance- do not have an obvious
relationship with grief. This can make a person “wander” from doctor to
doctor, after the death of the loved one, searching for a cause to their
discomfort.
When I come across a case like this in therapy -a patient whose discomfort
is not only psychological, but also physical- the first thing I do, is to send
them to the doctor for a referral to the specialist if it is due to a pathology
that has an organic origin. Grief is a process that involves a lot of stress for
the patient and this stress can influence the body, making it weaker.
It is quite usual for health to be affected during grief. This can be due to
several factors:
• Neglecting body care during the illness. This is common due to the
amount of hours spent in hospital, eating out, reduced resting time, or
the abandonment of treatments that were in progress, among other
factors.
• Mimicry with the patient. It is possible that the bereaver comes to

reproduce some of the symptoms experienced by the deceased person.
If they died from stomach cancer, the bereaver may express digestive
or intestinal discomfort; if they died from a heart attack, the bereaved
may present symptoms related to an increase in blood pressure, etc.
• Sustained stress over time. It may also occur that the physical
discomfort is connected to a deeper meaning on a psychological level,
and these are the elements with which expert grief psychologists work.
In these cases, we resort to the feeling and focalise all the attention
there, amplifying it and allowing for it to express itself. There is no direct
translation of that meaning, each person associates their emotions with
different meanings and the psychologist only validates and releases
them.
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In a traumatic grief case, I treated a man whose brother had died after
heart surgery. This patient had a very painful feeling in the diaphragm,
which at first did not attract our attention. He worked this discomfort with
a physiotherapist, but the sensation did not disappear. After a few sessions
with EMDR, he was able to associate that feeling to a tube that had been
placed inside his brother in order to drain an infection he had in his heart.
Up until that moment, that image had remained cornered in his memory and
connecting with it caused him a great deal of pain. He cried a lot throughout
the entire session; but during the following one, this feeling had completely
dissolved.
This is just one of the many cases I have seen in therapy throughout my
career; perhaps the most obvious one. However, during the daily practice
of grief psychotherapy, when working with the body of the bereaved, I
encounter feelings that enclose meanings that are related to the process of
loss.
These cases must be differentiated from others where the physical problem
is only a distraction from the main process, ie. a way to defend oneself
from the pain endured by grief.
A woman who had lost her husband endured ongoing headaches. These
headaches prevented her from leading a normal life and even from being able
to speak clearly during therapy. During more than five sessions we talked
about her discomfort, about the intensity of the headaches, or the frequency
and what she associated them with. They had no apparent relationship to
the grieving process, yet it was the first thing to appear during the sessions.
Each appointment began with a comment regarding how much her head
had hurt that week. In the sixth session, I asked her to talk to me about her
husband, placing her headache slightly aside for a while. She cried a lot and
spoke in great detail about what his death had been like and how much she
missed him. I did not ask her to not feel her headache, but to also bring back
the memory of her husband whilst keeping that physical pain in mind. The
process was slow, but we gradually stopped talking about her headaches
and started speaking only about her husband, until the pain dissolved.
On another occasion, a young man whose mother had passed away in a

rather traumatic way came to my office referred by his family doctor due to
a digestive problem that lacked an organic basis. During the first sessions
we talked about his medical issue and defined how it was affecting him.
After the fourth session, I asked him to tell me about his mother.
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Soon afterwards, from one session to the next, the digestive problem
disappeared as if by magic. Throughout the following sessions, we were
able to analyse details of his mother’s death and, gradually, the grief also
dissolved.
During the first sessions it is always important to leave room for the patients
to freely express themselves. Only once the bond has been formed can we
prompt interventions that can break that defence.
REMEMBER:
• Grief may have a mirror effect on the body that needs

to be taken care of.
• Organic origin disorders must be ruled out.
• It is important to reveal the meaning of the physical
symptom.
• Sometimes it is necessary to distinguished between
when the symptom is a defense and when it has a
symbolic content that needs to be revealed.
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GRIEF VERSUS DEPRESSION
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In an attempt to put our clinical experience into words and deepen the study
of grief, we have tried to define this process and describe the differences
between normal and complicated grief.
Human beings usually establish categories: we classify and systematise

reality. This implies setting the limits and boundaries between what is and
what is not a concept. The need to label disorders comes from an attempt
to generate a universal language among mental health professionals, one
that allows us to communicate regardless of the different viewpoints and
diverse ways of conceiving disease and psychological health.
This means speaking in a common language that allows us to understand

a complex diagnosis in few words. However, labels can be limiting and,
in fact, it is difficult to establish categorical differences between grief and
other realities.
Traditionally, grief is distinguished from major depressive disorder,

but a differentiation between normal grief and complicated grief is also
established. Comparing grief and depression implies comparing two similar
entities that, nevertheless, belong to different categories, as one of them
-depression- is systematised, defined and included as a disorder in the
DSM-5; while grief is defined as a disorder, but not recognised as such.
Grief is something that supervenes -it can happen or not- and it cannot be
prevented; whereas depression can be prevented, and it has degrees and
nuances. Both disorders can occur at the same time, but usually one of the
two is in the foreground and the other, in the background.
Some articles argue that comorbidity between grief and depression is

impossible. Moreover, they establish a distinction that, at first sight, seems
straightforward. However, between grief and depression there are hefty
differences that in our opinion prevent their comparison, as they belong
to different categories. The first of these is that depression is a disorder
and grief is not, as by definition it is the normal process that ensues after
any loss. In any illness -for instance, the flu- an event could interfere: for
example, an accident. In this case, we would not try to prioritise which of
the two prevails, because they cannot be compared. Without a doubt, grief
triggers an emotional, cognitive and behavioural process: as is the case
with any other event, although perhaps the latter has fewer studies.
By establishing the impossibility of comorbidity between grief and

depression, we are silencing grief, ignoring it, relegating and treating it
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GRIEF VERSUS DEPRESSION
solely as depression. This is not surprising, as we live in a thanatophobic

society that protects itself from pain and flees death until it has no other
choice but to face it. This causes us to live with the idea that death only
befalls other people, that we are invincible and can control each and every
aspect of our life.
Eventually, when death finally creeps into our lives -whether by accident,
foreseen or unforeseen- pain strikes the foundations of our structure and
causes us to stagger. It is then that we begin to handle the belief that
death is insurmountable, which thus prompts us to protect ourselves
from pain by avoiding it, hiding it or making it invisible once again.
Hence, it should not surprise us that it is also invisible at a clinical level.
On another hand, it seems somewhat simplistic to try to reduce these

symptoms into a category as rigid as major depressive disorder. Depression
usually requires medication, while grief, as a rule, does not. This distinction
raises some questions:
• Can grief generate depression or be its direct cause?
• Can depression complicate the grieving process?
The grieving process triggers a series of reactions that can lead the person
affected by this loss to isolate themselves, change their routines or lose the
reinforcing stimuli they had access to before.
When a bereaved person falls into the darkness of their sadness, can they
end up developing a depression? Has what was once a normal reaction
turned into a depression? Is time what differentiates health from disease
or what is normal from pathological? Are six months a normal period in the
case of grief, but not so if the period is six months and a day? Our opinion
based on experience leans more towards the criterion of the clinician than
towards diagnostic descriptions, even at the cost of losing some scientific
rigor, in the interest of greater efficacy and therapeutic success.
Grief involves an enormous revision of values and beliefs for the afflicted: it
invites us to reflect and question opinions that were held to be certainties.
This questioning often causes the bereaved to undergo a process of personal
growth. As a result of this, working with grief at a therapeutic level can
mobilise resources in the individual that help to unblock the entrenched
processes. In this sense, human beings are like a forest: it does not matter
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what you have influenced, as everything is restructured and organized

around what has been modified.
There are many unanswered questions regarding grief. The attempt to

answer those questions we posed at the beginning of this chapter has
raised further questions. This suggests that there is still a lot of ground to
explore regarding grief and that theory evolves slowly.
At the same time, we have found that the role of clinicians -who draw
on theory and experience to answer the specific questions posed by our
patients- follows one path, while the role of the grief researcher -who
amasses concepts, builds hypotheses and consolidates theories that they
place at the service of the clinician in a strategic alliance for both-, follows
another route, which is set at a different pace.
REMEMBER:
• Grief is not the same as depression, although it does
share some symptoms.
• Grief does not imply a loss of self-esteem.
• In grief the world is what has turned into a dark place.
• Medication does not seem to improve the grieving
process, however it does help in the case of depression.
• There is no consensus between researchers and
clinicians and it is difficult to define the limits of both
disorders.
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GRIEF DUE TO A LOSS BY SUICIDE
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Suicide is more than a taboo and can seem a source of shame or disgrace
for the family and the social circle of the person who commits suicide. It is
a death that is not mentioned, that does not show up in the statistics: it is
the death produced by a deliberate decision to take one’s own life.
This reality often leads the suicide of a loved one to remain hidden, making
their loss even more painful, because it is a death that encloses a secret.
Beyond cultural and social judgment, a death by suicide is a reality that
causes a lot of suffering, that must be addressed.
Is death by suicide different from a natural or accidental death?
It may seem so, but in reality, death is the same for everyone: the cessation
of vital functions required to make life possible. However, in this case, the
fact that it is the person who inflicts death upon themselves, can lead to
reflections and blockages by the family and social circle. The only thing
that changes is the judgment that society carries out and, quite often, the
family as well on an unconscious level. It is difficult to establish, in general,
the nuances of this type of grief, thus I will limit myself to a few broad
brushes that will allow us to comprehend the most common situations.
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When dealing with suicide grief in therapy, it is necessary to bear in mind

that it may require more time and it might come along with traumatic
images.
The need for time is associated with the ability of each griever to discuss
what has happened. If we try to intervene too soon or if we push the person
to move forward, we may lead them to abandon therapy, as the bereaved
will not feel that what they have experienced is understood or respected,
or they are not prepared to tolerate that level of pain.
Occasionally, it seems as though talking about the details regarding the death
constitutes disloyalty towards the deceased or the fear that psychologists
will judge this behaviour may arise. Hence, when we approach the bereaved,
we have to pay special attention in building trust, so that they see us as
trustworthy people who will not judge the suicide. If more time is required,
it will be added to the therapeutic process: time and patience.
I often find myself with grievers who are reluctant to talk during the first
sessions about the suicide or about how the death occurred. They will only
address it when they feel ready to do so. Frequently, remembering details
of the death can raise traumatic images or bring up traumatic feelings.
Trauma can stem from the circumstances in which the death occurred or
the way in which the news of the suicide was transmitted: if the griever
was witness to any shocking images involving deterioration, if they were
the ones who found the deceased, etc.
One of the most frequent aspects in therapy is that people are constantly
searching for a “reason”, one that explains why their loved one committed
suicide. This reason may remain hidden and each person must build their
own justification. The search for an explanation goes hand in hand with the
acceptance of a very shocking reality. The griever may experience feelings
of guilt for not having been able to avert the suicide, which is just another
way of denying death and exerting a false control over life.
Another “recurrent” detail is the pain caused by imagining how much the
suicide victim had to be suffering in order to end up making that decision.
In this context, it is common for the bereaved to experience guilt for not
having have noticed it or for not having been able to alleviate that pain.
Common elements:
• Taboo.
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• Pain.
• Feeling incomprehension.
• Wondering about the reasons that led to the suicide.
Usual elements:
• Impacts / traumatic elements.
• Physical alterations (correlative to trauma…).
• Feeling guilty.
Things that work:

• Sensitivity.
• Patience.
• Normalising all reactions and placing them in context.
• Encouraging dialogue on all the issues and nuances without pressuring
to do so.
• Staying calm when faced with “strange” reactions.
• Encouraging a medical review for the griever’s physical symptoms,
allowing the bereaved to have control over something small.
• Creating stories that help to explain what has happened.
• Generating hope.
REMEMBER:
• Suicide often entails a taboo.
• It frequently includes traumatic elements that add
more pain to the grieving process.
• It is essential to give the bereaved time and to be
sensitive when addressing this subject in therapy.
• One must not be frightened by the patient’s
revelations.
• It is advisable to discuss the causes of the suicide.
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GRIEF DUE TO A TRAUMATIC DEATH
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Within the traumatic grief category, we include all those that are caused
by the sudden and violent death of a loved one: traffic accidents, work
accidents, homicides, attacks, etc. In most of these cases, grief is joined by
post-traumatic stress disorder (PTSD), or at least by some of its symptoms.
This disorder is listed in the DSM-V as a separate chapter, within the

second section involving disorders. However, beyond scientific reviews, it
is important to understand the bases on which this grief is sustained.
Trauma is assembled around three axes:
1. The traumatic event, be it an accident, a homicide or an event that,

although objectively it may seem harmless, is traumatic for the bereaver
because they do not have sufficient resources to cope with it. In this
sense, I have occasionally treated people with a grief that, in appearance,
could have been healthy -loss of an elderly parent, after a long illness,
which after all is a fact of life- and yet, they had developed a traumatic
grief. The key to this is the way in which this event is experienced, which
depends on the resources that the bereaver has available. Their subjective
perception of the event is more important, and it always happens to be
associated with horror, destruction or the feeling of devastation.
2. Constant agitation or disturbance, also known as activated arousal.
3. The avoidance of everything connected to the traumatic event and the

related images regarding this situation that may have been stored.
The presence of some or all of the symptoms associated with post-traumatic

stress will force clinics to spend some more time working on the remission
of these types of signs. One technique that has proven to be effective in
treating this disorder is the EMDR (Eye Movement, Desensitisation and
Reprocessing).
This technique is a therapeutic tool that benefits the processing of the

traumatic event -in this case, a traumatic death-, if applied by a trained
psychologist. The technique consists in assisting the bilateral stimulation of
the brain -based on dual attention-, which removes symptoms, or at least
greatly decreases them.
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Bilateral stimulation occurs through different strategies, either with eye

movement, bilateral sounds or tapping. The latter is used to integrate
the trauma with all the information that has been stored in the neural
networks -the emotional and the rational-, in order to incorporate it into
a more normalised life story, where all the information has been released.
EMDR allows the bereaved to work around their avoidance issues. In

the end, it is about being able to “be present” regarding everything that
has happened, because avoidance prevents processing. With EMDR, the
tolerance threshold the patient has towards these images is amplified,
making them realize they are able to withstand it.
According to several studies, sudden loss is more difficult to elaborate

than other deaths in which the loss can be anticipated. This difficulty is
due to the fact that the bereaved lack the opportunity to mentally or
emotionally prepare themselves for the loss. Mental and emotional
processes need a certain amount of time so that they can assimilate
the impact. Frequently, a shock process is set off, in which the griever
cannot believe what has occurred. This blockage, normal at the
beginning, is linked with the assimilation process, where defence
mechanisms are activated in order to protect us from the reality of death.
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The defining characteristic of this type of grief is the feeling of unreality that
the bereaver expresses regarding the death of the loved one. Therefore,
primary support will focus on helping them work through the reality of the loss.
It is especially important to reminisce with the bereaved how they

experienced the death itself: how they received the news, how they
and their social circle reacted, how the farewell rituals were carried out,
etc. The counsellor or therapist will deliberately use the words “dead”
or “deceased” to help them work through the first task of grief. Under
no circumstances should this task be forced, as any attempt to resolve
the traumatic grief in a hasty manner can cause undesirable reactions in
therapy. When the patient is ready, it is important to “listen” and, above all,
to move forward gradually. Sensitivity is essential in trauma intervention.
Other frequent sensations regarding traumatic grief are feelings of guilt.

It is common for the bereaver to fantasise about different endings,
with different “What ifs” (“What if I had not left”, “What if I had not
left them the car keys”, etc.). In this way, the bereaved keeps the
deceased alive in their heads and, thus, block the first task of grieving.
Coming closer towards the reality of what happened and contextualising

the moment that death occurred are useful resources in order to work on
the acceptance of loss. Contextualising the moment of death consists not
only in sticking to how it occurred, but also in what happened days before,
how the bereaved was, how the deceased was, what was happening
in their lives… Thus enabling the bereaved to accept that accidents do
occur, that it was not up to them whether or not death took place, this
is to say: managing to finally remove power from all those “What if...?”
The elaboration of this type of loss will depend on the acceptance by the
bereaved that bad things occur, that things are not under our control
and that accidents or tragedies almost always involve a multitude of
factors. The final message that the expert must rescue for their patients
is a message of hope: “You will overcome it, do not pressure yourself,
give yourself time”, “You’re fine as you are, trust your resources,
trust your own abilities, trust therapy”. Without this message of hope,
it will be hard to bear the pain brought about by loss. This type of
grief may require a greater commitment from the therapist’s part.
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REMEMBER:
• We must respect each patient’s rhythm, because each person
is unique and, if we analyse the specific context, most
reactions are normal.
• It is not useful to pressure the patient to lessen the pain or
for it to last less.
• Observe and validate the bereaved person’s reactions.
• Display calm.
• Make it easier for the patient to trust you.
• Offer hope for the pain to be easier to bear.
• Turn to medication when the anxiety is very intense or to
EMDR to handle the most stirring images.
• We must be aware that behind all of this, there lies a human
being who is suffering a lot and who needs another human
being to protect, validate and be committed to them and their
process.
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GRIEF DUE TO A DISAPPEARANCE
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Grief over the disappearance of a loved one -whether or not it occurred

under violent circumstances- is a process as painful as one that could result
in death. However, grief has the additional pain of ambiguity, uncertainty
and doubt.
If it is already difficult to accept a loved one’s death when there is

physical evidence of their demise, in cases involving a disappearance
it is almost impossible to work on the first task of grieving: accepting
the reality of the death. This is because there is no way to prove
it. The law requires ten years to go by, in the course of which no
clue or lead can be found, before officially declaring the death of a
missing person. This affects those close to them on a legal, financial
(inheritances, widow’s or orphan’s pensions, etc.) and emotional level.
We can all probably remember a case with great media coverage, in

which the relatives of a missing person made a pilgrimage through
the different television channels, anxiously looking for new clues that
would allow them to feed their hope of finding their loved one alive.
In addition, in all cases involving a disappearance, society is moved
by citizen appeals, whether or not they have a social projection.
Occasionally, if the disappearance is of public domain the bereaver’s

suffering can increase, as the number of people who express their
opinion about the case rises exponentially and, every time a programme
talks about the subject, they “reexperience the disappearance” of their
loved one. Lawsuits and trials related to the disappearance will feed the
pain of the relatives. Still, public recognition of their situation helps to
alleviate their pain and the fear that the missing person will be forgotten.
There are no statistics or specific studies that describe the specifications

of this type of process. For those who experience this type of loss, the
struggle to reconnect with their loved one is of utmost importance, so they
focus all their energy on promoting the search for the missing person,
paying private investigators, creating profiles on Facebook or attending
television programmes. Their life is led by an eternal search, as it never
ceases, because they associate the idea of abandoning with that of
surrendering or with being a worse father / mother / son / friend, etc.
In therapy it is uncommon to find a case of grieving due to disappearance,

since -as previously mentioned- these bereavers focus their energy on
the search and not on the absence. But if we were faced with this type of
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case, we would focus on the pain caused by the absence because this is
real. In the case of a missing person, it is impossible to offer the grieving
person data that confirms the reality of the death of their loved one (which
hinders processing the first task), but it is possible to work on the grief
caused by the absence of the loved one and the pain of unmet expectations.
Work at an emotional level can also focus on the guilt and anguish caused
by uncertainty - two emotions that are very difficult to alleviate - as
well as the fear that the missing person’s existence will be forgotten.
• Uncertainty in grief
During the first moments after the disappearance of a loved one,

it is normal for the relative’s attention to be focused on the police
investigation and the help the media can offer by spreading the news
in order to find clues regarding the whereabouts of the missing person.
It is difficult to imagine that a person immersed in the search of a loved

one would want to receive support to resolve their grief. But if they did, it
is easily imaginable that it would be a complicated case.
One of the characteristic features of this type of case is that the relatives of the
missing person always hope to find them. However much time has elapsed, it is
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always possible to imagine that their loved one is alive elsewhere because, as
long as their body is not found, there is no evidence to sustain they have died.
What can be done and how can we help in a grief process due to a
disappearance
When caring for people who are grieving due to a disappearance - or over a
grieving in which the demise is not evident - we can work on the certainties:
• The pain caused by the absence, which is already a loss in itself,
regardless of how the case ends.
• Fear and uncertainty regarding what they imagine could have
happened.
• Fatigue derived from that permanent state of waiting, of awaiting for
news.
How to handle emotions caused by grief disappearance
It is difficult to direct the attention of the bereaver towards the pain and the
sensations that appear with time, because the urgency is centred around
the search. Frequently, people affected by this type of loss act impulsively,
searching tirelessly, engaging with the media, giving interviews... This can
lead to great physical exhaustion and stress around the immune system.
Psychologists have an important role in managing these ambiguous

grief situations. Among other things, by offering some guidelines to the
bereaved, such as:
• Rest adequately for a minimum number of hours each day.
• Disconnect the phone occasionally to avoid constant alertness.
• Keeping a healthy diet.
• Dosify the information that the bereavers are receiving.
• Dosify media and news exposure.
• Seek supports that provide comfort, companionship, or whatever each
person may need.
• Adjust to the needs of each person, without generalising or comparing.
Faced with a case of this type, we can help the bereaver by:
• Accompanying the fear and pain caused by the absence, allowing and
validating them.
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• Allowing them to express their feelings and vent. Naming what scares
us allows us to distance ourselves slightly.
• Allowing them to remain hopeful, respect each person’s rhythm, do not
force or pressure.
These guidelines can help a person who wants to support them during the
first moments, always keeping in mind that each grief case is unique and
that not all people react in the same way.
In this specific type of grief, two fundamental points can be addressed:

• Help people to live with the uncertainty and actual absence, so that
their functioning, their social relationships, etc. are affected as little as
possible (Barros-Duchene, 2010).
• Long-term maintenance of a high level of pain and anguish, which time
does not diminish, can have repercussions causing both psychological
(depression) and physical complications.
REMEMBER:
• Those who experience this type of loss concentrate all

their energy on promoting the search for the missing
person.
• The fact that the disappearance is in the public domain
can increase the suffering of the bereavers, as the
mediatic exposure will feed the relatives’ pain.
• Therapeutic work can focus on guilt and anguish
caused by the uncertainty, as well as the fear that the
missing person will be forgotten.
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GESTATIONAL OR PERINATAL GRIEF
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Fetal death, whether it is intra-uterus or it takes place during delivery,

entails the loss of a baby that was expected. In this chapter, we also include
deaths that occur from the conception of a child to their first year of life.
Different losses are also added to the loss of a baby: loss of the moment
one becomes a father or mother; if it was the first child, the loss
of the role of being a father or mother; loss of a family structure and
prospectives; loss of innocence regarding pregnancy and childbirth; loss of
the right to mention that child in certain places, as well as the loss of the
physical contact and the possibility of creating memories with the child.
These examples showcase that grief due to perinatal death constitutes a

complex experience. Consequently, offering the bereaved space and time
so they can express their experience, how they are living it and what
this means to them, is essential in aiding the evolution of this process.
Perinatal grief can have the following complications:

• According to studies, between 10% and 48% of those affected will
suffer from depressive disorders.
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• After a perinatal loss, anxiety disorders emerge when faced with the
possibility of a new pregnancy.
• The influence of post-traumatic stress disorders in instrumental deliveries,
or caesarean sections, rates between 2% and 5%. During the month
after the loss, this reaches 25% and four months later, it is up to 7%.
These data justify the importance of assisting this type of grief and how
professionals must remain vigilant to its evolution.
In perinatal grief there are two antagonistic vital moments: life and death.
This fact definitely marks a process that has specific nuances. For the
pregnant mother, experiencing the beginning and end of life is a brutal
shock.
On another hand, in no other type of grief does the bereaver experience

such a high hormonal component that is directly aimed at motherhood,
at the development of a bond and the creation of life. The death of the
baby - either in the womb, a few days after birth or during childbirth -
entails an abrupt rupture of the future mother’s expectations: her body
sends contradictory messages, prolactin versus cortisol and acetylcholine,
forming a difficult cocktail for her to manage.
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Another component which is absolutely differentiating is the shock

mothers experience due to the loss; it is really complex to assimilate
because the body sends them contradictory messages.
There is a taboo around this experience and little is said about the
death that occurs during pregnancy, or in the moments close to it. We
are not socially or professionally prepared to tend a grief with these
characteristics: midwives, nurses, doctors… they cannot find words, nor
do they know what to do under these situations. Some resort to common
sense and their own skills, but there is no specific, “humanised” protocol
established to address this heartbreaking experience. In this respect,
Spain has a long way to go.
In Anglo-Saxon countries, with far more experience in this field, they

have protocols for these type of cases. These include rooms equipped for
parents in order to say goodbye to their child or take photos of them, or
specialised clinics for women who have had previous gestational losses.
In the rest of the world, hardly any of these resources are available;
nonetheless, we should aim to achieve this goal: the development of
units designed to address these special situations.
A final aspect common to this type of loss is the delegitimisation of this

experience by the social circle, which often tends to downplay the grief
with phrases such as:
• “You can still have more children”.
• “You did not even have time to become fond of him/her”.
• “It is for the best...”.
In our society, the pain of a woman who has lost a baby prematurely is
diminished of its value or importance. And, when referencing the father,
the importance given to them is usually non-existent. This fact causes
couples who are going throught this experience to isolate themselves and
share their pain only with people who have undergone the same situation
as them.
Regardless of the nuances of this type of grief, the general formulas

discussed in previous articles remain valid, respecting or adapting them
to the needs of each particular case.
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Aspects that assist this process
There are several factors that can help to overcome this type of grief:
• Time will be an important ally: Not the only one, but pain is
mitigated over time. Grief requires time, like in any process.
• The legitimation of pain: We have talked about this on other

occasions, we must allow and normalise pain, because everything
that we resist persists and everything that we allow flows.
• Ask for what we need. Grief calls for parents who have lost a baby
to focus on their own needs, becoming active agents and seeking out
what they require by involving the community. We do not confront
grief alone: we live in communities and this process is also lived and
solved in community.
• Take nothing for granted. Sometimes words have different

meanings for each person. It is essential to clarify the meaning of
loss, what it implies for each individual to be feeling better or feeling
worse, because it is within the meaning of loss where the key to each
grief lies and it’s what differentiates one grief from another. To let go
of the pain, it is necessary to delve in the experience, communicate,
open up to others and share.
• Remain confident that it can be solved and overcome. We can

nurture it with our own messages or the words of others, with quotes
such as “This too shall pass”, or “Do not despair, because clean water
falls from the blackest clouds”, or “There was no night, no matter
how dark it was, that it did not dawn”.
Perinatal grief is a deeply shocking type of grief that produces a great deal of
pain and also has an impact on the social sphere. As this makes people want
to try to help, but sometimes it hinders the process instead of assisting it.
Things that help us:

• Gentleness.
• Sensitivity.
• Being present.
• Respect: not telling the bereaved what they should do or feel.
• Humanity: technical knowledge falls short under this situation.
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REMEMBER:
• Different types of grief are also added to the loss of

a baby, which makes it a complex type of grief.
• There is a taboo around this experience that
constitutes a shock, especially for the mother, since
her body sends contradictory indicators.
• A common aspect of this type of loss is the
delegitimisation of the experience by the social
sphere, which tends to downplay it.
• Offering time and space so that the bereaver can
verbalise their experience, how they are going
through it and what it means to them is essential.
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GRIEF AND FAITH
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Vilified by some and extolled by others, faith -as could not have been
otherwise- emerges surrounded by a halo of mystery. Many people wonder
about the role that religious beliefs play regarding grief resolution. Thus,
throughout this chapter we will analyse some of the questions that faith
poses.
First of all, faith confronts us with questions that we cannot answer; after
all, faith itself is based on the principle of believing without evidence. Faith
can be a refuge for those who have lost a loved one, bearing in mind that
one of the promises that religion makes is that we will be reunited with
our loved ones when we die and that the person we have lost, is now in a
better place.
For a lot of people, faith is a very important support. In our experience as

psychologists, we have found that faith is a bastion that allows believers
to relieve pain. There are those who, in the face of loss, cling to faith like a
lifeline, which provides them with peace and serenity. However, there are
also those who do not believe and who do not find this factor essential in
order to overcome grief.
If we interpret faith in a rigorous way, the acceptance of death can become

complex, as some messages may seem to be contradictory, although in
reality, they are not. In order to understand this statement, it needs to be
analysed in detail. For example, when the Catholic Church says that people
do not die, it is not denying the reality behind the physical evidence (that
the body stops functioning), it is arguing that a human being is not merely
a body, but rather that it is composed of body and soul. And, by asserting
that a human being does not die, it refers to said spirit or soul.
Faith is not at odds with Science, but rather, our interpretations of faith are
what sometimes dissent. When the Catholic Church says that the soul goes
to Heaven -or to God’s house- it does not refer to a physical heaven, nor
to a house with bricks, but we need images that can represent what we
consider as “eternal life” to be like; as by giving it content, it allows us to
grasp it in some way.
When they tell us that we can talk to our loved ones after their death, they
do not mean that we can send them messages, nor do they mean that
they can hear, speak or see as we are used to doing, as physical functions
cease to function and the dead do not see, nor hear, nor feel pain or joy.
However, we can address them or pray to them as those who pray to God
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and not that does not imply waiting for an answer. As you can see, we are
discussing abstract, vague concepts that could be difficult to understand by
a human being without the use of symbols or metaphors.
Faith allows us to give sense, meaning and order to the things that happen
to us, this is why trying to pathologise or question those who practise it is
not a good idea. It is also true that there are many people who go through
grief without needing faith. Throughout our professional experience we
have witnessed both cases.
In conclusion, having faith is a positive factor to help overcome grief, but

it is not essential. A mature faith not only lightens the burden of loss, but
it also offers hope and allows us to find meaning in death. Faith cannot be
imposed on those who do not have it, nor can it be extracted from those
who do.
Superstitions regarding grief
One of the oldest questions that human beings ask themselves is if there is
life beyond what we know, if we can or cannot believe in an eternal life, if
we will see our loved ones again. Different religions and this epigraph, in a
much more condensed way, try to answer this and other questions.
Frequently, a lot of people ask us for advice regarding the doubts they
have on subjects related to afterlife: what happens after death?, what
power do the belongings of the deceased have?, whether or not they can
be contacted... Some raise these questions openly, in a natural way, and
others feel ashamed when thinking about it and ask about it, expecting
rejection or judgment on our part.
On this subject, I do not uphold a categorical opinion, since it seems important

to me to reflect on these questions that are presented so frequently. There
are two positions before them and both seem legitimate to me: one option
is to give a scientific answer - stick to the physical, what we know, what
we have verified - and leave aside the most spiritual part, always being
respectful of beliefs of each person and with the options they make in their
attempt to overcome the pain.
Another option is to pay attention to these doubts, listening to them,

legitimising the meaning that the spiritual has and what it means for each
one of us. It is about being open to answers that imply the possibility
that there is something beyond what is strictly objectifiable or measurable.
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It is a position that neither affirms nor denies: it only contemplates the

possibility that this is so. This position cannot be feigned, it is shared or not
shared. It implies admitting that, in some way, there are people who have
the sensitivity to perceive things that are not evident, that are intangible
and go far beyond the purely testable.
Although the two options seem valid to me, this second position seems closer
to what our patients need from us. Otherwise, if we give them an insufficient
answer, we run the risk of leaving them at the mercy of unscrupulous people,
those capable of trying to answer their concerns by guiding them down
through dangerous paths for their mental health, or that may lead to fraud.
I understand that this conclusion may be controversial. Until relatively

recently, I prided myself on being strictly scientific and professional, asking
my patients to focus on what we could assert emphatically. Often this
answer is enough for them, and they follow my advice, but for others it
is not enough and that keeps them in a constant attitude of search that
prevents them from overcoming their grief.
Prior to writing this epigraph, I have been very hesitant and have reviewed
the possible risks associated with offering the possibility of believing
in something else to these types of patients: that is, what could be
wrong in offering answers that are not verifiable, but that allow us to
understand aspects that are profound. My conclusion is that I do not find
any danger in this, but I do find the possibility for the bereaver to find
peace, to free themself from guilt, to find a different meaning to the loss.
In his book “Many Lives, Many Teachers,” American psychiatrist Brian

Weiss also offers an approach that can revolutionise the way in which we
understand life and death. He declares, after having practiced hypnosis
to work on symptoms that did not remit with conventional therapy, that
life has no end, that we rotate from life-to-life learning things that we
need to learn, that after physical death we enter an intermediate state
in the that we rest and our teachers can teach us things. That we are
called to love, to help others, to teach. And that we take from each of
the lives that we live lessons that are shaping our spiritual baggage.
Weiss also states that when people die - as we understand physical death
- they see a light of irresistible, warm, attractive beauty, after which our
loved ones appear and we enter a period of rest in which the mind or the
soul can reflect or evaluate what it has learned in its life and what it needs
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to learn, until it reaches the full wisdom that is love. As he tells it, death
appears as something desirable and not as we have perceived it until now.
Can you imagine the paradigm shift this would mean for anyone who has
lost a loved one? As I understand it, it would allow us to reach the following
conclusions:
• Death itself does not imply suffering.
• There is an afterlife full of peace, fulfilment and reunions.
• All of our experience is related to what we need to learn and that is what
gives meaning to our existence and our death.
• We tend to love and knowledge, and that energy full of love and wisdom
is what brings us closer to God.
I understand that there may be professionals who are scandalised by this

content, but after having known it I feel responsible for making it public,
since I understand that it cannot bring harm, but it can bring many benefits.
In any case, as professionals we do not have all the answers, nor do I think
we will be having them in the shart term. With this, I am only try to make
this content accessible so that it can be used at the service of patients who
need it, not as an imposition but rather as another alternative.
Extremely personal reflections
As for our own personal opinions as psychologists, it is difficult to take a

stance on a subject where so many factors are involved.
We consider that it is impossible to establish a categorisation in relation

to mourning, since there is no mourning the same as another, rather the
opposite: we defend that mourning is what adds to what a person already
is. As there is no single person equal to another, neither can there be a duel
equal to another.
Individual experiences shape, colour and modify the experience of grief

for each one of us. For this same reason, the authors stand out from any
attempt to consider grief as a separate entity. Grief can only be measured
and evaluated in the light of the identity of the bereaved and their personal
history, all in all taking into account their culture, ideology and values.
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Individual experiences shape, colour and modify the experience of grief

for each one of us. For this same reason, the authors stand out from any
attempt to consider grief as a separate entity. Grief can only be measured
and evaluated in the light of the identity of the bereaved and their personal
history, all in all taking into account their culture, ideology and values. Then
- and only then - can we determine whether a person is going through a
complicated grief or not; or if you require therapy or not.
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REMEMBER:
• A too stern interpretation of faith can complicate the

acceptance of the loss of the loved one, other than that,
faith is not incompatible with Science.
• For those who have it, faith is an important support in
helping them overcome grief, but it is not essential in
order to elaborate this process.
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CLINICAL CASES
A.1 What always works during grief
In recent years, our entity has frequently received inquiries about grief via
email, most of them from people who have recently lost a loved one. When I
say “recently” I mean that, in general, when they contact us, only a couple of
weeks or even less have gone by since their loved one passed away.
These people write to us in anguish, overwhelmed by the intensity of the

emotions they are experiencing, feeling misunderstood. They request, in a few
words, for a short guideline so that they can continue with their lives, reposition
themselves in the first days or in the first weeks after the loss.
To all of them, to those who have seeked advice from us in the past and to
those who continue to ask, this letter is addressed to a recent griever:
What to do at the beginning of the grief process
When grief hits us, we need to be told that everything will be fine, that the pain
will pass, but we also need to be told how to do it.
Respecting the principle says that no single grief is the same as another, I dare
to propose below a formula of five key ingredients that must be present in a
healthy grieving process, regardless of whether each individual will need them
to a different extent.
Grief’s formula
This formula is an easy acronym to remember, taken from the Spanish “TERCA”.
Each letter stands for the initial of one of its main components. Undoubtedly,
this is a debatable formula and one that can be improved, but it is a starting
point from which to begin taking the first steps in those first instants after the
loss.
- T (from the Spanish Tiempo: Time). Time is a fundamental element in any

grieving process. It is not the only ingredient, nor is it the most important one,
but it is an essential one: time has to go by in order for this process to end,
and yet we know that time does not heal everything, but rather the key is what
each individual does with their own time. This is to say that time will play in our
favour or against us, in relation to what we do. If we search for and take the
determined decision to get through it, we will most probably manage to do so,
if however, we merely wait for time to go by, the most probable outcome is that
grief will hinder intactly.
- E (from the Spanish Esperanza: Hope). It is a vital component in any

psychological process, as well as in grief. It is extremely important to keep the
hope that it can be overcome, that we are to begin with enduring a healthy and
spontaneous process that will resolve itself without a medical or psychological
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intervention. In so doing, it is vital to always trust one’s own capabilities, both

with the process itself, and if it is necessary, with therapy.
R (from the Spanish, Red de apoyo: Support network). Grief is a process

that requires the presence of other people. We live in society, it is harder to
overcome grief alone than with people who supoort and allow us to legitimise
and normalise grief’s pain. This is the way we keep pain away from us. Without
this, it would remain inside of us.
C (from the Spanish Compasión: Compassion). Other people’s compassion and

our own is probably one of the most powerful ways with which to confront grief,
to undertake the path without any demands, pressure, with respect... Trusting
that each indivual’s own pace is correct, this is because we cannot control our
heart.
A (from the Spanish Amor: Love). Love is along with compassion, the
most powerful and thereapeutical force in the universe. Other people’s love,
expressed through their presence, their frequent visits, their assistance on day-
to-day tasks..., the love that arises from those professionals that get involved in
the process, true love as referenced by Carl Rogers and of course, the love we
offer ourselves, shown through selfcare.
It is signficiant that this letters form linked to rapid grief resolution, the
Spanish TERCA; as a great deal of stuborness and firm resolution are required
to overcome grief. As it normally is not resolved on the first try, but rather
requires quite a few tries.
A.2. Examples of answers and key points regarding grief: A study of ten
cases.
Through the presentation of these cases, we aim to offer guidelines into

answering the concerns a grieving person may face. For a significant
percentage of those who seek advice, these answers are sufficient. For the
remaining cases, a more profound therapeutic intervention will be required.
1) Erika is a woman who made an enquiry regarding the pain felt by

a very close friend after the death of a loved one. She states that she
wants to help her friend and asks us for guidance.
Good morning, Erika:
When we lose a loved one, it is normal to feel pain. I know that it is impressive
and sometimes even scary to see how sad the people we love or with whom
we maintain friendship ties are. But pain cannot and, above all, should not
be plugged. It is normal to feel pain, and guilt is one of the many forms this
emotion can take. What you tell me falls under the category of “normal” in a
grieve process.
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The way in which you can assist them is by:
Stay close by them and offer your help.
Let them express their pain without questioning it and without feeling
frightened by it.
Tell them that pain does not always feel that way, and that others have
overcome it and that they will too.
Offer concrete help: to go shopping, accompanying them to deal with

paperwork ...
Keep a hopeful message: it is a normal process, that follows the loss of a loved
one and it occurs with a wide range of reactions, almost all of these reactions
are normal.
If in six or seven months the pain remains exactly the same, you can visit a
mental health professional, who will surely be able to help or accompany you
throughout the process.
Wishing you both the best,
Yours sincerely.
2) Mayra is a woman who inquires how she can help a sister of hers
who has lost a child. She wants to know if it is harmful for her sister to
listen to an audio that she keeps.
Good morning, Mayra:
Thank you for contacting us for advice and for acknowledging our work. It is
difficult to answer your question. There are no things that are good or bad in
themselves, because there are no universals when it comes to reacting to grief,
that decision only depends on what you want, what comes from your heart.
From what you say, what you want is to bring her to the memory of his voice
and that is nice, regardless of whether it may hurt her as a mother. The audio
does not hurt her, what causes pain is that her son has died and, in any case, it
is okay that it hurts, that is not going to destroy her.
Crying is the way to heal from a broken heart. The progress of grievng is not
measured by whether the bereaved cry or not, it is normal that the loss of their
child hurts. What matters is the intention behind your actions, not so much
what she does with it. In any case, do not be afraid thinking that their grief will
go backwards or forward, that is not something that depends on you. Human
beings are very strong and we are prepared to overcome the losses that come
our way. Trust her and her ability to excel.
It is not easy to lose someone and to get over it, but it can be done. Good luck.
Yours sincerely.
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3) Agustina is a woman whose son has been dead for a week and is
scared of her own reactions.
Good morning, Agustina:
I am very sorry for your loss. I understand that now, just a week later, you
feel pain and you feel terrible. It’s normal, don’t panic. You are grieving, which
is the normal process that follows the death of a loved one. Grief comes from
“dolus”, a word of Latin origin that means pain. It is normal to feel pain in
the face of loss, the strange thing would be not to feel it. Surely everything
you feel is normal, it is difficult to make an intervention at this time. What is
recommended for these first days is to take care of food and rest, and, if you
are very distressed or have difficulty sleeping, ask your doctor to prescribe
something so that you can be more calm. Grief is a healthy process in principle
and you have to go through it. Although it may seem difficult right now, the
human being is prepared to respond to the loss, even that of a child.
I hope that my words serve as consolation and guide you in these first
moments, but if not, do not hesitate to contact us again.
Yours sincerely.
4) Liz is a woman who is worried because her boyfriend has lost his
mother and does not want to recibe any help. She contacts us seeking
guidance.
Good morning, Liz:
The best way to help a person who has lost a loved one is to be present, care
for their needs, and respect their time. There is no single way to accompany
a bereaver because each grief is unique. You can ask him what he needs from
you or how you can help him. This is how you let him to understand that you
consider him capable of overcoming his loss and that you are going to support
him in whatever he needs, without harassing him and respecting how he feels.
In any case, keep in mind that change is a door that only opens from the
inside. That is something that only he can do. On our website you can download
the Adult Grief Guide, which can help you better understand what is happening.
All the best.
5) Manuel is a man who has lost a son and wants to know if it would be
good to join a group of parents who, like him, have suffered the death
of a child.
Good morning, Manuel:
In response to your question, the grieving process is not a linear process, so

sometimes it may seem that you are backing down. Sometimes it can also
occur that, as the death of the loved one begins to be assimilated, the pain
increases and that is experienced as a setback when in reality it is an advance.
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In regards to your query, there are no universal answers. Some parents want
to know more about their children and others do not, so it is best to ask them
if they are interested in contacting you or not. If you feel like so, it may be a
relief to talk to someone who has dealt with your child lately.
Best wishes.
6) Daisy seeks advice from us because she feels guilty for not having
cared “enough” for her mother during her illness. She tells us that her
mother did not want to go to the doctor or be helped, but still she feels
guilty.
Dear Daisy,
Sometimes the situations that we live are very difficult, as in your case. How
difficult it is to judge yourself when all circumstances were against you, when
your mother did not cooperate, when your work did not allow you to spend
more time with her. How hard it is to live with that and how difficult to have
a compassionate look at oneself and to be able to say: “I did what at that
moment I thought was good and what the circumstances allowed me to do”.
Without that “permission” it is difficult to look at yourself with love. I think you
need a therapy in which an expert can accompany you through your pain and
help you to put words to it, drain it and forgive yourself. I’m so sorry for your
double loss. Hopefully in a short time you can write to tell me that things are
going better.
Best wishes.
7) Patricia consults us because she feels guilty for her father’s death,
she feels that she could have prevented it.
Good morning, Patricia:
I am very sorry for your loss and the immense pain it has caused you. One of
the things that causes the most pain is to think that the death of a loved one
could have been prevented. That adds a lot of pain to what already exists from
the loss. It seems that what hurts you the most is not having been able to
prevent it. This feeling of guilt is at the service of the denial of death.
I imagine that you will have thoughts in which you ask yourself “What would
have happened if ...”: if the doctor had done an X-ray before, if he had started
the treatment earlier and thus a long list of possibilities. That denial is blocking
the grieving process and keeping you from getting through it. Maybe it would
be good if you could start a therapy that helps you express your pain.
Best wishes.
8) Ana is an adult woman who is scared by the reactions she has after
the recent death of her mother.
133
APPENDIX
CLINICAL CASES
Good morning, Ana:
I am very sorry for your loss and the pain it has caused you. It has been a very
short time since your mother passed away and it is normal to feel pain after the
loss of a loved one. It is also normal that you deny the death of your mother
for a time, it is a mechanism that people use to cushion the blow. Still, I think
it is a good idea if you can talk to someone to help you through this process.
Unfortunately we do not know any psychologist in ____, we only work in
Madrid. If I find something in your area, I’ll let you know.
In the meantime, best wishes and I send you a big hug.
9) Paula is an adult woman who is worried because a friend of hers has

lost her mother, expresses the desire to die and does not want to talk
to her about it.
Dear Paula,
I understand your worries. In order to help your friend, you can just stay close
to her and offer your help from time to time, until she accepts it. You cannot
force the grieving process, it must necessarily start with the person who has
suffered the loss. The feeling of wanting to die is normal in people who have
lost a loved one, the desire is not the same as the suicide plan and she says
she has no plans. Be on the lookout for her a bit, but also give her a vote of
confidence.
Best wishes.
10) Alejandra explains that, five years after the death of her father,
she began to feel very sad and to have a lot of discomfort. She does
not understand why it has happened now and not before. She seeks to
make sense out of what is happening to her.
Good morning, Alejandra:
What seems to have happened to you is that you “postponed” your grief.
Sometimes we need to cushion the blow or give ourselves time and we just
tackle it or face it when we feel capable. It is probably now when you can
handle it, but keep in mind that grief hurts, it is its most characteristic note. In
90% of cases, grief as a process is resolved almost spontaneously, without the
need for any professional intervention.
If you notice that you are blocked, or that it hurts in a way that is too intense,
do not hesitate to contact a professional who is an expert in grief and who can
help you overcome that process in the best possible way. Grief can be overcome,
you just need to place energy on the process and, sometimes, a little help.
Sending you strength. All the best.
A.3. Common elements to all replies
134
APPENDIX
• A brief and explanatory guide to the grieving process.
• Explain that the most valuable thing about help in grief resides in the
presence of another human being.
• Allow and validate pain.
• Respect the rhythm of each one.
• Transmit confidence in the process and in the ability to overcome each

human being.
• Offer help if necessary.
Example of a reply that could be offered by any medical service when a

patient has experienced the loss of a loved one:
Dear griever:
You should know that the Spanish word “duelo”, is a term with Latin origins,
whose root “dolus” means pain. For this very reason, it is normal to feel pain
at the loss of a loved one. You should also know that each person feels pain in
a different way and that there are no rules into how to experience that pain,
neither in terms of its length, nor in terms of its intensity.
We are prepared to overcome the pain that loss produces, all we have to do is
to not interrupt the pain, but let it go, relying on the people who help us to be
better and who allow us to live the pain in our own way.
Grief is more intense in the intermediate phase and is less painful just after
death and at the end of the process. While we are grieving we cannot have
hope, it is incompatible with pain. There will be days when you feel worse:
during those days let yourself be carried away by grief, cry, unburden
yourself. There will be other days when you feel better, during those days
take advantage and go out with friends, take a walk.
Do not set rules for yourself to overcome grief and do not allow anyone to do
so either. Do not try to set a pace to the process, to neither make it longer nor
shorter, it is what it is. Keep hope alive because, as I have already told you, the
human being is prepared to overcome the pain of loss, in fact, 90% of people
who experience the loss of a loved one live a healthy grief.
EPILOGUE
136
EPILOGUE
Letter to a recent Psychology graduate
We do not know each other, but I know that you have just finished your
degree in Psychology or your master’s degree, and that you are thinking
of practicing your profession in a clinic. You think that it is simple and that
you have in your power all the tools to help many people. And you do not
lack skills, but it is necessary that prior to beginning, you become aware
of some things that you have not been told during your formative stage.
This is the letter that I would have liked to have received when I
started working in grief therapy. I would have liked someone to
have spoken clearly to me about the reality of this type of therapy,
about what is not said in the courses and the difficulties that I was
going to encounter, but also about how beautiful it was going to be.
Suggestions for the practice of clinical psychology:
• Don’t spend all of your energy at the beginning, this profession is

more of a long-distance race than a marathon.
• Start by accepting cases bit-by-bit. Don’t force yourself or pressure

yourself - if you feel uncomfortable or tired doing therapy, your
patients will notice.
• Surround yourself with a team that can support you and with whose
members you can vent.
• Combine your work with continuous training. This will give you
ease and help you incorporate new tools into your interventions.
Professional trainings are a great place to connect with people in your
industry and network.
• Supervise yourself, at least in the beginning. Being able to contrast

with another professional the approach you are giving to a specific
intervention can make you feel much more secure.
• Do not be afraid of not having all the answers to an intervention.

Experienced professionals also have doubts, we work with the most
probable hypothesis.
137
EPILOGUE
• Trust the human being’s potential. Professionals are not essential,

creating a bond constitutes half of the therapy or maybe even more.
• Fill your life with things that feed you and that can counteract the wear
and tear that therapy often entails. We accompany people during a
difficult moment of their lives and that has an impact on us.
The pros of practising grief therapy
Psychology needs people like you, with a lot of energy, ambition and desire to
succeed, wanting to help many people. We share a beautiful profession, but one
that wears down a lot if you don’t know how to protect yourself and even if you do.
We are lucky to be able to accompany people who suffer, but who will
trust your criteria. The privileges of practicing in a clinic and offering grief
therapy are evident: personal satisfaction, feeling that you can help and
are important to your patients, contemplating how people improve and
how strong the human being is... We are part of a unique relationship:
the one forged between therapist and patient.
The emotional cost for the grief expert
However, professionals who work in grief therapy also pay a toll that we
must be aware of. We often suffer with our patients. This may not be
very orthodox, but it is the reality. Witnessing their suffering makes us
vulnerable, it affects us in some way, and I think this is inevitable.
Sometimes, the fact that our work is based on human relationships

confronts us with complex relationships with complaints, anger or
undesirable reactions. It is necessary to assume that this is the price
we pay for dedicating ourselves to this beautiful profession. Hence, the
importance of each professional taking care of themselves in the way
that is most beneficial to them. And this self-care is ethically necessary,
because a burned-out professional can end up being negligent.
138
BIBLIOGRAPHY
CHAPTERS 1 & 2
• Gala León FJ, Lupiani Jiménez M, Raja Hernández R, Guillén Gestoso C,

González Infante JM, Villaverde Gutiérrez MC, Alba Sánchez I. (2002).
Actitudes psicológicas ante la muerte y el duelo. Una revisión conceptual.
Cuadernos de Medicina forense, (30), 39-50.
• Gil-Juliá B, Bellver A, Ballester R. (2008). Duelo: evaluación, diagnóstico y

tratamiento. Revista Psicooncología, 5 (1), 103-106.
• Prigerson HG, Vanderwerker LC, Maciejewski PC. Complicated grief as a

mental disorder: inclusion in DSM. Handbook of Bereament Research and
practice: 21 century perspectives. Eds. Stroebe M, Hansson R, Shut H. &
Stroebe W. American Psichological Associaton Press 2007, in press.
• Bayes, R. (2001). Psicología del sufrimiento y de la muerte. Martínez Roca.

Barcelona.
• Lacasta MªA, de Luis V. (2002). Evaluación de resultados a largo plazo de un

programa de atención al duelo. Rev Soc Esp Dolor, (9), 502-509.
• García JA, Landa V, Trigueros MC, Gaminde I. (2005). Inventario de Texas

revisado de duelo (ITRD): Adaptación al castellano, fiabilidad y validez. Aten
Primaria, 37 (7), 353-358.
• Prigeston HG, et al. (1997). Traumatic grief as a risk factor for mental and
physical morbidity. Psychiatry, (154), 616-623.
• Martikainen P, Walkonen T. (1996). Mortality after the death of spouse:

Rates and causes of death in a large finish cohort. American Journal of public
Health. (86/8), 1087-93.
• Parkes CM. (1964). Effects of bereavement on physical and mental health,

a study of the medical records of widows. British Medical Journal, (2), 274-
279.
• Zissok S, Shuchter SR. (1991). Depression through the first year after the
death of a spouse. American Journal of Psychiatry, (148), 1346-1352.
• Jacobs S, Hansen F, Kasl S, Ostfeld A, Berkman I, Kim K. (1990). Anxiety

disorders during acute bereavement: risk and risk factors. J Clin Psychiatry,
(51), 269-274.
139
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• Madison D, Viola A. (1968) The health of the widows in the year following
bereavement. J Psychosom Res, (12), 298-306.
• Jacobs S. (1999). Traumatic grief: diagnosis, treatment and prevention.

Philadelphia: Taylor & Francis, 89-101.
• Kaprio J, Koskenvuo M, Rita H. (1987). Mortality after bereavement: a

prospective study of 95,647 widowed persons. American Journal public
Health, (77), 283-287.
• Portillo MJ, Martín MJ, Alberto M. (2002). Adherencia al tratamiento del

duelo patológico. Cuadernos de medicina psicosomática y psiquiatría de
enlace, (62/63), 13-18.
• García JA, Landa V, Trigueros MC, Calvo P, Gaminde I. (1996). El duelo

por la pérdida del cónyuge: un estudio mediante grupos de discusión en
Atención Primaria. Originales Atención Primaria, 18 (9), 475-479.
• Gómez R. (2000). Las ansiedades del médico frente a la muerte. Psiquiatría

Publica; 12(3).
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Madrid: Síntesis.
• Tizón, J.L. (2004) Pérdida, pena, duelo. Paidós, Barcelona.
• Rothschild, B. (2009) Ayuda para el profesional de la ayuda, Desclée de

Brouwer.
• Worden, W. (2013) El tratamiento del duelo, Paidós.
• Rando, T.A. (1993) Treatment of complicated mourning, Champaign, IL,

Research Press.
CHAPTER 3
• Bucay J. (2006) El camino de las lágrimas. Ed. Debolsillo.
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pérdida del cónyuge: un estudio mediante grupos de discusión en Atención
Primaria. 1996;18:475-83.
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• García García JA, Landa Petralanda V, Trigueros Manzano MC, Gaminde Inda
I. Inventario de Texas Revisado de Duelo (ITRD): adaptación al castellano,
fiabilidad y validez. Aten Primaria. 2005; 35 (7): 353-8.
• Faschingbauer TR. Texas Revised Inventory of Grief manual. Houston:

Honeycomb Publishing; 1981.
• Neimeyer R. Aprender de la pérdida. Una guía para afrontar el duelo.

Barcelona: Paidós Ibérica.
• http://www.somosprimates.com/2011/02/el-duelo-de-los-animales/
• Worden W (1991). El tratamiento del duelo. Asesoramiento psicológico y

terapia. Paidós.
1st TASK

terapia. Barcelona: Paidós.
2nd TASK

• Neimeyer R (2002). Aprender de la pérdida: una guía para afrontar el duelo.

Barcelona: Paidós Ibérica.
3rd TASK

4th TASK
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(editado por Schoenberg B, Carr AC, Peretz D y Kutscher AH). Columbia
University Press, New York, 1974.
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GRIEF DUE TO DISAPPEARANCE
• Acinas P. (2012) Duelo en situaciones especiales. Revista digital de Medicina

Psicosomática y Psicoterapia. Vol 2.
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uncertainty. Personal interview, 15th February 2010. International
Committee of the Red Cross (ICRC).
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• López García de Medinaveitia, AP (2011). Duelo perinatal: un secreto dentro

de un misterio. Revista de la Asociación Española de Neuropsiquiatría; 31
(109), 53-70.
142

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ADULT GRIEF GUIDE

For socio-healthcare professionals

CHAPTER 1: Justification: Why the need for a guide on grief?.........................9

1.2 Why is a guide on grief necessary for socio-healthcare professionals?

CHAPTER 2: The most frequent questions made by

2.2 Is what is happening to me normal?

2.3 How long does grief last?

2.4 Why am I not hopeful?

2.5 When is grief therapy necessary?

2.6 Who can provide grief therapy?

2.7 What types of therapy are there?

2.8 When and where is it necessary to refer?

2.9 Why is it necessary to understand the process of grief?

2.10 Questions without answers.

CHAPTER 3: Grief intervention levels......................................................................31

3.2 Who is able to help with grief?

3.3 How can we measure grief?

3.4 What role do the different social agents play?

3.5 What does a grief patient seek at the doctor.

4.2 What is grief and what is not grief?

4.3 How does grief work.

CHAPTER 5: Irrational or erroneous ideas regarding

CHAPTER 6: What does the grief process consist

6.1 First task: Assume the reality of the loss.

6.2 Second task: Elaborate emotions related to grief.

CHAPTER 7: Anticipatory grief versus delayed grief...................................................90

CHAPTER 8: Grief and psychosomatics...........................................................................95

CHAPTER 9: Grief versus depression..............................................................................99

CHAPTER 10: Grief due to a loss by suicide...................................................................103

CHAPTER 11: Grief due to a traumatic death..................................................................107

CHAPTER 13: Gestational or perinatal grief....................................................................117

CHAPTER 14: Grief and faith.................................................................................................123

APPENDIX: CLINICAL CASES...............................................................................................130

o What always works in grief.

o Examples of answers and keys to grief. A study of ten cases.

o Common elements connected to all questions.

o Letter to a recent Psychology graduate.

In this new edition, we wish to incorporate the main questions that

Throughout this guide we want to reply to all those questions that we

It is an enormous responsibility for us to develop a guide that provides

In my experience, these “ideas” based on our own beliefs, on general

It is important to distinguish a professional opinion from a personal one.

Generally, a person going through a grieving process visits the social-health

It is an increasingly generalized perception that in our society death is not well

1.1 Reflections regarding grief

In order to discuss grief, it is essential to reflect on the human being’s need

JUSTIFICATION: WHY THE NEED FOR A GUIDE ON GRIEF?

In that sense, there are moments or experiences in which we find ourselves

“Void” is not an easy term to explain or manage. Irving Yalom, an existentialist

1.2 Why is a guide on grief necessary for socio-healthcare

On another hand, bereavement is considered as a cause of morbidity and

Among the possible physical complications compiled in multiple studies, we

In summary, a correct elaboration of grief is essential for an individual’s good

Socio-healthcare professionals who assist people in situations of pain, grief or

evidence of the importance psychological support from healthcare professionals

By providing the socio-health professional with training on how to cope with

We aim for this guide to be useful at any level of intervention: whether it is

• Counselling: The purpose of counselling is to aid the person in the

• Accompaniment: The aim of accompaniment is to be by the side of a