Commentary On "Normal Grief: Good or Bad? Health or Disease?"

Professor Kopelman's paper Normal Grief: Good or Bad? Health or Disease is tightly argued and reaches the conclusion that normal grief is adaptive and good. Her terms of reference are philosophical; mine will be clinical, reflecting what one sees in practice. While agreeing with Kopelman, I will be emphasizing the clinical importance of recognizing the many ways in which the normal processes of mourning may become pathological.

The work of Bowlby (1969) and Parkes (1972) has been particularly important in helping us to understand grief and mourning. In his monumental work on attachment, Bowlby argued that the bond between the mother and child is not forged (as Freud supposed) through the oral phase of taking in food at the breast. Instead, he postulated that there is a more basic affective attachment mediated through vision, sound, touch, and smell. This bonding between human beings, he argued, is not restricted to infancy. It can occur at any time, from the cradle to the grave. He studied infants in particular, however, describing a definite sequence of behavior that occurs when the child is separated from the mother. This starts with searching, moves on to protest, then to despair, and finally to detachment. Parkes, working with widows, described the mourning process in terms of similar phases: alarm, searching, protest and mitigation.

Death is a form of separation that is final and irreversible, and human beings have to cope with this fact. The child who loses sight of his mother has an expectation of seeing her again, and certainly does not reach the sense of finality with which adults respond to irreversible events. Adults reacting to death start with a sense of being stunned and a feeling of numbness. This feeling usually develops within a few minutes and may last hours or days. It is followed by a period when reality begins to register and the reaction (as Parkes described) becomes one of fear and alarm. This reaction is experienced clinically as anxiety and is a common constituent of the depressive picture. The anxiety may reach panic proportions, but it usually consists of being "on edge," snappy, irritable, or easily frightened. In addition to anxiety, there may be insomnia. This may take the form of loss of sleep, early wakening, or difficulty in getting off to sleep.

The next phase in grief, as in separation in the baby, is the phase of searching. The search may be conscious and deliberate. "I can't help looking for him everywhere. . . . I walk around searching for him." This intense desire to find the departed person organizes perception in such a way that expectation is high, and the desperate desire for the lost person may be fulfilled in a variety of ways. The husband is "seen" in the street, in his car, sitting in his favorite chair, in bed. In a detailed study of 227 Welsh widows and 66 widowers, Rees and Lutkin (1967) found that 14 percent experienced hallucinations or illusions of the dead person's presence from time to time, while 39 percent had a sense of the dead person's presence.

Next, the bereaved experience the phase of protest. Intimately related to alarm and searching are anger and irritation. These are equivalent to the child's protest. Anger is expressed by the child through tears, screaming, shouting, banging, and lying on the floor and kicking, and generally this frantic activity has a clear goal, namely to bring mother back. No amount of anger will bring the dead person back, and yet anger is generally present in the first year of bereavement in sufficient intensity to be commented on by most widows surveyed (Parkes 1971). The anger has several components. The first, and certainly a most painful one, is the anger arising from the feeling of being abandoned. This anger cannot be easily directed at the dead person, but it can be used against others, for example those who were in attendance prior to the death, namely physicians, nurses, hospital staff members, ambulance drivers. Sometimes the anger is turned against oneself. If the husband was asked to do anything, nagged, or...