Grief questions

There is no set timeline. There are no quick fixes after a loved one dies, though the intensity tends to ease over time for most people. You can tell things are improving when good days start to outnumber the bad ones. Grief can continue for life in a quieter, more bittersweet form and may flare up around anniversaries, even years later. If intense grief has not eased after a year, see the questions on prolonged grief disorder below.

Sources: Mayo Clinic, National Institute on Aging, SAMHSA

Not in the way most people picture them. Grief researcher Bonanno of Teachers College, Columbia University, says a stage model assumes everyone goes through the same sequence, and "there is nothing like that." He points out that earlier stage theorists mostly studied people who struggled to get past a loss. He also says most people have an innate resilience that lets them mourn and move on. In his words, "Some people struggle. Some people cope very well."

The Five Stages of Grief, and What Grief Is Really Like

Sources: Teachers College, Columbia University

Grief affects the body as well as the mind. It can bring tiring easily, feeling exhausted, trouble eating or sleeping, more headaches and other illnesses, and trouble concentrating. Sleep problems, appetite changes and physical problems or illness can also show up. Tears can come easily in unexpected places, or you may not be able to cry. Check in with your health care team to make sure all is well physically. New or worsening health problems, or severe physical sensations such as pain, are among the signs that a grieving person may need more help.

Sources: Mayo Clinic Health System, MedlinePlus, SAMHSA tip sheet

Trouble sleeping is one of the most common complaints among grieving people. Thoughts of the person can keep you from falling asleep, and dreams about them can wake you at night. Try a dark, cool, quiet bedroom, no screens for an hour before bed, fewer daytime naps, and no caffeine or alcohol after early afternoon. Keep a regular sleep schedule too. If grief is getting more intense and interfering with your sleep, talk with your doctor.

Sources: Sleep Foundation, NIH

Difficulty concentrating is one of the ways grief can show up. It can appear along with tiring more easily and trouble eating or sleeping. Check in with your health care team about symptoms like these to make sure all is well physically. Keep a daily routine and a regular sleep schedule, and talk with a doctor if everyday activities are getting hard.

Sources: Mayo Clinic Health System, NIH

Anger is one of the feelings that can follow a loss. Anger, guilt, anxiety, sadness and despair are among the mental reactions to grief. A person may feel anger toward the one who died. Intense emotional pain such as anger or bitterness, and avoiding reminders of the death, are among the symptoms the American Psychiatric Association lists for prolonged grief disorder, which can be diagnosed when the death was at least a year ago for adults. If anger stays strong and makes it hard to get back to daily life, tell your health care team or consider seeking a therapist who specializes in grief.

Sources: MedlinePlus, National Institute on Aging, American Psychiatric Association, Mayo Clinic

Guilt is common. It is a feeling that shows up after both sudden and expected deaths, and it is among the normal reactions to loss. SAMHSA's guidance lists excessive guilt among the feelings that can complicate grief, and describes self-blame and repeated "what if" thinking as common obstacles to adapting to a loss. If those thoughts are taking over your days, tell your health care team or consider a therapist who specializes in grief.

Sources: Hospice of the Valley, MedlinePlus, SAMHSA, Mayo Clinic

They overlap, but they are not the same. In Psychiatric News, an author writing about her husband's death said that in grief, death causes the pain, while in depression, death can feel like the solution to the pain. She described grief as coming in waves and depression as feeling unending. A 2018 American Psychological Association article quoted a grief researcher saying depressed people usually do not have the longing and yearning that mark grief. SAMHSA warns that grief is often mistaken for depression or PTSD, which can lead to the wrong treatment. A SAMHSA tip sheet lists sadness or no ability to find joy, extreme fatigue and suicidal thoughts as signs that a grieving person may need more support.

If you or someone you know is struggling or in crisis, call or text 988 or chat at 988lifeline.org (Suicide & Crisis Lifeline, U.S.). Outside the U.S., find a local line at findahelpline.com.

Sources: Psychiatric News, American Psychological Association, SAMHSA, SAMHSA tip sheet, NIH

Grief can come back on anniversaries, birthdays, holidays, and even with a song or a familiar place. These feelings are not necessarily a setback, though strong reactions can last for days. Suggestions:

• Prepare ahead, knowing these reactions are normal.
• Schedule time with friends or family for moments you may feel alone.
• Start a new tradition, such as a donation in your loved one's name or planting a tree.
• Write a letter about good memories and add to it over time.

Sources: Mayo Clinic

Plan ahead and give yourself options. Talk over holiday plans with people close to you, find ways to remember your loved one, and let your feelings be your guide. Hospice Foundation of America offers the Three Cs: choose which events to attend, communicate your choices to family, and compromise where people grieve differently. Examples of rituals include lighting a candle, a moment of silence or a toast. Grief counseling or a support group can also help during this season.

Sources: Mayo Clinic Q&A, Mayo Clinic Health System, Hospice Foundation of America

Consider it when grief stays intense for a long time or makes it hard to get back to daily life. Tell your health care team or seek a therapist who specializes in grief. Talk with your doctor if sadness keeps you from handling daily life. Warning signs include big changes in sleeping or eating, pulling away from others, new or worsening substance use or risky behavior, and new or worsening health problems.

Sources: Mayo Clinic, National Institute on Aging, NIH, SAMHSA, SAMHSA tip sheet

Prolonged grief disorder is a diagnosis listed in the American Psychiatric Association's DSM. The APA says it can be diagnosed when the death was at least a year ago for adults, or at least six months ago for children and adolescents. The key feature is intense longing for the person who died, or preoccupation with thoughts of them, nearly every day for at least a month. The grief must cause significant distress or problems in daily life, go beyond what social, cultural or religious norms would expect, and not be better explained by another mental disorder.

Sources: American Psychiatric Association

The APA lists feeling that part of yourself has died, marked disbelief about the death, avoiding reminders, intense emotional pain such as anger or bitterness, trouble reconnecting with friends or planning ahead, emotional numbness, feeling that life is meaningless, and intense loneliness. The APA's patient page says a diagnosis needs at least three of its listed symptoms nearly every day for at least the last month. Only a licensed clinician can diagnose it. A 2018 American Psychological Association article, citing research, put it at about one in 10 bereaved people and described a 16-session grief-focused therapy called complicated grief treatment. The APA says help is available.

Sources: American Psychiatric Association news release, American Psychiatric Association patient page, American Psychological Association

Many people find them useful. Groups bring grieving people together to help one another, and some focus on a specific loss, such as a spouse or a child. To find one, check with religious organizations, local hospitals, nursing homes, funeral homes or your doctor. Hospice programs offer bereavement support to family members, even if your spouse did not use hospice. Peer support can offer mutual understanding after sudden or traumatic losses. Examples include The Compassionate Friends and GriefShare.

Support Groups for Child and Grandchild Loss

Sources: National Institute on Aging, SAMHSA

It can be. After a sudden death, shock and disbelief last longer, there is no time to say goodbye, and many feelings arrive at once. After an expected death, grief may start before the person dies, and there may be time to prepare, say goodbye and settle unfinished matters. Reactions before a death can even include relief when a loved one has a good day. A 2018 American Psychological Association article said prolonged grief is more likely after sudden or violent deaths. Guilt is common in both situations.

Anticipatory Grief: Grieving Before a Loss

Sources: Hospice of the Valley, Hospice Foundation of America, American Psychological Association

Be honest, use plain words, and let them show grief in their own way. Use the words dying, death and died, because phrases like "went home" can lead a child to expect the person to return. Children's moods can shift fast, and laughing or playing does not mean they did not love the person. Children under about five may not grasp that death is permanent. Around five to seven, most children start to understand that death is final. Older children may feel responsible for the death. If a child needs extra support, consider a counselor or grief group.

Sources: Mayo Clinic, SAMHSA

Expect grief that comes and goes. Teens often grieve in an on-again, off-again way for longer than adults, and they may hide their pain to spare you. Helpful steps include listening, talking side by side instead of face to face, encouraging them to talk about the person who died, not asking every five minutes how they are doing, restoring routines quickly, and meeting with the school counselor. Teens may act out or take more risks.

Sources: Hospice of the Valley, SAMHSA

Start by reaching out, then keep doing it. Ask how they are coping, offer a personal condolence instead of a stock phrase, and give specific help such as meals, cleaning, childcare or funeral planning. Call regularly, ask open-ended questions, be comfortable with silence, say the person's name, and let them steer the conversation. Phrases to avoid include "You'll get over it soon," "They would want you to...," "They lived a good life" and "You're so strong."

What to Say to Someone Who Lost a Loved One

Sources: SAMHSA

The federal Family and Medical Leave Act does not cover bereavement leave, though some states, such as Oregon, have their own rules. Bereavement leave in the U.S. often averages only 3 to 5 days, after which workers must use sick, vacation or personal time. Ask your employer's HR department what applies to you, since policies vary by employer. Grief can include difficulty concentrating, so your focus may be off at first.

Returning to Work After a Loss

Sources: Nolo, SAMHSA, Mayo Clinic Health System