The Inner Workings Of Grief


Bereavement has been a primary concern in psychotherapy for decades. However, making the appropriate distinctions between complicated grief (CG) or Prolonged Grief Disorder (PGD) and acute grief have provided much difficulty for clinicians. As more patients become debilitated by chronic bereavement, there has been a greater need for understanding what factors complicate the healing process. Therefore, the purpose herein is to use a neurobiological approach to conceptualize the bereavement process. More importantly, we plan to use this approach to formulate better assessment and treatment options for the use of psychotherapy, cognitive behavioral therapy, psychotropic medicines.

Keywords: Complicated Grief (CG), Prolonged Grief Disorder (PGD), Dopamine (DA), Nucleus Accumbens (NAcc).


Most individuals in their lifetime experience loss of a loved one. Regardless of the circumstances surrounding death, it can be life-changing. That devastation may initiate a cycle of grief with no clear end or beginning. For those who have not endured death, this concept may seem foreign. However, exploring the bereavement process provides insight into what many people face everyday. Grief is defined as deep sorrow and pain that is caused by someone’s death. Yet this definition just barely scratches the surface of what some people actually endure in the months and years following death.

As initially proposed by Elisabeth Kubler-Ross in her 1969 book entitled Death and Dying, grief can include, but is not limited to Denial, Anger, Depression, Bargaining, and Acceptance. Collectively, these stages are known as the bereavement period. During the stage of denial, the individual struggles to cope and refuses to accept that their loved one has actually passed on. This stems from being unable to address the magnitude of pain that comes with acceptance. In this stage, individuals actively deny loss by employing distractions. For example, you will see someone burying themselves in work to prevent subconscious feelings of sadness from emerging.

In comparison to denial, anger manifests itself in various forms. For example, unresolved matters with the person who has died can lead to a sense of resentment and blame. In the midst of anger, friendships and family relationships can be destroyed by irrational thoughts such as: “Why did you have to enable your sister’s drinking? It’s your fault that she died.” In fact, feelings of anger during mourning may lead to maladaptive coping strategies such as excessive drug use, partying, and even isolation. The emotional complexities within this stage are endless, but it is imperative to become aware of these issues in order to become that non-judgmental, loyal, and supportive clinicians. Having a sense of awareness about the bereavement process prevents any undue stigma.

Kubler-Ross has defined bargaining as the victim pleading for the return of their loved one in exchange for doing something. Often times you will hear someone saying: “I would trade anything in the world just to have my mother back, even if it is just for one second.” This stage is also where feelings of guilt creep in. People may blame themselves for things they didn’t say or do to improve the situation. That guilt propels the need to bargain or try to reiterate different scenarios in their minds that would have changed the outcome of death. This is one of the most difficult stages of grief to endure because the circular thinking leads to sleep deprivation, depression, and unrelenting feelings of anger towards oneself.

The Stage of Acceptance comes into fruition when the individual who experienced loss is able to not only obtain a sense of closure, but also come to accept the reality of death. In this stage there is the ability to compartmentalize the loss as outside of one’s own control and eliminate sense of guilt, blame, or depression because that person has been able to properly deal, rather than resorting to maladaptive coping strategies.