The grief that does not speak...

Is it hiding in the bushes?

Yes, yes...I know it is spring and we should all be focused on the bright and colorful future of the coming season. Tis not the time to sour our thoughts with sadness and melancholy. However,  I find myself here, at this crucial vibrant moment, enjoying the paradox that I am about to present.  Giving words to an otherwise quiet repression.

Its been a long hard winter for many people that I hold near to my heart. For these folks death, tragedy, trauma, disappointment, bereavement, and terrifying pain are still thickening the air even in these first days of spring.  Of course, grief is quite notorious for its darkness, and by darkness I mean retreat and uncomfortable stillness. In the emotional realm, the cave of sadness becomes both too small and extraordinarily expansive all at the same time. Who has not felt the heavy vacancy of grief, squirming uncomfortably in one's own skin, desperate not to succumb to its cold, wintry shadow?

Ironically, it is in these treacherous moments that we are meant to find our healing a world that often lacks the right words and the right space to do so.  For many, grief remains unfathomable. It is process that is not well understood, foreign, or even terrifying. Often times grief is also not well attended to, perhaps due to it's inconvenient, embarrassing nature, or simply because it is too costly a luxury.  Under these circumstances, grief clings to the spirit as a passive-aggressive patience, waiting to jump out from behind the bushes and wreak havoc on everything that is beautiful and good. Let it out I say!

The following paragraphs are a reworking of research I completed in fulfillment of my degree in herbal medicine from the Scottish School of Herbal Medicine and the University of Wales.  Looking back upon my writing, I have found cavernous room for improvement. However, today I present to you a thorough literature review regarding the definition of grief and it proposed impact upon human health and wellness.  These words are intended for practitioner and client alike, as I hope to shine some light upon critical research that took place within the field of psychology during the latter half of the 20th century (old news right?). 

"Jules Bastien-Lepage-Ophélie-Musée des beaux-arts de Nancy" by Jules Bastien-Lepage - Own work Ji-Elle. Licensed under CC BY-SA 3.0 via Wikimedia Commons 

"Jules Bastien-Lepage-Ophélie-Musée des beaux-arts de Nancy" by Jules Bastien-Lepage - Own work Ji-Elle. Licensed under CC BY-SA 3.0 via Wikimedia Commons 

A little bit of context...

“Give sorrow words, the grief that does not speak, knits up the o’erwrought heart and bids it break” (Shakespeare, McBeth, 4.3.210)

It is within the most beloved literature of Western culture that the seeds of this work were sown, in light of integrative concepts approached by the ‘new holistic paradigm’ arising in alternative and complementary medicine.  This theoretical framework is  based on the re-integration of centuries-old human intuitive wisdom of the body, mind and spirit, collectively, into the rationalist and reductionist scientific method and understanding of life that dominates modern medicine. 

Mills (1991, pg. 25) likens this basis as a return to the ‘cosmic view of life’.  He calls upon the medical practitioner to look to the processes within the living being rather than the actions and functions of a mechanism:

“The human is a willful vibrant idiosyncratic wonderful being not to be divided into compartments, whether these are of ‘body’, ‘mind’ or ‘spirit’, or separate functional fragments… Such an approach to physiology will demand that one looks at the processes within a living being…these processes are reflected as much in human psychological, emotional, social, and even spiritual dimensions as in the somatic sphere.”

It is from a response to this call that this study built momentum.  As a student of herbal medicine and through a desire to integrate such an approach into the therapeutics of health and wellness within my clinical practice, I continue to be drawn to this vitalistic perspective.  I hope you are too.

The original research aimed to explore the potential role of herbal medicine in the facilitation of the grieving process.  Within such an exploration grows an awareness of how as a herbal medicine practitioner I might able to assist my clients in achieving a release from yet another factor that may be negatively affecting their health. This work was orchestrated with the hope of emphasizing the importance of human emotions in determining health and wellness, and therefore determining the breath of which the herbal medicine practitioner may need extend their art and science.

One of the objectives of this study sought to identify the impact of the emotional process of grief on the physical health of the human body. Through this identification I attempted to connect the relevance of such phenomena to a widening of therapeutic strategy within my clinical practice and herbal medicine at large. However, as I dug out the trenches of my literature review it became evident that some serious background information was needed. What is grief and the grieving process? Why and when would the process need to be facilitated, if at all? And finally, of what relevance is this to a health care provider?

What are you talking about?

"Michelangelo Caravaggio 070" by Michelangelo Merisi da Caravaggio - The Yorck Project: 10.000 Meisterwerke der Malerei. DVD-ROM, 2002. ISBN 3936122202. Distributed by DIRECTMEDIA Publishing GmbH.. Licensed under Public Domain via Wikimedia Commons 

"Michelangelo Caravaggio 070" by Michelangelo Merisi da Caravaggio - The Yorck Project: 10.000 Meisterwerke der Malerei. DVD-ROM, 2002. ISBN 3936122202. Distributed by DIRECTMEDIA Publishing GmbH.. Licensed under Public Domain via Wikimedia Commons 

Grief is an emotional response to loss.

'Grief’ has been described as a process of realization, or integrating into reality or consciousness, the event of ‘loss’.  In this light, grief is seen as a learning experience of change through which one becomes used the lost object no longer being physically present (Parkes, 1998).  This points out the concept of ‘grief’ as an emotional response to ‘loss’, a response that requires time and adjustment (Tatelbaum, 1997).  If ‘grief’ has therefore been described as a ‘process’ that occurs in response to the event of ‘loss’, it is important to ascertain what lies within the concept of ‘loss’.

‘Loss’ as a causation of ‘grief’ and the initiator of the ‘grieving process’ has been identified and discussed in reference to a number of life events. Amputation, or loss of a limb (Kessler, 1951: Parkes, 1972), loss of a home (Parkes, 1972), divorce or separation (Schmale, 1958), forced migration and loss of culture (Munoz, 1980), death or loss of a domestic pet (Keddie, 1977), and loss of a job (Fagin and Little, 1984), are a few examples of ‘loss’ that are thought to elicit a grief response. The object that is lost can be real or symbolic, human or non-human (Parkes, 1998). 

The idea that the event of ‘loss’ encompasses more than just death of a loved one increases the likelihood that ‘grief’ may be present in our lives, even if we do not consciously acknowledge its presence.  In this regard, the widening of definitions may help us to not take the presence of ‘grief’ for granted. In a clinical scenario, some cases ‘grief’ may be obvious to the herbal medicine practitioner, especially when the client confides in them about an event of ‘loss’ that is proving difficult for them to come to terms with.  However, in the case of clients who do not share much directly, listening to their story for events such as divorce, loss of a job, etc., may serve as red flags indicating something more is going on underneath their presenting complaint.  Moreover, this is not to say that every person with a history of divorce, for example, is suffering from ‘grief’.  It is just a call for an awareness of such a possibility to be in the mind and heart of the herbal medicine practitioner.

'Normal' vs 'Abnormal Grief.

There are many theories about different stages within the ‘normal’ or ‘uncomplicated’ processes of grief (please refer to Parkes, 1998; Speigel, 1977; or Tatelbaum 1997 for different models). Overall, there appears to be an ideological pattern followed by someone experiencing the grieving process. It is only the classification of these different stages that differs between the various theories.  In general, the ‘grieving process’ is thought to run a consistent course.  The initial phase of shock, which may include denial that the ‘loss’ has occurred, is followed by a stage of awareness where most emotional and physical distress is thought to take place. Finally, there is a prolonged stage of amendment and recovery where the trauma of the loss is overcome and states of emotional, physical, and spiritual health and well-being are re-established (Engel, 1961).

‘Abnormal’, ‘complicated’, or ‘pathological’ grief is defined as a grieving process that has literally gotten stuck or is not progressing.  It is no longer a means to an end, but state of being that remains unresolved (Speigel, 1977). According to Parkes (1998) there are two main forms of ‘abnormal grief’ termed ‘avoidance’ or ‘repression’ and ‘chronic grieving’.  ‘Avoidance’ or ‘repression’ is manifest when a person attempts to inhibit their feelings.  Unfortunately, in most cases they only end up prolonging the process.  This may or may not be the case in ‘chronic grieving’, where the sufferer never really seems to complete the grieving process, but rather remains static, never reaching the stage of amendment or recovery. It is in the presence of ‘avoidance’ or ‘repression’ and ‘chronic grieving’ where the most significant effects on physical health may be seen, as if the grief is coming out in some other way (Tatelbaum, 1997).  However, grief’s potential of affecting physical health is thought to be possible at any stage of the process (Stroebe and Stroebe, 1987).

To classify a grieving process as ‘normal’ or ‘abnormal’ is difficult and tends to place individual people and their processes within the same confines (Engel, 1961). Needless to say, it is not a very holistic method of observation.  To emphasise this point, within the academic discourse of the grieving process, it is believed by some that there are very few symptoms of grief that reliably point to a pathological or ‘abnormal’ processes (Stroebe and Stroebe, 1987).  Therefore, this section has only been presented in hopes of highlighting the fact that not all grieving processes are the considered the same within the field of psychology and we all should have an awareness that such matters do not always go according to plan.  This is expressed by the following:

“There is an optimal level of grieving which varies from person to person. Some will cry and sob, others will betray their feelings in other ways.  The important thing is for thoughts and feelings to be permitted to emerge into consciousness. How they appear on the surface may be of secondary importance (Parkes, 1998, pp. 174)”

Why some things just don't go according to plan.

Factors involved in an abnormal grief response

So what factors might precipitate an ‘abnormal’ grief response?  I discovered that answering this question is crucial to identifying what people may be at the greatest risk of acquiring health problems in association with the grieving process and why (Car and Schoenberg, 1970). This is directly relevant to the herbal medicine practitioner and our roles in prevention of health problems through identification of those clients at greatest risk.  However, it is important to remember that there are many proposed factors that herbal medicine may not be able to address.  

Stroebe and Stroebe (1987) categorize interfering factors as sociodemographic (age, sex, ethnic group, social class), and individualistic (spirituality or religious beliefs, personality, prior health), and also include variables such as bonds to the lost object, mode or suddenness of loss, and circumstances after the loss (accompanying stresses i.e. paying the mortgage, lack of social support). Fortunately, even though most of these factors cannot be addressed with herbal therapeutics directly, the herbal medicine practitioner has the unique opportunity to assist a client with a previous medical history maintain their health through an emotionally stressful experience.  Moreover, the practitioner may also be able to assist the client in the form of appropriate social support.  This concept is best understood in reference to the following section where the emphasis is placed on one factor that appears to be a common thread throughout the literature on the underlying etiology of ‘abnormal’ grief responses.   

Culture and society

Some blame Western society in terms of industrialization, changes in social structure over time, and the limitations of social institutions (such as law, employment, funeral homes, the medical system), for creating communities that are no longer supportive or tolerant of the grieving process (Osterweis et al., 1984).  One author believes the manifestation of such social and cultural change has led to a society that limits the expression of emotion and idealists appearing strong in times weakness, especially in regards to the male (Peretz, 1970).  In regards to bereavement itself, it is believed that the decrease of community solidarity, ceremony, and ritual, from industrialized Western society to that of modern day, plays a significant role in these ideologies. In keeping, research has discovered that people who perceive themselves to be lacking community, social tolerance, and support networks have a much poorer outcome of the grieving process, including in regards to the onset of ill-health (Maddison and Walker, 1967).  It is also firmly believed by some that where the religious or spiritual ritualization of grief has mostly disappeared, there is also a lack of this community, social tolerance, and support (Speigel, 1977). I suppose that is something to chew on, eh?

When grief takes its toll...

Below is a limited review of the most highly researched physiological consequences of grief and the grieving process as it took place in the latter half of the 20th century.  What is being put forward is that regardless of whether or not these physiological responses are part of a ‘normal’ or ‘abnormal’ process, they could have serious health implications in both the long and short-term.  Although to some this research may seem dated, I ask that you keep an open mind in light of what this may mean to herbal medicine and therapeutics. 

'Normal' physiological responses to grief

Below is a list presented from Stroebe and Stroebe (1987) that sheds light onto what is considered to be within the confines of ‘normal’ physiological responses to grief.  However, the authors state that even though these physiological responses are thought to be normal, it doesn’t mean they don’t require medical attention, or in themselves lead to or exacerbate more serious health conditions.  This section has been presented in hopes of illuminating possible health factors that the herbalist should not only be aware of, but could also supportively address.

 ‘Normal’ Physiological Responses to Grief (Stroebe and Stroebe, 1987)

  1. FatigueReduction in general activity level, slow speech and cognition, general lassitude. Retardation of thought and concentration Slowed thinking and poor memory, even as a potential result of fatigue.
  2. Loss of Appetite: (Occasionally overeating) accompanied by changes in body weight; sometimes a considerable loss of weight.
  3. Sleep disturbances: Mostly insomnia, occasionally oversleeping; disturbances of day/night rhythm, occasionally nightmares.
  4. Bodily complaints: Headaches, neckaches, back pain, muscle cramp, nausea, vomiting, lump in the throat, sour taste in the mouth, dry mouth, constipation, heartburn, indigestion, flatulence, blurred vision, pain on urination, tightness in the throat, choking with shortness of breath, need for sighing, empty feeling in the abdomen, lack of muscular power, palpitations, tremors, hair loss.
  5. Physical complaints of the deceased: Appearance of symptoms similar to those of the deceased, particularly those symptoms of the terminal illness; the bereaved may be convinced of having the same illness that afflicted the deceased.
  6. Changes in drug taking: Increased use of psychotropic drugs (i.e. tranquillisers, etc.), increased alcohol consumption, increased cigarette smoking.
  7. Susceptibility to illness and disease: Particularly infections (lowering of immunity), also those relating to healthcare (cancer, tuberculosis), and stress-related conditions (heart disease).

Real or imagined?

"Sadness" by Sasha Wolff from Grand Rapids - Sadness 90/365. Licensed under CC BY 2.0 via Wikimedia Commons 

"Sadness" by Sasha Wolff from Grand Rapids - Sadness 90/365. Licensed under CC BY 2.0 via Wikimedia Commons 

Despite the numerous studies regarding the negative effects of grief on physical health, there appears to be an ongoing and multifaceted debate about the reality of this connection.  Some researchers purposefully state that grief is not a causative factor of disease, but rather a stressful life event that precipitates latent disease states evident in people predisposed to them (Osterweis et al., 1984). One study that represents this view firmly was carried out by Schmale (1958) where 31 out of the 42 patients studied experienced the onset of disease within a week after the final separation from or loss of a valued object or relationship.  Another 8 patients reported that the loss happened within a month of the onset of illness, and of the three remaining patients, two reported that loss occurred between 6 and 12 months prior to the onset of symptoms.  The researchers address a number of variables that could have influenced the results of this study, but nonetheless conclude that separation or loss was not the cause of the many diseases reported, but rather one of the possible or necessary conditions that made the patients more susceptible to becoming ill.

Other researchers are more prone to agree with the idea that the increase and/or appearance of physical symptoms are more a sign of abnormal grieving and are psychosomatic in nature rather than signs of a truly pathological process.  Peretz (1970 pg. 18) states:

“At times the bereaved person flees from his own painful feelings by selecting those aspects of social values or expectations which permit him prematurely to terminate the bereavement.  In our society, symptoms of physical illness, being more acceptable, are frequently substituted for painful emotional states.”

There have been many studies that confirm this perspective.  An example of this was put forth by Parkes and Brown (1972) in a study where structured interviews were carried out with 49 widows and 19 widowers all under the age of 45, as well as with a control group.  Widowers reported an increase in acute physical symptoms but neither sex had more chronic physical symptoms than the controls.  Two to four years follow-up showed that there was little difference in health between the bereaved and the control group, but there was evidence of persisting psychological factors.  The acute symptoms spoken of were classified more as somatic symptoms that are commonly associated with anxiety.  However, the researchers also believe that despite this classification, the actual subjectively perceived ill-health of the participants confirms prior studies’ claims that the response to loss or bereavement can contribute to ill-health.

Another study that is commonly referred to on the subject of bereavement and health was carried out by Maddison and Viola (1968). The researchers found that 33 of the 57 symptoms included in their questionnaire were reported with significant increased frequency in the bereaved than in the non-bereaved control group.  Based on these results they claim a marked deterioration of health in 32% of the bereaved group versus 2% in the controls. They state that even though there was a high frequency of symptoms commonly associated with anxiety, there was little change in the frequency or severity of major diseases.  However, the researchers also state that the frequency or severity of major diseases may have been responsible for the deaths of some of the participants during the study.

Another proposed avenue of explanation of grief’s effects on physical health surround behavioral changes in response to loss and subsequent grief as stressful life events.   Rosenbloom and Whittington (1993) conducted a study interviewing both widowed and married subjects over the age of 60 to elicit information about eating behaviors and changes in eating behaviors in widowhood.  Results of this study indicated that widowhood produced negative effects on eating behaviors and resultant nutrient intakes. The researchers state their concern for the long-term health implications of such a change in behavior and conclude that it is an area that necessitates further attention from the wider health-care community.  This study coincides with the wider opinion that stressful life events, such as loss or bereavement, are thought to be likely to lead to a number of behavioral changes.  This includes personal hygiene, increasing in smoking, alcohol, and drug intake (Stroebe and Stroebe, 1987).  In some circles of thought these changes in behavior, within the context of a short-term reaction, are normal and natural regardless of their health implications.  However, it is when these behavioral changes extend beyond the short-term that the real threat of health deterioration begins (Peretz 1970b).  However, the ‘short-term’ is never defined in these pieces of research.  How long is a piece of string?

There is significant research into all sides of the debate, a complete review of which is outside the scope and constraints of this study.  However, the specific effects of grief on physical health, whether as a direct or precipitating factor, which are most relevant to this study and also represent the largest amount of research on the subject, are presented below.

Further health consequences...

The majority of clinical research into the negative effects of grief on physical health surrounds the response to bereavement, or death of a loved or valued person.  However, as explored above, grief has been defined as an emotional response to the loss of a variety of different objects, both tangible and symbolic.  Although research into the effects of grief on the physical body have only surrounded death and bereavement, it has also been proposed that the reactions to other types of loss can be considered as severe and can therefore carry with them similar health implications (Parkes, 1972). 

"Pearl of Grief" by Rembrandt Peale - Licensed under Public Domain via Wikimedia Commons 

"Pearl of Grief" by Rembrandt Peale - Licensed under Public Domain via Wikimedia Commons 

Clinical depression

In specific regards to bereavement, it has been shown that in both men and women grief can lead to clinical depression.  One study showed significantly more depression 14 months after bereavement in comparison to a control group of non-bereaved participants.  Interestingly, after 2 to 4 years in follow-up widowers remained significantly more depressed than married controls, but widows were found to no longer be depressed (Parkes and Brown, 1972).  This is an interesting finding when juxtaposed to the Western cultural biases that make men’s emotional expression of grief less acceptable than women’s (Peretz, 1970).

One study (Paykel et al., 1969), tried to establish types of ‘life events’ that occurred prior to the onset of clinical depression as potential causative factors.  One category of ‘life events’, which the researchers termed as ‘exits’, were found to be significantly more frequent in the diagnosed clinically depressed patients than in the controls. ‘Exits’ included events such as divorce or martial separation, failure or loss of business, loss of health or serious personal illness, death of an immediate family member, and loss of a job or job status.

It has been claimed that grief only becomes clinically relevant when depressive reactions are excessively intense and when the process of grieving is unduly prolonged (Stroebe and Stroebe, 1987). However, within these classifications the terms ‘excessive’ and ‘prolonged’ lack definition in respect to the individual and tend to be appropriated from the literature onto the population en masse, ignoring the optimal level and length of grieving that inevitably varies from person to person (Parkes, 1998). 

immune system integrity

There has been an extortionate amount of research into the effects of stressful life events and emotional stress on the integrity of the immune system.  In the field of research known as psychoneuroimmunology, this is a concept that is becoming more widely accepted (Ader et al., 2001). In respect to grief as an emotional stress, one study that is repeatedly referred to in the literature monitored T and B cell numbers and function, as well as hormone concentrations of 26 bereaved individuals 2 weeks after bereavement and again at six weeks.  The researchers concluded that their study was the first to prove that emotional stress, like that of grief, can produce a quantifiable decrease in immune system function, especially in regards to T lymphocyte responses (Bartrop et al., 1977).  The validity of this study has been disputed because participants did not undergo standardized psychiatric evaluations or mood ratings and therefore may have been suffering from clinical depression as a result of grief. This would bias the results of a direct relationship between bereavement and decreased immune function (Calbrese et al., 1987).  This was also the claimed weakness of a similar study carried out (Schleifer et al., 1983) which in many ways resembled that of Bartrop et al.(1977), as it underlined the possibility of impaired antibody formation following bereavement.  However, as discussed above, depression is accepted as a health consequence of a poor bereavement outcome, and is often not easily differentiated from the grief process itself.  Therefore, regardless of the presence of depression in these studies, evidence of decreased immune system integrity, whether due to direct bereavement or depression as a result of bereavement, could carry with it health implications. This may include increased susceptibility to infection or allergies, as well as precipitation or exacerbation of autoimmune conditions (Stroebe and Stroebe, 1987).  This is especially the case in those individuals who already harbor potential physiological weaknesses in immune function (Dubovsky, 1997).

Cardiovascular pathology

In a patient with already existing heart disease and diminished cardiac reserve, events that increase the work demand on the heart can potentially result in the development of congestive heart failure (Haslett et al., 2002).  Loss or bereavement, and consequent grief as an emotional stressor, are ‘events’ that are understood to do just that (Parkes et al., 1969). This phenomena has been recorded throughout historical and modern Western medicine.

For example, Parkes (1982) reminds us of the American physician Benjamin Rush (1885) who gave detailed descriptions of organ disease that he believed responsible of death from grief.   Autopsies of the bereaved individuals typically showed signs of what he called ‘congestion in and inflammation of the heart, with rupturing of its auricles and ventricles’. Landauer (1926) described the symptomatic picture presented by grief as, 

…Heartbreak or heartsickness.  The heart aches or is wounded, it burns, Accordingly, pain is usually described as pressure, soreness, burning, sometimes also as cramps and contraction near the heart, comparable to the grief that lies like a ‘great weight on the chest”. (As found in Spiegel, 1977, pp.240)

In modern medicine emotional stress has been shown to be a frequent precipitating factor in the development of congestive heart failure in patients with already existing cardiac disease.  Chambers and Reiser (1953) proposed this connection in a study based on the investigation of the precipitating events connected with 25 consecutive hospital admissions of patients suffering congestive heart failure.  For 19 of the 25 cases studied it was an acute and overwhelming emotional experience that was found to be ultimately responsible for inducing cardiac failure. Bereavement or sudden loss of a loved one was included in the researcher's definition of an acute and overwhelming emotional experience.

Summary and Discussion: Relevance to Herbal Medicine

The hypothesis that ‘grief’, as an emotional response to ‘loss’, predisposes to or exacerbates physical illness has been proposed for clinical depression, autoimmune, and heart disease. It has been argued that there is not enough evidence linking each of these diseases to loss and grief due to the fact that much of the evidence is based on small numbers of clinical case reports, and that bereavement and grief have not been well differentiated from other psychological states that are thought to have the same negative effects on health (Osterweis et al., 1984).  The argument here seems to surround definitions and boundaries, or classifications that in the reality of the sufferer may not actually exist.  This lack of clear-cut definition and classification does create variability that complicates scientific research.  Regardless, is it not what the individual is experiencing and their perception of health that is most important?

Others would agree, stating that loss or bereavement and consequent grief is a factor in the development of a wide range of physical illnesses that has been successfully substantiated by scientific research (Carr and Schoenberg, 1970).  As demonstrated by Parkes et al. (1969), after bereavement or other forms of loss, consultation rates in general practice can increase by nearly half. In these cases, the herbal medicine practitioner may be one of those health care professionals consulted. 

"Gather Ye Rosebuds While Ye May" by John William Waterhouse - Licensed under Public Domain via Wikimedia Commons 

"Gather Ye Rosebuds While Ye May" by John William Waterhouse - Licensed under Public Domain via Wikimedia Commons 

REFERENCEs and bibliography

  1. ADER, R., FELTEN, D., and COHEN, N., eds., (2001). Psychoneuroimmunology, Third edition, Vol.2. London: Academic Press.

  2. BARTROP, R.W., et al., (1977). ‘Depressed Lymphocyte Function after Bereavement’. In, The Lancet, 1: 834-836.

  3. BROWN, J., and STOUDEMIRE, A., (1983). ‘Normal and Pathological Grief’. In, Journal of the American Medical Association, Vol. 250, No. 3, pp. 378-382.

  4. BURTON, R., (1621). The Anatomy of Melancholy. London: Chatto and Windus.

  5. CALABRESE, J.R., KLING, M., and GOLD, P., (1987). ‘Alterations in Immunocompetence During Stress, Bereavement, and Depression: Focus on Neuroendocrine Regulation’. In, The American Journal of Psychiatry, 144:9, pp. 1123 – 1134.

  6. CARR, A.C., and SCHOENBERG, B., (1970). Object loss and Somatic Symptom Formation. In SCHOENBERG, B., et al., eds., 1970. Loss and Grief: Psychological Management in Medical Practice. New York: Columbia University Press.

  7. CHAMBERS, W.N. and REISER, M.J., (1953). ‘Emotional Stress in the Precipitation of Congestive Cardiac Failure’. Psychosomatic Medicine, 15: 38-50.

  8. CLAYTON, P.J., et al (1974). Mourning and Depression: Their similarities and differences. Canadian Journal of Psychiatry 19:309-312.

  9. DUBOVSKY, S., (1997). Mind Body Deceptions: The Psychosomatics of Everyday Life. London: W.W. Norton & Company, Inc.

  10. GORER, G., (1965). Death, Grief, and Mourning in Contemporary Britain. London: The Cresset Press.

  11. GREEN, W.A., and MILLER, G., (1958). Psychological Facotrs and Reticuloendothelial Disease: IV. Observations on a Group of Children and Adolescents with Leukemia. Psychosomatic Medicine, 20:124.

  12. HOROWITZ, M.D., et al., (1980). ‘Pathological Grief and the Activation of Latent Self-Images’. In, The American Journal of Psychiatry, 137:10, October, 1157-1162.

  13. LANDAUER, K., (1926). Equivalencies of Mourning. As found in SPIEGEL, Y., (1977). The Grieving Process. London: SCM Press Ltd.

  14. KITSON, G.C. (1982). ‘Attachment to the Spouse in Divorce: A scale and its application. Journal of Marriage and the Family. May, 379-93

  15. KUBLER-ROSS, E., (1973). On Death and Dying. Norwich: Fletcher & Son Ltd.

  16. LINDEMANN, E., (1944).  Symptomatology and Management of Grief. American Journal of Psychiatry 47:14-25.

  17. LUNDIN, T., (1984). ‘Long-term Outcome of Bereavement’. In, British Journal of Psychiatry, 145, 424-428.

  18. MADDISON, D., and VIOLA, A., (1968). ‘The Health of Widows in the year following Bereavement’. In, Journal of Psychosomatic Research, Vol. 12, pp. 297-306.

  19. MADDISON, D., and WALKER, W., (1967). Factors Affecting the Outcome of Conjugal Bereavement. British Journal of Psychiatry 113: 1057-1067.

  20. MILLS, S., (1991). The Essential Book of Herbal Medicine. London: Arkana.

  21. OSTERWIES, M., SOLOMON, F., and GREEN, M., eds. (1984). Bereavement: Reactions, Consequences and Care. Washington DC: National Academy Press.

  22. PARKES, C.M., et al., (1969). Broken Heart: A Statistical Study. British Medical Journal, vol. 1:740

  23. PARKES, C. M., (1972). ’Components of the reaction to loss of a limb, spouse or home’. In Journal of Psychosomatic Research, Vol. 16, pp. 343-9. Pergamon Press.
  24. PARKES, C. M., (1982). Bereavement: Studies of Grief in Adult Life. London: Penguin.
  25. PARKES, C.M., and BROWN, R.J., 1972. Health after Bereavement. Psychosomatic Medicine 34: 449-461.
  26. PARKES, C.M., and WEISS, R.S., (1983). Recovery from Bereavement. New York: Basic Books.
  27. PAYKEL, E.S., et al. (1969). Life Events and Depression: A Controlled Study. Archives of General Psychiatry Vol. 21: 753-60.
  28. PELLER, S.,  (1952). Cancer in Man. International Universities Press.
  29. PERETZ, D., (1970). Development, Object-Relationships, and Loss. In SCHOENBERG, B et al., eds., 1970. Loss and Grief: Psychological Management in Medical Practice. New York: Columbia University Press.
  30. PERETZ, D., (1970b). Reaction to Loss. In SCHOENBERG, B et al., eds., 1970. Loss and Grief: Psychological Management in Medical Practice. New York: Columbia University Press.

  31. RAEBURN, D., (2004). Metamorphoses: A New Verse Translation. London: Penguin Books. 

  32. ROSENBLATT, P.C., WALSH, R.D.,  and JACKSON, D.A. (1976). Grief and Mourning in Cross Cultural Perspective. NY: HRAF Press.

  33. ROSENBLOOM, C. and WHITTINGTION, (1993). ‘The Effects of Bereavement on Eating Behaviors and Nutrient Intakes in Elderly Widowed Persons’. In, Journal of Gerontology, Vol. 48, no. 4, S223-S229.

  34. SCHLEIFER, S., et al., (1983). ‘Supression of Lymphocyte Stimulation Following Bereavement’. In, Journal of the American Medical Assocation, Vol., 250, no. 3., pp. 374-377.

  35. SCHMALE, A.H., (1958). Relationship of Separation and Depression to Disease. Psychosomatic Medicine 20:259-77

  36. SCHOENBERG, R., et al., eds. (1970). Loss and Grief: Psychological Management in Medical Practice. Columbia University Press.

  37. SPIEGEL, Y., (1977). The Grieving Process. London: SCM Press Ltd.

  38. STROEBE, W., and STROEBE, M., (1987). Bereavement and Health. Cambridge University Press.

  39. TATELBAUM, J., (1997). The Courage to Grieve. London: Vermillion.

  40. VAN der HART, O., ed. (1988). Coping with loss: The Therapeutic Value of Leave-taking rituals. New York: Irvington.