Understanding Grief in Veterinary Medicine
No one ever told me that grief felt so like fear. I am not afraid, but the sensation is like being afraid. The same fluttering in the stomach, the same restlessness, the yawning…There is a sort of invisible blanket between the world and me.[i]
The literary author, C.S. Lewis, opened his book, A Grief Observed, with these sentences upon the death of his wife and writer, Joy Davidman. Grief is an emotion most of us will experience in our life and one where we’ll know someone who has. It has been written about extensively, from classical texts including the Bible to modern poets, literary authors, and musicians. It has been debated as to whether or not it is an actual emotion. (Spoiler alert: it is, with the potential for serious negative consequences if not addressed.)
Grief in companion animal owners has been studied for more than 30 years, resulting in the conclusion that the impact of the loss or death of a companion animal can be profound. Yet, only in the past 15 years has neuroscience caught up with what companion animal owners have been reporting for decades: the loss of a pet can feel similar to the loss of a human loved one.[ii]
In this article, we’ll explore grief in veterinary medicine, the symptoms of Profound Grief Disorder and the neuroscience of loss as well as what can be done to help those who are experiencing grief.
What is grief?
In reviewing the various definitions for grief, we choose the ones provided by The American Heritage Dictionary (1985): a “deep mental anguish, as over a loss: sorrow.”[iii] (p576) and by Merriam-Webster (2022): “a deep poignant distress caused by or as if by bereavement; a cause of such suffering.”[iv]
Just as there are varying types of grief, there are as many different ways to grieve, and for different reasons. Grief presents itself in various ways, physically, emotionally, and cognitively. How a person grieves is dependent on several factors, including, age, culture, gender, and religious or faith views. There is no right way to grieve and no time limit for grieving the loss of a loved one, including a companion animal.
Types of Grief
Anticipatory Grief. Anticipatory grief is one type of grief and occurs while a loved one is still living, but they have been diagnosed with a serious, debilitating, or terminal illness. Anticipatory grief allows time to prepare for someone’s death, although, it can be just as devastating as the sudden death of a loved one. For companion animal owners the emotional pain can be equally heart breaking.
Disenfranchised Grief. Disenfranchised grief occurs when a loss is unacknowledged, and the grieving person is unable to express their grief.[v] The grieving person’s loss is not validated by others nor is it recognized as a loss and may result in increased stress or emotional distress. A literature review of 48 studies on pet bereavement and coping mechanisms found pet owners reported feelings of embarrassment and loneliness following the loss of their companion animal.[vi]
Prolonged Grief Disorder. Another type of grief, Prolonged Grief Disorder, which is also referred to as complicated or traumatic grief, has recently been added to the DSM-5-TR in 2022 and is defined as:
An intense yearning or longing for the deceased (often with intense sorrow and emotional pain), and preoccupation with thoughts or memories of the deceased (in children and adolescents, this preoccupation may focus on the circumstances of the death).[vii]
Symptoms of Prolonged Grief
Prolonged Grief Disorder is viewed as being out of context for duration, societal, cultural, or religious norms and its symptoms include:
Identity disruption (e.g., feeling as though part of oneself has died)
Marked sense of disbelief about the death
Avoidance of reminders that the person is dead
Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death
Difficulty moving on with life (e.g., problems engaging with friends, pursuing interests, planning for the future)
Emotional numbness
Feeling that life is meaningless
Intense loneliness (i.e., feeling alone or detached from others)[viii]
Grief Symptoms in Pet Owners
In 2020, researchers were interested in determining if the grief symptoms of grieving companion animal owners were similar to the DSM-5 (2013) grief symptom clusters. The authors found companion animal owners who were experiencing grief “exhibited substantially more depression, loneliness, negative religious coping, and alcohol/drug coping…support[ing] the validity of the DSM-5 grief disorder construct.”[ix] (p3)
These research findings are significant in the context of neuroimaging that found the following effects of complicated grief with human loss:
Abnormalities in autobiographical memory, neural systems involved in emotional regulation (e.g., prefrontal cortex, amygdala), and neurocognitive functioning
Alterations in functioning of the reward system (in response to reminders of the deceased person) detected on fMRI[x] (p154)
Complicated grief has also been shown to be associated with both physical and emotional health problems such as:
Sleep disturbance
Substance abuse
Suicidal thinking and behavior
Abnormalities in immune function
Increased risks of cardiovascular disease and cancer (p154)
How to Address Grief in Your Veterinary Practice
Veterinary practices can implement Morgan and McDonald’s (2007)[xi] four-step process with the goal of creating and fostering an inclusive and collaborative relationship between the veterinary practice and the companion animal owner.
By implementing the Morgan and McDonald four-step process well before a companion animal is near the end of their life, a relationship between the veterinarian and the owner will more likely be based on trust in one another. The four-step process encompasses:
Information gathering
Education and counseling
Relationship building
Activation and partnership
There are also several questionnaires that can be used by the veterinarian to assess a client’s experience with pet bereavement, decision making for end-of-life care, and measuring clients' perceptions of relational empathy by the veterinarian. These questionnaires were found to help establish a “shared decision-making” relationship between the veterinarian and the companion animal owner:
Pet Bereavement Questionnaire (PBQ)
Regret of Bereaved Family Members (RBFM)
Shared Decision-Making Questionnaire (SDM-Q-9)
Consultation and Relational Empathy Measure (CARE)[xii]
Resources
Professional Mental Health Support
The loss of a companion animal is seen by some mental health professionals as a loss just as significant as the loss of a relative or friend in terms of grief symptoms and grief reactions.[xiii] [xiv]
For some companion animal owners who are experiencing grief, a referral to a licensed mental health professional may be warranted, and often, a veterinary social worker or other mental health professional who has training in animal-related grief and bereavement may be the best referral.
Identifying local mental health professionals who specialize in grief and understand the significant impact of pet loss can help companion animal owners after the death of a pet. Providing this list of resources to all clients experiencing the loss of a pet validates and normalizes the need for companion animal owners to process their feelings of grief and loss. This also eliminates the challenge to the veterinary team of identifying which pet owners are experiencing grief and need additional help.
The licensed mental health professional can use the following tips to help the pet owner mourn their companion including encouraging their client to:
Talk about the deceased companion animal
Talk about the circumstances surrounding the loss
Talk about their adjustment to life without the companion animal
Create a range of strategies for healthy coping
Create a memory book of the companion animal
Journal about their grief and favorite memories
Read self-help books on companion animal loss
Enroll in a support group for companion animal loss[xv]
Support Groups for Companion Animal Loss
Several studies have evaluated the effectiveness of bereavement and companion animal loss support groups and found them to be effective. [xvi] The Additional Resources section has several organizations that provide pet loss support, including support groups.
Additional Resources
Association for Pet Loss and Bereavement APLB’s mission is to promote and expand the field of pet loss and grief support by providing direct to pet family support services and resources that honor the human/animal bond. They provide a list of free support groups as well as a list of pet loss counselors and specialists (some of whom are licensed mental health professions).
The AVMA Guidelines for Pet Loss Support Services includes information on support helplines and support groups.
Center for Loss and Transition offers grief resources such as locating a counselor and numerous books, including one on pet loss. They also offer multi-day bereavement trainings.
The Center for Prolonged Grief offers grief resources to both the general population and professionals. The Center also provides trainings for mental health professionals.
Several veterinary schools in the U.S. offer free and fee-based support for companion animal owners.
Conclusion
Grief is an emotion that will affect all of us at some point in our lives, including companion animal owners. However, some companion animal owners report experiencing disenfranchised grief when their loss is not recognized as comparable to the loss of a family member or friend. We know companion animal owners also experience complicated grief or what is now referred to as Prolonged Grief, which has been added to the DSM-5-TR in 2022.
Fortunately, there are steps a veterinarian can take to address companion animal grief that include the use of Morgan and McDonald’s four-step process. There are also several questionnaires that are designed to establish a “shared decision-making” relationship between the veterinarian and the companion animal owner. Both of these processes will help foster an inclusive and collaborative relationship between the veterinarian and the companion animal owner.
Support in the form of counseling has been shown to help companion animal owners and resources have been provided.
References
[i] Lewis, CS. A Grief Observed. HaperCollins ebooks; 1961. https://portalconservador.com/livros/C-S-Lewis-A-Grief-Observed.pdf. Accessed on May 25, 2021.
[ii] Rujoiu O, Rujoiu V. Human-animal bond: Loss and grief. A review of the literature. Revista de Asistenta Sociala. 2013;3, 163-171. . https://www.researchgate.net/profile/Octavian-Rujoiu/publication/287995122_Human-Animal_Bond_Loss_and_Grief_A_Review_of_the_Literature/links/567bd70708ae1e63f1e00a5a/Human-Animal-Bond-Loss-and-Grief-A-Review-of-the-Literature.pdf. Accessed May 26, 2022.
[iii] “grief.” The American Heritage Dictionary (2nd ed). Houghton Mifflin Company.
[iv] “grief.” Merrium-Webster.com. https://www.merriam-webster.com/dictionary/grief. Accessed May 25, 2022.
[v] Spain B, O’Dwyer L, Moston S. Pet loss: Understanding disenfranchised grief, memorial use, and posttraumatic growth. Anthrozoös. 2019;32(4), 555-568. doi.org/10.1080/08927936.2019.1621545
[vi] Park RM, Royal KD, Gruen ME. A literature review: Pet bereavement and coping mechanisms [published online ahead of print, 2021, Jun 7]. Journal of Applied Animal Welfare Science. 2021;1-5. DOI: 10.1080/10888705.2021.1934839
[vii] American Psychiatric Association. Prolonged grief disorder. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-ProlongedGriefDisorder.pdf. Accessed May 25, 2022.
[viii] American Psychiatric Association. APA offers tips for understanding Prolong Grief Disorder. Published September 22, 2021. https://psychiatry.org/news-room/news-releases/apa-offers-tips-for-understanding-prolonged-grief. Accessed May 25, 2022.
[ix] Lee SA. Does the DSM-5 grief disorder apply to owners of deceased pets? A psychometric study of impairment during pet loss. Psychiatry Research. 2020;285. https://doi.org/10.1016/j.psychres.2020.112800
[x] Shear MK. Complicated grief. The New England Journal of Medicine. 2015;372(2):153-60. DOI: 10.1056/NEJMcp1315618
[xi] Morgan CA, McDonald M. Ethical Dilemmas in Veterinary Medicine. Veterinary Clinics of North America: Small Animal Practice. 2007;37(1):165–179. doi.org/10.1016/J.CVSM.2006.09.008
[xii] Testoni I, De Cataldo L, Ronconi L, et al. Pet grief: Tools to assess owner’s bereavement and veterinary communication skills. Animals. 2019;9(67). doi:10.3390/ani9020067
[xiii] Field NP, Orsini L, Gavish R, Packman W. Role of attachment in response to pet loss. Death Studies. 2009;33:334-355. DOI: 10.1080/07481180802705783
[xiv] Sharkin BS, Knox D. (2003). Pet loss: Issues and implications for the psychologist. Professional Psychology: Research and Practice. 2003:34(4):414-421. DOI: 10.1037/0735-7028.34.4.414
[xv] Cordaro M. (2012). Pet loss and disenfranchised grief: Implications for mental health counseling practice. Journal of Mental Health Counseling. 2012;34(4):283-294.
[xvi] Hess-Holden CL, Monaghan CL, Justice CA. Pet bereavement support groups: A guide for mental health professionals. Journal of Creativity in Mental Health. 2017;24(4):440-450.