Psychological medicine

Grief and Bereavement

Theories of Grief

  • Freud: work of mourning: detachment from person who has died. Healthy resolution when this is completed 
  • Kubler-Ross: Stages of terminal illness: denial, anger, bargaining, depression, and acceptance. But it‟s not sequential, and this only talks of emotions, not physical or behavioural dimensions
  • Worden: Tasks of mourning:
    • Accept reality of loss (harder if no body etc)
    • Experience pain of grief 
    • Adjust to an environment in which the deceased is missing (often very practical – change in roles etc) 
    • Withdraw emotionally and invest in new relationships (later he revised this to emotionally relocate the deceased and move on) – put the deceased in another place
  • Silverman:
    • There is a continuing bond between deceased and survivor
    • Stages:
      • Impact: this is not real
      • Recoil: I‟m going crazy, why am I worse now (can be months later) 
      • Accommodation: what do I carry with me? Being a living memorial – don‟t have to cut off – can move on and still carry something with them 
  • Stroebe et al: Dual process moving between expression of grief and containment of grief (women prefer former, men latter)

Characteristics of Grief

  • Reassure bereaved person that these are normal.  If overwhelming, seek help 
  • Emotional: bewildering and intense range or emotions without warning – shock, numbness, relief, anxiety, anger, blame, guilt, loneliness, helplessness, hopelessness 
  • Physical: hollow stomach, tight chest, breathlessness, weakness, lack of energy, ¯sexual desire, sleep disturbances, symptoms similar to person who died (this can be pathological) 
  • Cognitive responses:  disbelief, confusion, ¯concentration, going crazy, preoccupation 
  • Behaviours: searching, crying, sighing, absent minded, restless, ¯socialising, visiting/avoiding places that are reminders

 Coping with Loss

  • Losses are a common cause of illness – they often go unrecognised
  • Conflicting urges lead to a variety of expression of grief – but there is a pattern 
  • Understanding factors that predict problems in bereavement enables these to be anticipated and prevented
  • Grief can be avoided or it may be exaggerated and prolonged
  • Doctors can help to prepare people for the losses that are to come
  • People may need permission and encouragement to grieve and to stop grieving

Factors Complicating Grief – Risk Factors for Pathological Grief

  • Dependent family members (children, handicapped, elderly)
  • Loss of primary care giver/constant companion
  • Loss of financial provision
  • Loss of home (feared or actual)
  • Anxiety about decisions
  • Unable to share feelings
  • Family discord
  • Uncontrolled pain/emotional distress before death
  • Concurrent life crisis
  • Prolonged reaction/suicidal thoughts
  • Lack of community support

Children’s Grief

  • It is not possible not to communicate to children (ie not telling them is not an option)
  • Help should start at the time of diagnosis
  • Talk about what won‟t change as a result of the illness
  • Maintain things that are important in a child‟s life (e.g. routines)
  • Talk about practical concerns
  • Provide extra stability, order, routine and physical affection
  • They need to know who will take care of them if key people leave or die
  • Offer reassurance
  • Children often assume responsibility for what has happened and feel very guilty
  • Offer clear, simple, truthful information: repeat, repeat, repeat
  • Don‟t use euphemisms (e.g. asleep – explain death, body stops working)

Signals for attention from a grieving child

  • Marked change in behaviour: illegal behaviour, persistent aggression (> 6 months), tantrums, withdrawal, drug abuse
  • Inability to cope with problems and daily activities
  • Many complaints of physical aliments
  • Persistent depressions, panic attacks
  • Change in school performance
  • Fearfulness for self, or for loved ones

Helping Families

  • Listen effectively
  • Foster communication
  • Engage siblings
  • Check social supports
  • Address symptoms
  • Provide constant factual data
  • Help build positive memories
  • Don‟t take offence