Psychological medicine
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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