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