Bereavement Free Essay

INTRODUCTION

Almost everyone in the world experiences an event which can be considered as a loss. It is the disappearance of something or someone important to an individual, grief is the natural response to the loss, people feel a range of emotions when they suffer a loss such as shock, panic, denial, anger and guilt. Death is one of the major events associated with loss but there are many others that occur which can also have a negative effect on someone’s life by impacting in various ways.

A description of a range of losses which may trigger grief

Any significant loss in our life can cause grief, and individuals can have a mixed range of feelings with regards to their loss. These losses include Infertility where the individual will experience emotions common to the death of a loved one, this type of loss can trigger many reactions such as depression, anger towards life in general or towards others that have children, shame, they feel they are less of a person as they are unable to have children, frustration, it can also result in the avoidance of social interactions (www.infertility.about.com). Divorce where the individual feels they have lost all hope and dreams for the future, fear of now having to cope alone, resentment towards the other person, guilt, they may also struggle with a lifestyle change which may also have a negative impact on social aspects of their life due to financial changes(www.divorcesupport.about.com). The loss of a job where the individual feels anger, jealousy of others who have a job, they may feel they have lost their identity and are useless. This can also cause the individual to suffer social exclusion (www.helpguide.org). There are many more that can trigger grief such as loss of a body function, rape, loss of a friendship, homelessness, role-redefinition.

A description of two theoretical models of grief

One model of grief I looked at was Kubler-Ross (1969) who initially developed the five stage model of grief, Denial, Anger, Bargaining, Depression, and Acceptance and later added to more, Shock and Testing. The stages are set up
in the following way – Shock Stage – The first response in hearing the unpleasant news, the person may freeze and be unable to take in what is being said. Denial Stage – This is a defence mechanism it is the refusal to accept what has happened. Anger Stage – This is when the person will suffer feelings of rage and may look for someone to blame ‘Why me, It’s not fair’. Bargaining Stage – This sis the stage where a person will try to negotiate or compromise, ‘can we still be friends? ’, they may also pray try and bargain with a god they believe in. Depression Stage – Person might withdraw at this stage, they will feel sadness, regret, fear, when at this stage it shows the person is beginning to accept the situation. Testing Stage – This is where the individual looks for realistic solutions to the problem. Acceptance Stage – This is when the person begins to come to terms with the event and can finally see a way forward.

Another model that is similar to Kubler-Ross is Psychodynamic or ‘Griefwork’ model by Colin Murray Parkes. This model also breaks the grief process down into five stages:

1 Alarm
2 Searching
3 Mitigation
4 Anger and Guilt
5 Gaining a new identity

Parkes idea was that when a loss occurs the individual affected will inevitable go through transitions in their lives. These transitions can be very challenging as people have a feeling of security from their own every day routines in their lives. Parkes described this as a person’s ‘assumptive world’ and this is created on how it has always been. An individual’s concept is that this is how it will always be, to think differently from this would create feelings of insecurity. A persons thoughts would have to change from what they normally take for granted in order to cope with what has changed.

Parks explains that most life changing events ‘ psychosocial transitions’ are those that:

Entail people to alter their belief about the world.
Are lasting in their implications rather than temporary.
Take place within a short time giving little opportunity for preparation.

If these three factors are present during a changing event then Parks explains that the persons ‘assumptive world’ endures major change.(Hnc Social Care Open Learning Pack)

A description of a range of agencies which can offer support to people experiencing loss and grief A range of agencies who can offer support to people experiencing loss and grief include the following:

Statutory Agencies – The local housing department, Nhs, G.P, department of social security who can help deal with any financial issues arising from the situation and the social work department who can help by providing services such as homecare, occupational therapy and community care.

There is also a large number of voluntary organisations available to support people experiencing loss or grief such as Age concern who help to come to terms with old age and improve later life for everyone, they offer advice and information regarding health and housing and opportunities for training.(Age Concern.org.uk) Cancer Link offers counselling and support programmes to help cancer patients cope with their illness and treatment(www.cancerlink.co.uk). Victim Support gives free confidential help to victims of crime. They offer emotional and practical support such as counselling, help to fill out form, getting medical treatment and rehousing(www.victimsupport.co.uk). Cruse Bereavement Care Scotland offers support after bereavement and also offers information , support and training services to those who are helping someone who has suffered a bereavmenet(www.crusebereavment.org.uk), and Ardgowan Hospice who offer support, respite care and end of life care to people suffering cancer or other life limiting illness. They offer a wide range of services from counselling, spiritual and bereavement support for patients and their family to yoga, hypnotherapy and relaxation classes.

A description of how you supported an individual experiencing loss and grief not associated with death

I have supported a person in my work place that experienced loss and grief by using effective communication including being a good listener. The service user had been the victim of a sexual assault. When the incident initially happened the service user was in denial and told no one, but it was clear from their behaviour that something was wrong with them, they were frightened of being alone and wanted constant reassurance that I would not move from outside their room door. I sat with the service user reassuring them that I was here for them and trying to encourage them to open up to me. Eventually the service user made the disclosure and we discussed how it would be dealt with i.e. contacting police and relevant agencies. Throughout this ordeal the service user has encountered a range of emotions from shame, guilt, feeling of being dirty, scared, they felt they had lost control of their lives and lost trust in people. I helped the service user work through these issues by sitting with them and listening carefully and being able to empathise with them. They were able to explore all their thoughts and feelings without feeling they were being judged. I also encouraged them to write about what they were feeling and thinking at times when they found it difficult to talk about. Through time and patients they grew stronger and were able to face what had happened to them and find a way to look to the future.

A description of the legal and other procedures to be followed in the event of a death in two care settings Procedures following death in a care home for the elderly

At the time of death the person who discovers the deceased needs to record the time of death, who was present and any relevant details of devices used or if cpr was given along with their details on the relevant paper work. The next step would be to inform the medical practitioner responsible for that person’s care, as verification needs to be completed by them or an appropriate qualified nurse before the body can be removed. The person verifying they death must be aware of local guidance regarding verifying death. Which will be in line with national guidance. Verification should take place as soon as possible. The verification details should be recorded on the appropriate paperwork. The person verifying the death is responsible for confirming identity of deceased. A name band with the deceased person’s name, D.O.B, address and nhs number should be attached to the deceased person. The death then needs to be reported to the coroner and the relatives of the deceased informed, if the death is unexpected the police must be informed and the body cannot be moved.

Procedures following death in a hospital

When death occurs within a hospital if the deceased was a patient the charge nurse will contact the deceased’s family to inform them, if the deceased was not a patient the family will be informed and asked to identify the body. If clinicians are unsure about the cause of death a post mortem must take place by legal requirements to determine the cause of death. The deceased person’s relatives must provide proof to allow them to collect the person’s personal possessions. Staff must be made aware if the deceased person was an organ donor. The hospital will then liaise with the families chosen undertaker, obtain the death certificate and make arrangements for the next of kin to collect the certificate. The following procedures for both including legal are taken from the Scottish Executive Website – www.scotland.gov.uk/library5/social/waad-pp.asp

A description of how attitudes and practices surrounding death have changed in Britain Attitudes and practices have changed considerably in Britain today. In the past death was an event that was witnessed by all who lived in the house, including children. Once the person had died they remained in the house where family members would prepare the body for burial, they body would remain there until it was taken for burial. During this time normal daily life continued for the other members of the family. However this is now no longer the case as more people are now dying in hospital, this has therefore moved to the medical professions responsibility rather that the families. Funeral directors now remove and prepare the body and arrange all aspects of the funeral arrangements for the deceased’s family. Today’s attitudes to death are very different, Britain’s attitude to death is described by Katz and Siddell (1994) as a ‘death denying society’. Due to people now living longer and epidemics no longer killing thousands because of the ever increasing progress of the public health service death is often seen as a failure of the medical profession to keep someone alive.(open learning pack)

A description of the rites and practices of two major religions Christianity – Christian belief is one of resurrection and the eternal life of the deceased person’s soul. A religious service takes place to celebrate that person’s life on earth and the new journey they have taken through death. These services usually include special readings, hymns and prayers only used for funerals. After the service the deceased is either buried or cremated, during this part of the tradition special prayers for the deceased are said. Mourners traditionally wear black clothing on this day and after the burial or cremation they gather together for food and drink.

Hinduism – Following the death of an individual the family come together to prepare the body and will perform prayers. Hindus mostly cremate their dead as they believe this releases their spirit. The flames during the cremation are an important symbol as they represent the presence of the holy god Brahma the creator. White is considered the appropriate colour to wear and traditionally they will wear Indian garments. Prayers are said at the entrance to the crematorium, there may also be offerings of flowers and sweetmeats passed around. The chief mourner usually the eldest male represents the family and they will push the button to make the coffin disappear as well as lighting the funeral pyre. After the cremation the family will gather for prayers and food then begin a 13 day mourning period.(www.ifishoulddie.co.uk)

A description of the rites and practices of one new religious movement Jehovah’s Witness – Jehovah’s witness have no special rituals for those who are dying but will usually appreciate a visit from one of the elders of the faith. There are particular beliefs surrounding blood transfusions, Jehovah Witness’s regard blood transfusion as morally wrong and are therefor prohibited. Organ transplants are generally not permitted and they are not likelt to be willing or permitted to donate or receive an organ through which blood flows. They also do not celebrate events such as birthdays and Christmas.(funeralwise)(open learning pack)

A description of two non-religious responses to death

Humanist Funeral – This type of funeral is for people who are non-religious. The British Human Association formed in 1967. Their principles are not based on religion but on the principles of reason and respect of others. Humanist ceremonies acknowledge loss and celebrate the deceased’s life without any religious rituals. This type of service centres more on the person who has passed away, where the family will choose such things as music, poetry or write a personal tribute that is read out by family or friend. This type of funeral gives more opportunity for personal input from the deceased’s loved ones. The funeral can take place at a cemetery, crematorium and woodland burial ground. Normally a printed copy of the ceremony is given to mourners on arrival at the service, which can be kept as keep sake.(www.ifishoulddie.co.uk)

New Age – This is a non religious belief which formed its foundations in Britain in the 1960’s. This was a reaction against what some people thought that Christianity had and Secular Humanism had failed in such as to provide them with guidance both spiritually and ethically. Unlike most formal religions it has no holy texts, central organisation, membership, formal clergy, dogma or creed. It is a network of believers and practitioners who share similar beliefs and practices which they can add to whichever religion they follow. New age rituals focus on healing the mind,body,spirit or earth using methods such as reiki or rolfing, they believe these techniques help to heal the body ailments and bring spiritual awareness. Influenced by Asian tradition they often hold retreats or workshops with a spiritual teacher or guru. With regards to the New Age response to death for many followers, ecological funerals, commonly known as ‘green burials’, may be their preferred choice as a more environmentally friendly form of woodland burials, nature reserve burials or burials at home. (www.patheos.com), (open learning pack)

CONCLUSION

In conclusion some people associate grief and loss with only death but as can be seen from the beginning of this essay grief and loss are not exclusive to those who have experienced a death. There are many other forms of grief and loss that are equally intense for those experiencing other types of loss such as end of a relationship,rape and infertility to name a few. Although there are some common symptoms in response to loss and grief there is no universal predictable emotional path that every individual follows and the grief process is very personal and unique to every individual.There are many theories with regards to the grief process one of which is Kubler-Ross who believes that no matter what the loss, every individual goes through a certain process in order to deal with the loss .Individuals may feel they are alone when it comes to dealing with their grief but there are a wide range of statutory abd voluntary agencies available to help with the process and any financial issues individuals might face.

When I had the opportunity to provide support to a service user who suffered a loss it gave me a closer insight in to how the individual feels and copes when supported in a positive way and the process they had to go through to overcome what happened to them.With regards to death we see that although care settings can have different procedures when dealing with a death the correct legal procedures are the same throughout and must be adhered to. We see that attitudes towards death have also changed, people are no longer accepting all the responsibility for dealing with the death of a loved one , preferring to allow undertakers to organise the arrangements and nowadays there is a mourning period . We also see that religions take different approaches when it comes to a funeral service Christianity and Hinduisim each have their own tradittions with regards to the service and attire but the service is centered around the persons religion , whereas with a Humanist Funeral focuses on the deceased person and the life that they had. The grief process no matter what the loss is not pleasant it is only by dealing with the grief through help or mourning that we can move on.

REFERENCES
www.scotland.gov.uk/library5/social/waad-pp.asp
www.infertility.about.com
www.divorcesupport.about.com
www.helpguide.org
www.changingminds.org
Social care open learning pack
www.ifishoulddie.co.uk
www.patheos.com
www.funeralwise.com
www.ageconcern.org.uk
www.cancerlink.co.uk
www.victimsupport.co.uk
www.crusebereavment.org.uk
www.ardgowan hospice.org.uk

Doctors are well acquainted with loss and grief. Of 200 consultations with general practitioners, a third were thought to be psychological in origin; of these, 55—a quarter of consultations overall—were identified as resulting from types of loss.1 In order of frequency the types of loss included separations from loved others, incapacitation, bereavement, migration, relocation, job losses, birth of a baby, retirement, and professional loss.

After a major loss, such as the death of a spouse or child, up to a third of the people most directly affected will suffer detrimental effects on their physical or mental health, or both.2 Such bereavements increase the risk of death from heart disease and suicide as well as causing or contributing to a variety of psychosomatic and psychiatric disorders. About a quarter of widows and widowers will experience clinical depression and anxiety during the first year of bereavement; the risk drops to about 17% by the end of the first year and continues to decline thereafter.2 Clegg found that 31% of 71 patients admitted to a psychiatric unit for the elderly had recently been bereaved.3

Despite this there is also evidence that losses can foster maturity and personal growth. Losses are not necessarily harmful.

Yet the consequences of loss are so far reaching that the topic should occupy a large place in the training of health care providers—but this is not the case. One explanation for this omission is the assumption that loss is irreversible and untreatable: there is nothing we can do about it, and the best way of dealing with it is to ignore it. This attitude may help us to live with the fact that, despite modern science, 100% of our patients still die and that before they die many will suffer lasting losses in their lives. Sadly, it means that, just when they need us most, our patients and their grieving relatives find that we back away.

Summary points

  • Losses are a common cause of illness; they often go unrecognised

  • Conflicting urges lead to a variety of expressions of grief; even so there is a pattern to the process of grieving

  • A knowledge of the factors that predict problems in bereavement enables these to be anticipated and prevented

  • Grief may 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

Recent approaches to loss

A 1944 study of bereaved survivors of a night club fire focused attention on the psychology of bereavement, and led to the development of services for the bereaved and to other types of crisis intervention services.4 It established grief as a distinct syndrome with recognisable symptoms and course, amenable to positive or negative influences. This, in turn, fuelled interest in the new fields of preventive psychiatry and community mental health. Elizabeth Kubler Ross’s studies extended this understanding to dying people,5 and helped to provide a conceptual framework for the humanitarian work of Dame Cicely Saunders and the other pioneers of the hospice movement.

More recently the improvements in palliative care have led to improvements in home care for the dying. Home care nurses have bridged the gap and general practitioners have had a central role, not only in caring for dying patients and their families but also in supporting people through many other losses. This is the main theme of this series, which draws together authorities with special knowledge of the losses which afflict our patients and their families and looks at the practical implications for doctors.

The components of grief

Three main components affect the process of grieving. They include the urge to look back, cry, and search for what is lost, and the conflicting urge to look forward, explore the world that now emerges, and discover what can be carried forward from the past. Overlying these are the social and cultural pressures that influence how the urges are expressed or inhibited. The strength of these urges varies greatly and changes over time, giving rise to constantly changing reactions.

Most adults do not wander the streets crying aloud for a dead person. Bereaved people often try to avoid reminders of the loss and to suppress the expression of grief. What emerges is a compromise, a partial expression of feelings that are experienced as arising compellingly and illogically from within.

Much empirical evidence supports the claims of the psychoanalytic school that excessive repression of grief is harmful and can give rise to delayed and distorted grief—but there is also evidence that obsessive grieving, to the exclusion of all else, can lead to chronic grief and depression. The ideal is to achieve a balance between avoidance and confrontation which enables the person gradually to come to terms with the loss. Until people have gone through the painful process of searching they cannot “let go” of their attachment to the lost person and move on to review and revise their basic assumptions about the world. This process, which has been termed psychosocial transition, is similar to the relearning that takes place when a person becomes disabled or loses a body part.

The course of grief

  • Numbness

  • Pining

  • Disorganisation and despair

  • Reorganisation

The normal course of grief

Human beings can anticipate their own death and the deaths of others. Unlike the grief that follows loss, anticipatory grief increases the intensity of the tie to the person whose life is threatened and evokes a strong tendency to stay close to them.

Although the moment of death is usually a time of great distress, this is usually quickly repressed and, in Western society, the impact is soon followed by a period of numbness which lasts for hours or days. This is sometimes referred to as the first phase of grieving.6 It is soon followed by the second phase, intense feelings of pining for the lost person accompanied by intense anxiety. These “pangs of grief” are transient episodes of separation distress between which the bereaved person continues to engage in the normal functions of eating, sleeping, and carrying out essential responsibilities in an apathetic and anxious way.

All appetites are diminished, weight is lost, concentration and short term memory are diminished, and the bereaved person often becomes irritable and depressed. This eventually gives place to the third phase of grieving, disorganisation and despair. Many find themselves going over the events which led up to the loss again and again as if, even now, they could find out what went wrong and put it right. The memory of the dead person is never far away and about a half of widows report hypnagogic hallucinations in which, at times of drowsiness or relaxation, they see or hear the dead person near at hand. These hallucinations are distinguished from the hallucinations of psychosis by the circumstances in which they arise and by their transience—they disappear as soon as the bereaved arouse themselves. A sense of the dead person near at hand is also common and may persist.

As time passes the intensity and frequency of the pangs of grief tend to diminish, although they often return with renewed intensity at anniversaries and other occasions which bring the dead person strongly to mind. Consequently the phases of grief should not be regarded as a rigid sequence that is passed through only once. The bereaved person must pass back and forth between pining and despair many times before coming to the final phase of reorganisation.

After a major loss such as the death of a loved spouse or partner, the appetite for food is often the first appetite to return. By the third or fourth month of bereavement the weight that was lost initially has usually returned, and by the sixth month many people have put on too much weight. It may be many more months before people begin to care about their appearance, and for sexual and social appetites to return. Most people will recognise that they are recovering at some time in the course of the second year.

Assessing the risk

Much research, in recent years, has enabled us to identify people at special risk after bereavement either because the circumstances of the bereavement are unusually traumatic or because they are themselves already vulnerable (box). These risk factors can give rise to complicated forms of grief that can culminate in mental illness. A clear understanding of these factors will often enable us to prevent psychiatric disorder in bereaved patients.

Factors increasing risk after bereavement

Traumatic circumstances  Death of a spouse or child  Death of a parent (particularly in early childhood or adolescence)

Sudden, unexpected, and untimely deaths (particularly if associated  with horrific circumstances)

Multiple deaths (particularly disasters)

Deaths by suicide

Deaths by murder or manslaughter

Vulnerable people General:  Low self esteem

Low trust in others

Previous psychiatric disorder

Previous suicidal threats or attempts

Absent or unhelpful family

Specific:

Ambivalent attachment to deceased person

Dependent or inter-dependent attachment to deceased person

Insecure attachment to parents in childhood (particularly learned fear  and learned helplessness)

Complicated grief

Bereavement has physiological as well as emotional effects (lower box). It also affects physical health: after bereavement, the immune response system is temporarily impaired7,8 and there are endocrine changes such as increased adrenocortical activity and increases in serum prolactin and growth hormone,2 as in other situations that evoke depression and distress.

A variety of psychiatric disorders can also be caused by bereavement, the commonest being clinical depression, anxiety states, panic syndromes, and post-traumatic stress disorder. These often coexist and overlap with each other, as they do with the more specific morbid grief reactions. These last disorders are of special interest for the light that they shed on why some people come through bereavement unscathed or strengthened by the experience while others “break down.”

It is a paradox that people who cope with bereavement by repressing the expression of grief are more likely to break down later than are people who burst into tears and get on with the work of grieving. The former are more liable to sleep disorders, depression, and hypochondriacal symptoms resembling the symptoms of the illness that caused the bereavement (“identification symptoms”). Not all psychogenic symptoms, however, are a consequence of repressed or avoided grief. Some reflect the loss of security which often follows a major loss and causes people to misinterpret as sinister the normal symptoms of anxiety and tension.

At the other end of the spectrum of morbid grief are people who express intense distress before and after bereavement. Subsequently they cannot stop grieving and go on to suffer from chronic grief. This may reflect a dependent relationship with the dead person, or it may follow the loss of someone who was ambivalently loved. In the former case the bereaved person cannot believe that he or she can survive without the support of the person on whom they had depended. In the latter, their grief is complicated by mixed feelings of anger and guilt that make it difficult for them to stop punishing themselves (“Why should I be happy now that my partner is dead?”).

Some degree of ambivalence is present in all relationships. To some degree its effects can be assuaged by conscientious care during the last illness, and many people will recall “We were never closer.” If members the family have been encouraged and supported so that they have been able to care, and the death has been peaceful, anger and guilt are much less likely to complicate the course of grieving.

These two patterns of grieving often seem to occur in “avoiders” (people with a tendency to avoidance) and “sensitisers” (those with a tendency to obsessive preoccupation), respectively.9

Complications of bereavement

Physical

  • Impairment of immune response system

  • Increased adrenocortical activity

  • Increased serum prolactin

  • Increased growth hormone

  • Psychosomatic disorders

  • Increased mortality from heart disease (especially in elderly widowers)

Psychiatric Non-specific:

  • Depression (with or without suicide risk)

  • Anxiety or panic disorders

  • Other psychiatric disorders

Specific:

  • Post-traumatic stress disorder

  • Delayed or inhibited grief

  • Chronic grief

Preventing and treating complicated grief

Doctors are in a unique position to help people through the turning points in their lives which arise at times of loss. In order to fulfil this role we need information and skills. One of our problems as caregivers is our ignorance of our patients’ view of the world. Not only do we seldom know what they know or think they know about the situation they face, we do not even know how that situation is going to change their lives. It follows that we need to find out these things and, where possible, add to their knowledge or correct any misperceptions, taking care to use language that they can understand. (This is easier said than done when words like “cancer” and “death” mean different things to doctors than they do to most patients.) Above all, we should spend time helping them to talk through and to make sense of the implications of the information we have given. If need be, we should see them several times to facilitate this process of growth and change. General practitioners, because they are likely to know the person, are often well placed to provide this “trickle” of care. For most bereaved people the natural and most effective form of help will come from their own families, and only about a third will need extra help from outside the family.

Anticipatory guidance

Members of health care teams can often prepare people for the losses that are to come. People need time to achieve a balance between avoidance and confrontation with painful realities, and we need to take this into account when we impart information that is likely to prove traumatic. One way is to divide the information that needs to be confronted into “bite sized chunks.” Doctors do this when we break bad news a little at a time, telling a patient as much as we think he or she is able to take in. Patients seldom ask questions unless they are ready for the answers, and they will usually ask precisely what they want to know and no more. It follows that we should invite questions and listen carefully to what is asked rather than assuming that we know what the patient is ready to know. By monitoring the input of information, a person can control the speed with which they process that information.

Although a little anxiety increases the rate and efficiency with which we process information, too much anxiety slows us down and impairs our ability to cope, our thought processes become disorganised and we “go to pieces.” Anything that enables us to keep anxiety within tolerable limits will help us to cope better with the process of change. If we are breaking bad news (box) it helps to do so in pleasant, home-like surroundings and to invite the recipient to bring someone who can provide emotional support. A few minutes spent putting people at their ease and establishing a relationship of trust will not only make the whole experience less traumatic for them but it will increase their chance of taking in and making sense of the information which we then provide.

Breaking bad news

  • Consider social support (who to ask to be present)

  • Consider setting (where to meet)

  • Try to establish a relationship of mutual respect and trust

  • Discover what the patient or the family knows or think they know already

  • Invite questions

  • Give information at a speed and in a language that will be understood

  • Monitor what has been understood

  • Recognise that it takes time to hear and understand bad news

  • Give the patient or the family time to react emotionally

  • Give verbal and non-verbal reassurance of the normality of their reaction

  • Stay with the patient or the family until they are ready to leave

  • Offer further opportunities for clarification, information, or support

Supporting bereaved people

A visit from the general practitioner to the family home on the day after a death has occurred enables us to give emotional support and to answer any questions about the death and its causes that may be troubling the family. Newly bereaved people often feel and behave, for a while, like frightened and helpless children and will respond best to the kind of support that is normally given by a parent. A touch or a hug will often do more to facilitate grieving than any words.

During the next few weeks bereaved people need the support of those they can trust. We can often reassure them of the normality of grief, explain its symptoms, and show by our own behaviour and attitudes that it is permissible to express grief. If we feel moved to tears at such times there is no harm in showing it. Bereaved people may need reassurance that they are not going mad if they break down, that the frightening symptoms of anxiety and tension are not signs of mortal illness, and that they are not letting the side down if they withdraw, for a while, from their accustomed tasks.

As time passes people may also need permission to take a break from grieving. They cannot grieve all the time and may need permission to return to work or do other things that enable them to escape, even briefly, from grief. It is only if they get the balance between confrontation and avoidance wrong that difficulties are likely to ensue.

The first anniversary is often a time of renewed grieving, but thereafter the need to stop grieving and move forward in life may create a new set of problems. People may need reassurance that their duty to the dead is done, as well as encouragement to face the world that is now open to them. The most important thing we have to offer is our confidence in their personal worth and strength. We should beware of becoming the “strong” doctor who will look after the “weak” patient for ever, but this does not mean that we become angry and dismissive, reprimanding the patient for becoming “dependent.” In the end, most bereaved people come through the experience stronger and wiser than they went into it. It is rewarding to see them through.

Appendix

In the acute stages it is usually best to give support by personal contact, preferably in the client’s home. Later the help of a group in which bereaved people can learn from each other, as well as a counsellor, may be helpful. Organisations such as Cruse Bereavement Care and the member organisations of the National Association of Bereavement Services may be able to provide either of these types of help. The Compassionate Friends (for bereaved parents), Lesbian and Gay Bereavement, Support after Murder and Manslaughter (SAMM), and the Widow-to-Widow programmes that exist in the United States and other parts of the world provide mutual help by bereaved people for others with the same types of bereavement.

Further reading

Markus AC, Parkes CM, Tomson P, Johnstone M. Psychological  problems in general practice. Oxford: Oxford University Press,  1989.

Parkes CM. Bereavement: studies of grief in adult life. 3rd ed.  Harmondsworth: Pelican, 1998.

Footnotes

Funding: No additional funding.

Conflict of interest: None.

The articles in this series are adapted from Coping with Loss, edited by Colin Murray Parkes and Andrew Markus, which will be published in July.

References

1. Clark S. Loss and grief in general practice: a pilot study. National convention of the Royal Australian College of General Practitioners, 1986.

2. Jacobs S. Pathologic grief: maladaptation to loss. Washington, DC: American Psychiatric Press; 1993.

3. Clegg F. Grief and loss in elderly people in a psychiatric setting. In: Chigier E, ed. Grief and mourning in contemporary society. Vol 1. Psychodynamics. London: Freund, 1988:191-8.

4. Lindemann E. The symptomatology and management of acute grief. Am J Psychiatry. 1944;101:141.

5. Ross EK. On death and dying. London: Tavistock; 1970.

6. Bowlby J, Parkes CM. Separation and loss within the family. In: Anthony EJ, ed. The child in his family. New York: Wiley, 1970.

7. Bartrop RW, Lazarus L, Luckhurse E, Kiloh LG, Pennry R. Depressed lymphocyte function after bereavement. Lancet. 1977;i:834–836.[PubMed]

8. Schleiffer SJ, Keller SE, Camerino M, Thornton JC, Stein M. Suppression of lymphocyte stimulation following bereavement. JAMA. 1983;250:374–377.[PubMed]

9. Horowitz, M. Stress response syndromes. Northvale, NJ: Aronson, 1986.


Articles from The BMJ are provided here courtesy of BMJ Publishing Group

0 comments

Leave a Reply

Your email address will not be published. Required fields are marked *