Bereavement and Separation Loss

• Grief is a normal phenomenon common to all of us.
• As we go through life, we experience a wide variety of losses for which we grieve.
• It is not possible to go through life without suffering losses.
• Grief is the response to any loss and is therefore a common human experience.
• A common but often unrecognized part of life cycle changes.
• Often seen as interfering with life, rather than being intrinsic to life.
• Who feels the grief?
• All ages, all persons, and often even care providers.

Definitions

• Grief is the process of psychological, social, and somatic reactions to the perception of loss.
• Mourning is the cultural response to grief.
• Bereavement is the state of having suffered a loss.
• Grief Work is the work of dealing with grief, requiring the expenditure of physical and emotional energy.

Common Causes of Death

• Infections
  • Malaria
  • Pneumonia
  • Diarrhoeal disease
  • Vaccine-preventable diseases
• Neonatal deaths
• Accidents
• Tumours

Elements of Appropriate Grieving

Grieving is:

• Active
• Healing
• Skillful
• Transformative
• Connective
• Social

• Gender
• Closeness to the child
• Family support structure
• Background psychiatric/personality disorder
• Number of children
• Method of death
• Use of psychotropic drugs
• Individual patterns of coping
• Previous grief or bereavement
• Culture and religion

Bereavement: Gender Issues

Men may have different coping styles than women and are more likely to:

• Remain silent.
• Engage in solitary mourning or secret grief.
• Take physical or legal action.
• Become immersed in activity.
• Exhibit addictive behavior.

These phases need to be interpreted not necessarily as sequential but more likely as concurrent processes.

1. Acute or Self-Protective Phase
   • Initial shock, denial, and disbelief.
   • May feel dissociated from the world around them.
   • If the family is well-prepared, there may not be the same amount of shock or avoidance.
   • Sometimes, there is an intellectualized acceptance without an emotional component (initial denial of the loss).
2. Confrontation
   • The most intense experience of grief.
   • Emotional extremes are common.
   • Rapid and large swings in emotion often cause fear and more anxiety.
   • Anger is a common component, including anger that may be directed towards physicians and other healthcare team members.
   • Guilt, or inwardly directed anger, confronts the bereaved with questions like:
     • What if I had done more? Did I do enough?
     • What did I do wrong? What did I do to deserve this?
   • Guilt around self: so-called survivor guilt.
     • Why wasn’t it me?
   • Sadness and despair.
   • Inability to concentrate or process information.
   • Preoccupation with the deceased.
   • Over time, the extreme emotional swings lessen.
   • Intermittent denial may also occur.
   • Social manifestations of this phase include:
     • Restlessness and inability to sit still.
     • Lack of ability to initiate and maintain organized patterns of activity.
     • Difficulty completing or concentrating on tasks at work.
     • Withdrawal from the very people who may be able to help.
     • Spiritual issues.
3. Reestablishment
   • Grief gradually softens to an acceptance of the reality of the loss.
   • Gradual decline in symptoms as grief becomes integrated into life.
   • Grief is compartmentalized, but periods of grief may arise at specific times such as birthdays, etc.

Kubler-Ross Stages of Grief

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Disorders of Grief

• Delayed or absent grief
• Conflicted grief
• Chronic grief
• Psychiatric disturbances associated with grief
• Physical illness associated with grief

• To accept the reality of the loss
• To experience the pain of grief
• To adjust to an environment in which the deceased is missing
• To withdraw emotional energy and reinvest it in other relationships

Goals of Grief Counselling

• To increase the reality of the loss
• To help the bereaved deal with both experienced and latent affect
• To help the bereaved overcome impediments to readjustment
• To encourage the bereaved to make a healthy emotional withdrawal from the deceased and reinvest energy into other relationships

Steps in Grief Counselling

• Begin grief counseling if possible while the patient is still alive
• Understand that the family is the unit of care
• Grief counseling requires much listening and less talk by the counselor
• Make the individual realize that he/she has enough time to grieve
• Contact the bereaved at intervals (preferably in a home setting)
• Medications are rarely required except in the extremely distraught
• Identify and deal with concurrent problems that might interfere with grief
• Identify and manage abnormal grieving patterns