Bereavement & Grief

Bereavement and Grief

Bereavement is the experience of the death of a loved one. Grief is the emotional response to a loss. Note that grief can also include the emotional response to the losses discussed above that don't include death. Although approximately 15 to 50 percent of people experience minimal grief and return to normal functioning quickly, and another 15 percent go on to develop more severe, chronic problems with grief that persist beyond one or two years (Bonnano & Kaltman, 2001). Studies of grief among older adults suggest that older adults who lose a spouse may grieve longer than many others. Plus, older adults who have lost a spouse have shown significantly more symptoms of grief than adults who lost a family member other than a spouse (Lehman, Wortman, & Williams, 1987; Thompson, Gallagher-Thompson, Futterman, Gilewski, & Peterson, 1998). This difference has been found up to seven years after the death, which led the researchers to suggest that some later-life widows and widowers may never entirely resolve their grief.

Experts have developed models of the process of grieving. These models are frameworks from which to understand what might be happening with an individual who is grieving. They do not necessarily outline what each individual should expect to experience after a loss, or define what an individual must experience in order to resolve the grief.

Stage Model of Grieving

In perhaps the best-known model, Elisabeth Kubler-Ross (1969) suggested that people go through a process of grieving that involves five stages: denial, anger, bargaining, depression, and acceptance. She described these stages in relation to getting a diagnosis of serious illness, and the stages were later used more generally in relation to grieving. Years after her original publication about these stages, we no know that most people do not progress linearly through any set stages. The concepts she described are useful in thinking about what some people may experience, however, particularly with regard to anticipatory grief. Anticipatory grief is experienced in advance of a loss, such as by people who learn about a life-limiting illness for themselves or a  loved one. People being to grieve as they think ahead about what will be lost. Anticipatory grief is common among family members caring for relatives with dementia or other chronic, life-limiting illnesses.

Denial

Denial can be an adaptive response that buffers unexpected shocking news. Reacting with disbelief helps to prepare for impending loss. It allows time to collect oneself until other coping responses can be used. Denial can be detrimental if maintained too long. Working with people who refuse to accept the reality of a situation can be very frustrating. It is futile, insensitive, and most often counterproductive to force people to deal with something before they are ready to do so. This is especially true after the loss of a loved one.

Anger

Anger is the second stage of grief in this model. Anger may be directed at the disease, at doctors for failing to prevent the illness or death, or at the deceased for having the disease and dying. Anger may be directed at oneself for not doing more before the onset of the disease, or for remaining healthy. Experience of loss can make people feel very out of control. Anger may be a way to try to exercise some control over a situation. If someone or something is to blame, that implies that something could have been done differently and that future situations can be controlled.

Bargaining

When the angry response doesn't work to change the situation, Kubler-Ross suggests that people try to bargain, like a child might after a temper tantrum doesn't work. People may plead with God or powerful others to return to them that which they have lost, promising to do more or be a better person in return.

Depression

Some symptoms of depression may be expected after getting new about a life-limiting illness or the loss of a loved one. It is important to note, however, that clinical depression is not part of normalgrief. If symptoms of depression interfere with an individuals ability to function and persist beyond two months, the individualmay be experiencing traumatic grief or a major depressive episode, and should be referred to a mental health professional.

Acceptance

Acceptance of an illness, disability, or death can feel like giving up, so many people avoid it as long as possible. Acceptance can invoke a great deal of fear of living with a disability or without a deceased loved one, as well as apprehension about building a new life in that world. Acceptance can also bring a sense of peace. Fighting an uphill or futile battle is exhausting. Once a person is able to stop the fight, they can focus energy on moving forward, into the stage of hope

Task Model of Grieving

Another way of looking at grief is through a task model, in which the bereaved individual has a number of tasks to complete in the grieving process. This is different from the stage model in that people may be working on all of the tasks at the same time, but the effort associated with them may increase or decrease in importance over the course of the grief. One does not need to complete one stage before moving on to the next, and some tasks may apply more to some people than to others. In contrast to the stage model, in which it is expected that people passively pass through each stage in due time, the task model may be more empowering to some. Believing that there are tasks that they can actively work on to manage their grief may be comforting. At the same time, it may not be the case that checking each of these tasks off a list will relieve all suffering.

Experts have developed multiple task models, each of which has a slightly different focus. One example of a task model is presented here (Vickio, 1999). Completion of these tasks is expected to facilitate not only a return to normal functioning but to facilitate growth through the creation of new meaning in life.

Accepting the Reality of Loss

This task can involve not only the belief that the individual is gone, but coming to terms with all of the associated losses described above (transportation, cleaning, cooking, paying bills, income, etc.). Many people, particularly older adults who have lost a spouse, have described seeing, hearing, or feeling the deceased after they have passed. These sensations may be misunderstood as psychiatric symptoms (i.e., hallucinations) and evidence that the individual has not accepted the loss. This experience is actually not unusual and may not be a psychosis. Some experts have also questioned whether sensing the deceased may be sensory recall (remembering and re-experiencing a visual, auditory, or touch perception). In the absence of other psychotic symptoms, it is possible that these visions may be comforting and not require intervention.

Some theorists suggest that the process of grieving facilitates the breaking of bonds with the deceased. For many people, particularly those who have had a lifelong relationship with the deceased, it may be helpful to think of the grieving process as changing the relationship from a physical or interpersonal connection to a spiritual connection.

An 87-year old woman whose husband had died created somewhat of a shrine to him on her dresser with pictures and medals he had won. She spoke to him daily and told people that he responded to her. When her children became distressed about this behavior, they brought her to a psychologist. Exploration of the relationship with her deceased husband revealed that she was comforted by being able to talk to her husband daily, believing that he was in heaven listening to her. She didn't physically hear him respond to her (i.e., she was not hallucinating); she just knew him so well that she knew what he would say. Continuing to have conversations with him allowed her to feel connected to him, prevented her from feeling lonely, and allowed her to maintain regular activities without getting depressed about the loss. The psychologist suggested to her children that they think of her mother's behavior like talking to God or an angel. They found this explanation useful.

Doing One's Duty to the Deceased

This task may involve following through on promises made before an individual died, taking up causes or activities the deceased was involved in, or, in the case of questionable deaths, investigating causes of the death and searching for justice. However, seeking to avenge a death or tirelessly taking up a deceased cause only out of guilt will not facilitate grief.

Regaining a Sense of Control

Loss of a loved one and being unable to do anything about it is very dis-empowering. Grieving individuals may feel as though they no longer have control over anything, including their own emotional response to the loss. Although it may seem paradoxical, feelings of guilt may be an effort to regain a sense of control. Many survivors come to believe that if they had just asked the doctor to run one more test, treated the deceased with more respect, just been a better person, then maybe the deceased wouldn't have died, died so soon or suffered so much. Believing that one may have been able to prevent the death or prevent suffering implies that the bereaved had some control over the situation. Guilt may be somewhat helpful in the short term to prevent the shattering of the world as they knew it. It may take time and talking with a good friend or therapist to sort out feelings of guilt.

Finding a Sense of Purpose

For many grieving people, and particularly those whose life centered around the deceased, this task becomes paramount. Finding a sense of purpose can be particularly challenging for older adults who were caring for the deceased for an extended period before death.

Relearning the World

Particularly for an older adult who had a relationship with the deceased for many years, one part of relearning the world is mentally and practically coming to terms with living without them. Practical tasks may involve learning to negotiate the bus system or pay bills. Those whose worldview was shattered by the death may have more mental or emotional relearning to do. For example, if one's long-held belief was that children outlive parents and a child dies, it may rattle an entire belief system. The same may be true for someone who expected to die before a spouse or believed that spouses are together forever. Developing a new belief system about the world can be a very daunting tasks. This may be particularly difficult for older adults who have lived a long life and had their belief system shatter in later life.

STUG Reactions

Many people experience grief and come to feel as though they have returned to a normal state of functioning, only to experience a sudden flash of seemingly unbearable sadness. This resurgence leaves many who have struggled through the grieving process feeling as though they have lost all gains they had made. Therese Rando(1988) called these experiences STUG reactions: sudden temporary upsurges of grief. These reactions are often triggered by a situation, a place, a holiday, or a scent that reminds the survivor of the deceased. Most often, STUG reactions are brief and do not indicate that the individualis experiencing pathological symptoms. Bereaved persons can be reassured that these reactions are normal and may occur periodically but typically become less intense and taper off over time.

What Can You Do?

When faced with a grieving senior or family member, there are several things that may be helpful for you to do:

  • Be aware of your own attitudes toward dying, death, and grief. Death is such a taboo topic in so many cultures that most people do not think about or discuss it with others. Some activities that may be helpful to you to familiarize yourself with death and dying:
    • Visit or volunteer in hospice or a nursing home. Expose yourself to those near the end of life.
    • Have a conversation with someone close to you about your coming death or the death of a loved one.
    • If you are still struggling with a loss of your own, talk with a therapist about the experience and what it means to you
  • Most people are very uncomfortable talking about death or listening to someone else talk about it. Grieving people often feel alone in their experience and do not want to burden others with discussion of death. Giving a grieving person an opportunity to share personal feelings can be a very powerful experience. Encourage the expression of feelings, needs, and beliefs, and listen closely to what is being expressed. Whether an individual is experiencing denial, anger, confusion, fear, or guilt, the listener should remain calm, even when the emotions of the grieving person are intense.
  • Do not take anger or irrational outbursts personally. Remember that the individual is grieving. Reacting to anger with anger will only escalate the situation.
  • Because each person experiences grief very differently, do not tell a grieving person that you know what they are feeling or understand what they are going through. In all likelihood, you do not. Tell them instead that you are sorry for their loss and offer your sympathy and support.
  • Do not try to talk individuals out of their feelings. People experience intense emotions flowing a loss and need a safe place to express them. Use active listening skills, like responding to statements without agreeing, challenging, or disputing the other person's perspective. Listen carefully and acknowledge what you have heard the person say.
  • Allow an individual time to think about the loss. This is especially true for older adults who may be processing information more slowly.
  • Have a list of area bereavement services available for your clients and their families. If the grief is interfering with daily functioning for more than two months after the loss, referralto a therapist may be beneficial.

 

Traumatic Grief

Although most people are able to function normally following bereavement, some experience what has been called traumatic grief (TG). Traumatic grief is a relatively new diagnosis and has not yet been included in the Diagnostic and StatisticalManualof MentalDisorders (DSM-IV, American PsychologicalAssociation). A growing body of literature has demonstrated that TG is a distinct syndrome and predicts poorer functioning, lower energy, and poorer mental health than normal grieving (Silverman et al., 2000). One study showed that 57 percent of older adults with TG had suicidal thoughts, compared to 24 percent of bereaved older adults without TG (Szanto, Prigerson, Houck, Ehrenpreis, & Reynolds, 1997). Another study found that older adults with TG had higher rates of cancer, heart trouble, high blood pressure, and changes in eating habits than those without TG one to two years after the death of a terminally ill spouse (Prigerson et al., 1997). As many as 20 percent of older adults may experience traumatic grief following the loss of a spouse (Prigerson & Jacobs, 2001).

Traumatic grief is a syndrome with two clusters of symptoms. The first cluster reflects separation distress symptoms, including searching and yearning for the deceased, having intrusive thoughts about the deceased, and experiencing excessive loneliness since the death. In TG, these symptoms occur at least daily or to a marked degree. The second cluster of symptoms reflects the trauma response, with symptoms similar to those in post traumatic stress disorder. In response to the death, 6 of the following 11 symptoms are experienced at least daily or to a marked degree at part of TG:

  • purposelessness, feelings of futility about future
  • subjective sense of numbness, detachment, or absence of emotional responsiveness
  • difficulty acknowledging the death (disbelief)
  • feeling that life is empty or meaningless
  • feeling that a part of oneself has died
  • shattered worldview (lost sense of security, trust, control)
  • assumption of symptoms of harmful behaviors of, or related to, the deceased
  • excessive irritability, bitterness, or anger related to the death
  • avoidance of reminders of the loss
  • shocked or daze from the loss
  • feeling that life is not fulfilling without the deceased

As with defining normalgrief, the most controversialcomponent of the TG diagnostic criteria is the length of time that symptoms are present before they are considered pathological. As a general rule, however, if a person is experiencing the symptoms of TG for longer than two months after the death of a loved one and those symptoms impair the individualsability to carry out daily activities, referralto a mental health professional is recommended.

The information above is reprinted from Working with Seniors: Health, Financial and Social Issues with permission from Society of Certified Senior Advisors® . Copyright © 2009. All rights reserved. www.csa.us