04‏/02‏/2012

Grief and Loss

Grief and Loss


In our hearts, we all know that death is a part of life. In fact, death gives meaning to our existence because it reminds all of us that life is precious.


Introduction
            Loss is a universal experience that everyone encounters at one time or another during their lives. Loss from the death of a loved one can be especially devastating. Grief resulting from this kind of loss causes significant disruption in a person’s functioning both internally (physically and emotionally) and externally (socially and occupationally). Historically, mental health practitioners have received little in-depth training related to grief and loss intervention. In addition, there have been only a few theories of grief and loss that have been postulated by experts in the field. However, as the topic of grief and loss has gained wider acceptance and more visibility, there is a need for an understanding of the grief process that consider the individual within the context of the environment in which she/he functions, rather than just examining the internal psychic experience of the individual. In this intro I’ll provide a brief overview of several theories of grief and loss.


Theories of Grief and Loss

Freudian Theory of Loss
            In the early 20th century, Freud provided a theory of “mourning and melancholia” that distinguished between “normal” and “pathological” mourning. He suggested that relinquishing emotional ties with the object of attachment involved obsessive remembering followed by complete severance of emotion to the loved one and re-attaching that emotion to another person. Although this other person is only a substitute for the lost loved one, the mourner eventually internalizes the reality of the loss, extinguished the emotional energy expended on the lost loved one, and, in turn, frees it to be directed toward another. Freud also believed that the psychological identification with the lost person is internalized so that aspects of that person become part of the mourner’s psychological make-up thus making the grief process challenging yet survivable. Freud also distinguished healthy mourning from pathological mourning and differentiated between “mourning and melancholia” in both cases, the emotional experience is similar; however, with melancholia, the mourner has a lack of self-esteem, is self-critical, and eventually develops pathological melancholia or grief. Freud postulated that this prolonged depression that accompanied the grief process was due to unconscious conflicts with the person who died that led to a more complicated mourning period. Threads of Freud’s theory of mourning can be found in more recent theories and frameworks that guide current practice. Clearly, Freud’s theory furthered our understanding of the grief process; however, his focus on the intra-psychic and unconscious elements of a person’s psyche failed to account for environmental influences that impact the mourner’s coping capacities


Erich Lindemann and Crisis Theory
            Following in the footsteps of Freud’s theory of mourning, Erich Lindemann’s research following the 1944 Cocount Grove Night Club disaster in which over 500 people were killed advanced ideas about the grief process. He coined the term “grief work” with his suggestion that resolution of grief necessitated the completion of three specific tasks. First, the mourner must relinquish the attachment to the loved one. Secondly, he/she must re-adapt to life without the presence of the loved one. Finally, the person must establish new relationships with others. Based on interview with survivors of the nightclub fire, Lindemann named six characteristics of “acute” grief, which include (a) physical distress, (b) ruminations about the deceased, (c) survival guilt, (d) angry reaction to others, (e) decline in functioning, and (f) tendency to internalize characteristics of the deceased. This work also contributed to crisis intervention theory and responses to traumatic grief experiences.

Bowlby’s Theory of Attachment
            Bowlby’s theory of attachment developed from his early research on infants separated from their mothers and the emotional, cognitive, developmental, and biological consequences of attachment versus separation. According to Bowlby, life span development of attachment involves the formation of bond (falling in love), maintenance (loving someone) and disruption (grief and mourning). He delineates over the course of three volumes how attachment behaviors maintain the affectional bond and, therefore, a state of homeostasis or balance. When loss of the attachment figure occurs and the bond is disrupted, the person experiences stress and distress as represented by crying, clinging, and angry behaviors in an attempt to regain the connection. When these behaviors are repeatedly unsuccessful they gradually diminish but not stop completely.
            Bowlby (1980) hypothesized that the grief process is a reflection of this basic attachment dynamic. He further described the psychological reorganization that must take place following a loss as involving four phases. The first phase entails a period during which the mourner experiences numbness and denial that serves to deflect the anguish and despair accompanying the loss. This phase can be periodically disrupted by extreme and physically exhausting emotions. The second phase is characterized by yearning and searching as the mourner begins to confront the loss. Common behaviors during this phase include interpreting events as signs from the loved one and seeking out evidence of the loved one’s presence. When these activities are unsuccessful, anger and frustration ensue. The third phase is predominated by feelings of disorganization and desolation. The realization that the attachment bond has been severed and the activities of prior phase have failed in integrated by the mourner. The person experiences a depletion of energy and sense of being overwhelmed. This prompts a re-evaluation of the mourner’s identity and self-concept that can lead to massive psychological upheaval. The final phase, according to Bowlby, involves gradual movement toward organization. There is growing acceptance of the permanence of the separation and the need to construct a life despite the absence of the loved one. These phases maybe experienced multiple times during the grieving process and may takes days, months, or years. 

Rando’s Theoretical Framework of the Grief Process

            Building on Kubler-Ross’s work, Therese Rando suggested that mourning involves three phases that must be completed for a healthy resolution of grief. “Avoidance” is the first phase of this process. During this period, the mourner’s task is to recognize the reality of the loss. During the second phase of “confrontation,” the mourner responds to the loss, experiencing and expressing the emotions prompted by the grief reaction. Memories or recollections of the deceased are prominent and precipitate the relinquishing of the attachment to the loved one. The final phase, “accommodation,” involves a readjustment to the world without the deceased and placement of energy into current and future relationships.

 

Worden’s Task-Oriented Framework of Mourning

            Worden (1991) developed a task-oriented, practice framework based on Bowlby’s theory of attachment that emphasizes the continuum of grief as moving from the pain of separation to the adjustment of new relationships. He describes four basic tasks that must be completed for mourning to be resolved. He emphasizes the fact that these tasks are not necessarily sequential in nature and a person can move back and forth from one task to another. All of the tasks, according to Worden (1991), involve effort or work by the bereaved person. The four basic tasks are outlined below:

1-      To accept the reality of the loss.

2-      To work through the pain of grief.

3-      To adjust to an environment in which the deceased is missing.

4-      To emotionally relocate the deceased and move on with life (Worden, 1991, pp. 10-18).

 

Kübler-Ross and Stages of Grief

 This theory viewed the Grief process as it starts and end into five stages. The five stages, denial, anger, bargaining, depression and acceptance are a part of the framework that makes up our learning to live with the one we lost. They are tools to help us frame and identify what we may be feeling. But they are not stops on some linear timeline in grief. Not everyone goes through all of them or in a prescribed order. Our hope is that with these stages comes the knowledge of grief’s terrain, making us better equipped to cope with life and loss.

The model below is extended slightly from the original Kubler-Ross model, which does not explicitly include the Shock and Testing stages. These stages however are often useful to understand and facilitating change.

The Extended Grief Cycle

The Extended Grief Cycle indicating the roller-coaster ride of activity and passivity as the person wriggles and turns in their desperate efforts to avoid the change.
The initial state before the cycle is received is stable, at least in terms of the subsequent reaction on hearing the bad news. Compared with the ups and downs to come, even if there is some variation, this is indeed a stable state.
And then, into the calm of this relative paradise, a bombshell bursts...
·         Shock stage*: Initial paralysis at hearing the bad news.
·         Denial stage: Trying to avoid the inevitable.
·         Anger stage: Frustrated outpouring of bottled-up emotion.
·         Bargaining stage: Seeking in vain for a way out.
·         Depression stage: Final realization of the inevitable.
·         Testing stage*: Seeking realistic solutions.
·         Acceptance stage: Finally finding the way forward (changingminds.org).



Grief and the Constructivist Framework

Another popular view of grief originates from a constructivist framework that views the experience if bereavement as one in which the mourner actively searches for a way to understand the loss, her changed life following the loss, and to attach some symbolic significance to the loss and its influence on her “new” life. The extent to which a mourner is able to “make meaning” of her loss is believed to influence her transition to life without the deceased. It has been purported that this conceptualization is especially relevant to those who are grieving a traumatic loss. In the case of traumatic grief, research suggests that bereaved persons who search and find some meaning in the loss as well as those who feel no need to look for significance in the loss many have better psychological outcomes compared with those who search but can’t find meaning.
            According to this viewpoint, the mourner’s process of reconstructing their life after a death is grounded in sociological, cultural, and community influences that regulate norms around grief and bereavement. A mourner’s interface with their environment provides affirmation to the grieving experience and the mourner’s effort to “relearn the self” and “relearn the world”.
            The mourner’s process also interacts with an internal psychological component as the individual mourner attempts to adjust her internal and psychological life of the loss. Such adjustments include attempts to integrate the loss into the “personal narrative” of the mourner’s life and fit the loss into a “meaningful plot structure”.
            The construction of meaning around the death of a loved one is a very personal endeavor that varies with each individual. Often mourners will engage in activities or being projects or organizations in memory of their loved one. Their non-profit, bereavement support organization “For the Love of Christi” is one such example. This organization was founded by parents whose daughter was killed by a drunk driver and found little support available to help them with their grief. It provides community-based grief groups for adults, children, and families. For other mourners, making meaning of the loss may take the form of significant changes in the way they live, such as attending to one’s health, staying in closer touch with family and friends, and working less in order to spend more time relaxing or with family.

Continuing Bonds framework of Grief

            In the last decade, an evolving model of mourning and grief has emerged that reduces the emphasis on detachment from the loved one who has died and instead, focuses more attention on the internalized, ongoing relationship with the deceased. Silverman and Nickman (1996) summarize this perspective in the book “Continuing Bonds” by stating, “Survivors hold the maintaining an inner representation of the deceased is normal rather than abnormal”. For example, a 75-yearsold gentleman loses his wife after 50 years of marriage and remarries 2 years later to a woman who was friends with his wife. He often started that this new wife made him feel more connected to his wife because they were friends and shared a common history. In another case, an adolescent internalizes the positive attributes of her father and describes her motivation to become a successful professional as related to her father’s optimistic attitude toward her career goals. In the sense, the young woman’s development encompassed her father’s belief system and shaped her identity as competent and goal. Oriented individual who could succeed in her college education and career.
       These connections that are continually held with the deceased to be common among bereaved individuals. This view suggests it is not pathological to have a continuing relationship whit the deceased and that it, in fact, may be healthy to do so. Therefore, the mourning process involves understanding how the continuing bond whit the deceased can maintained, enhanced, and utilized to promote a healthy response to the future for those who are no longer physically connected to the deceased person. Silverman and Nick man (1996) suggest that the centrality of bond with the deceased may change over time; however, the relationship remains an important aspect of the person’s internal life.


FAMILY SYSTEM AND THE GRIEF PROCESS

Family system theory is particularly relevant for understanding the grief process both for individuals and the family as a unit. Ackerman describes the family as dynamic, organic whole that is influenced by changes in the internal and external environments. Repeated family transactions form the basis of rules by which members communicate and behave. The death of family member disrupts the patterns of interaction among family members and causes a state of disequilibrium. In order to maintain homeostasis or balance, family members must establish new patterns and roles by which to continue functioning .Some families openly acknowledges the loss and are able to express and share their life-enhancing grief reactions whit each other. Roles that they once held are transformed. Some are relinquished, others are adopted by different members, and some roles may include added responsibilities due to the death. As these new patterns are negotiated, the family re-establishes a state of equilibrium. The family as a whole accommodates and adapts to the loss and, in essence, a new family emerges.
        For other families, accommodating to the death of a member is much more is much more difficult to achieve. Life-depleting grief reactions such as refusal to talk about the loss within the family. withdrawing from the family, focusing all the attention on one symptomatic family member or filling the void by creating chaos prevents the family from re-establishing new boundaries and rules, developing healthy communication patterns, and assuming new roles. These families often require outside intervention in order effectively adapt to the Andre-developlife- enhancing patterns.
     For both types of family systems, the practitioner can use the strengths- based perspective to assist the family in identifying and utilizing their collective strengths in order to shore up the family’s life-enhancing grief responses, there is no timeline for a family’s adaptation to loss. It could a few months to a few years. As family development occurs a whit children growing up. Getting married and starting families, the grief over the loss may be revisited periodi- cally and need for intervention may arise.






Societal Response to Grief and Loss

In general, ours is a society is intensely fearful of death. This fear permeates the culture, producing a death – denying society that is reflected in the media. Products and services that promote youth, health, beauty, and pleasure also detract from the inevitability of death and dying. “There appears to be a belief that death is incompatible with or even antithetical to life and, therefore, not a natural part of the human experience“. Death is often viewed as an adversary that we spend millions of dollars attempting to out smart and prolong. This phenomenon is often to credited to advanced in technology that allowed people to live longer lives, Indeed, it is not unusual to find middle –aged individuals in grief in counseling for their first significant loss. Additionally, the typical death no longer occurs in the home, but in the hospital, and is thus removed from common experience.
         Understanding the societal climate surrounding issues of dying, death, and bereavement is important to the clinician because it influences how mourners perceive themselves and their grief process. Due to the superficial coverage of these issues and the lack of accurate information that is disseminated about death and bereavement, many individuals find them selves feeling inadequate in how they are managing the death. Statements such as, :I don’t know why I’m having such a hard time “and “ I know I should be over it by now “ are indicators that  societal expectations may be playing a role in the mourners attempts to cope with the loss, Although there are difference among cultures, some of the dominant society’s expectations suggest the following:
 One should “get over the loss and move on with life” as quickly as possible.
¨      A person should not talk about his \her grief in social situations.
¨      Grief is depressing and thus, should be avoided.
¨      Something “wrong” with a person who cannot mask his\her emotional responses to loss.
¨      Distractions a prescribed script of emotions that everyone should follow when experiencing grief.
¨      Grief should be a time-limited experience with a definite endpoint.

Unfortunately, many bereaved individuals these societal norms as valid notions of right way to grieve and, therefore, experience their grief in life-depleting ways. They may refuse offers of support or counseling due to their belief that asking for help would indicate personal weakness. The practitioner can help by pointing out the fallacy of these expectations and normalizing the reality the mourner’s experience. Asking can be reframed as a life-enhancing coping mechanism while moving through the grief experience.
       In addition, certain types of death, such as suicide, homicide, or drug over- dose are highly stigmatized by society, making it even more difficult for mourners to find support for their loss. For example, if woman’s partner commits suicide, it is likely that she uncomfortable merely the circumstances of the death, much less discussing the subject in death. To complicate matters, even her close friends may feel awkward providing to her. Thus, the women may feel very isolated, alone, and rejected by others at a time when she most needs their support.
       As a product of society’s ineffectiveness in related matters, there are compelling reasons for a person in mourning to isolate himself and repress his emotional experiences. Therefore, it is incumbent upon practitioners to make use of opportunities to educate the public the process of death, dying, grief, and loss.


Cultural Response to Grief and Loss
           Cultural response to grief and loss vary widely it is critical to understand the cultural context of the mourner. In the United States, there are numerous cultures represented across the country, each possessing formalities and perspectives in relation to death and bereavement. It is a daunting, if not impossible, task for any one practitioner to develop an understanding of the grief experience across multiple cultures. Therefore, you as the must listen and from the clients stories about his\her cultures on the mourning process. Such stories can illuminate relevant cultural influences that are life enhancing or life depleting for the client. The practitioners’ sensitivity to cultural norms is an essential component for an accurate assessment of client needs and strengths. A lack of cultural awareness can result in serious misunderstandings between the practitioner and client and may detract the therapeutic benefit of the interaction. For example, according to certain Buddhist religious practices, the dead person must be honored with ceremonies that last up to 49 days in order to assure the rebirth of the deceased. Consider the problems this would pose for an hourly wage earner in the United States to leave work in order to fulfill this obligation. A practitioner who is unaware of this practice may be tempted to encourage the return to work for the sake of the family’s security. On the other hand, an informed practitioner might be able to assist the worker and help facilitate the leave time from his or her job. Practitioners must be comfortable expressing to the client their need for information about the client’s culture so that may better understand the cultural influence impinges on the client behavior and decision making abilities. Cultural influences can be a potent source of strength for individuals and must be taken in to consideration when working client.


The Cognitive Model of Bereavement

            From the cognitive perspective, a loss through death is an adverse external event over which one has no control but which nevertheless changes one’s belief system and its related emotions and behaviors. Grief, then, is not only an emotional process but also one of cognitive and behavioral adaptation to the consequences of the loss. Particularly when the cause of death is more sudden, stressful, or traumatic (i.e., homicide, suicide, accidents, and natural or man-made disasters), emotions seem to dominate over cognitions, especially during the acute phase.
            In traditional therapies, the emotional dimension of the process of grief is the focus of intervention: The presence or absence of anger, depression, shame, and guilt reactions have customarily been crucial indicators for understanding and evaluating short- and long-term bereavement outcomes as well as normal and complicated forms of bereavement. According to traditional models, an exaggerated emotional response, the absence of these emotions, and avoiding their expression are all indications of complicated grief. For this reason, most traditional interventions apply cathartic techniques to help the bereaved person alleviate the intensity of these emotions cognitions are seen only as the byproducts of emotional disturbance. The tendency of therapists to emphasize emotions as central to the process of grieving has led them to neglect its cognitive aspects.
In contrast, the cognitive perspective emphasizes the relationship between one’s emotions and behaviors and one’s cognitive evaluations about oneself, the world, and the future. The death event is assumed to have a profound impact on a person’s most fundamental assumptions or assumptive world, his or her fundamental cognitive structures or schemata about the self and the world, and his or her belief system about the self, others, and the world. A death event deconstructs the existing views that a person holds about life and relationships, requiring a painful internal process of cognitively reorganizing what has been shattered following the external event; of modifying one’s knowledge, thoughts, and feelings; of giving up old meanings to one’s life and forming new ones. The loss event is new information that has to be processed and then assimilated (revising and processing new information into preexisting cognitive structures) or accommodated (adapting preexisting knowledge to the new reality)
Whether primarily cognitively processed or emotionally experienced, the cognitive perspective asserts that the more traumatic the event is the greater its impact on one’s belief system and other cognitions. Thus, the cognitive approach upholds that for the grieving process to take an adequate course toward functional and satisfying outcomes, grief-related cognitions should be identified, included, assessed, and treated as an equal part of intra-psychic processes. Bereavement is viewed as a process that includes coping with the stress evoked by the death event on one hand and ongoing relationships with the deceased on the other.
According to the cognitive approach, psychopathological grief takes the form of distorted thinking, where an excessive emotional reaction (such as depression) is related to negative cognitive evaluations (automatic thoughts) of oneself, the world, and the future. For example, bereaved persons with distorted thinking may interpret loss as an intended rejection (How could he or she have done this to me) or as a confirmation of being worthless (I am guilty and a worthless person for not saving his or her life). During stressful life events, people often use maladaptive cognitive processes, referred to by Beck as cognitive distortions and by Ellis (1962) as irrational beliefs. According to rational emotive behavior therapy (REBT), overreaction and lack of reaction to the death of a loved one are not in themselves “right” or “wrong,” or preferred or undesirable, but rather are related to a specific set of beliefs (cognitions) that are functional or dysfunctional (adaptive or maladaptive). In the case of loss through death, negative emotional reactions (e.g., sorrow, sadness) may be regarded as relating to adaptive cognitions (e.g., “Life has changed forever, and it’s sad and painful” “The doctors did all they could do to save my child; I don’t blame them;” “I know we did everything to keep him alive, but it didn’t help, and he died”). Complicated grief, on the other hand, is seen as a negative emotion related to and maintained by maladaptive cognitions (e.g., “Life is not worth living without my loved one,” “I can’t stand my life without my loved one”). Thus, from a cognitive perspective, complicated grief is defined as persistence over time of distorted, irrational beliefs as the dominant set of cognitions affecting the emotional consequences in the form of depression or anxiety.



Person’s feeling and React to Death:
            In dealing with the death, you can go through all kinds of emotions. You can be sad, worried or afraid. You might be shocked, unprepared, or confused. You could angry, cheated, relieved, guilty, exhausted or just empty. Your emotions might be stronger or deeper than usual or mixed in a way you have never experienced before.
Some people find they have difficulty concentrating sleep, study, eat, or if they are to cope with the death. Others lose interest in activities they used to enjoy. Some people lose themselves in computer games or eat or drink to excess. And some people feel numb, as if nothing happened. All these are normal ways to react to a death. feeling strong emotions such as sadness and, physical reactions, such as not sleeping or even waves of nausea have spiritual reactions to the death – for example, some people find themselves questioning their beliefs and feelings of disappointment in their religion, while others find that they feel more strongly than before on their different mourners.
Most people who suffer a loss experience one or more of the following:
  • A feeling of tightness in their throat or heaviness in their chest.
  • Have an empty feeling in their stomach and lose their appetite.
  • Feel guilty at times and angry at other times.
  • Feel restless and look for activity but find it difficult to concentrate.
  • Feel as though the loss is not real; that it did not happen.
  • Sense the loved one’s presence, as in finding themselves expecting the person to walk in the door at the usual time, hearing their voice, or seeing their face.
  • Wander aimlessly, forget, and neglect to finish things that they have started around the house.
  • Have difficulty sleeping, and dream of their loved one frequently.
  • Experience an intense preoccupation with the life of the one who has died.
  • Assume mannerism or traits of their loved one.
  • Feel guilty or angry over things that did or did not happen in their relationship with the person who has died.
  • Feel intensely angry at the loved one for leaving them.
  • Feel as though they need to change for people who seem uncomfortable around them by politely not talking about their feelings of loss.
  • Need to tell and retell and remember things about the loved one and the experience of his or her death.
  • Cry at unexpected times.


People around griever; feel and react:
It can be tough to know what to say or do when someone you care about is grieving. It’s common to feel helpless, awkward, or unsure. You may be afraid of intruding, saying the wrong thing, or making the person feel even worse. Or maybe you feel there’s little you can do to make things better.
The most important thing they can do for a grieving person is to simply be there. Their support and caring presence will help them cope with the pain and begin to heal. But there are things make it better to understand grief for people around him:
  • There is no right or wrong way to grieve.
  • Grief may involve extreme emotions and behaviors.
  • There is no set timetable for grieving (www.helpguide.org)

Treatment for Grief

Grief therapy may allow the mourner to see that anger, guilt, or other negative or uncomfortable feelings can exist at the same time as more positive feelings about the person who died.

In grief therapy, 6 tasks may be used to help a mourner work through grief:
1.      Develop the ability to experience, express, and adjust to painful grief-related changes.
2.      Find effective ways to cope with painful changes.
3.      Establish a continuing relationship with the person who died.
4.      Stay healthy and keep functioning.
5.      Re-establish relationships and understand that others may have difficulty empathizing with the grief they experience.
6.      Develop a healthy image of oneself and the world.

Complications in grief may come about due to uncompleted grief from earlier losses. The grief for these earlier losses must be managed in order to handle the current grief. Grief therapy includes dealing with the blockages to the mourning process, identifying unfinished business with the deceased, and identifying other losses that result from the death. The bereaved is helped to see that the loss is final and to picture life after the grief period.(www.medicinenet.com)

Treatment According to CBT Therapy:

CBTs were reported to be particularly effective with individuals suffering from posttraumatic stress disorder, depression, anxiety, and chronic or traumatic grief. Cognitive therapies focusing on the individual’s belief system and the related consequences (emotions and behaviors) were found suitable and effective. Cognitive therapy (CT) and CBT are based on the premise that emotional disturbance and behavioral symptomology are maintained as a result of distorted thinking, which can be modified with the use of a variety of cognitive, emotional, and behavioral techniques, not only during the sessions but also between sessions, in the form of homework assignments. It is not surprising, then, that in cases of acute and prolonged grief following death, there is increasing use of CT and CBT—combining guided imagery, exposure techniques, thought-stopping, cognitive restructuring, breathing exercises, and skill acquisition—all aimed at assisting clients to cope with loss and to reorganize their relationship with the living and the dead. A major focus of recent CT interventions has shifted from assisting bereaved persons to adapt to a new reality that excludes the deceased toward assisting them to reconstruct new meanings.

Coping Mechanisms
We are complex creatures living complex lives in which we are not always able to cope with the difficulties that we face. As a result, we are subject to feelings of tension and stress, for example the cognitive dissonance and potential shame of doing something outside our values. To handle this discomfort we use various coping methods.

Here are coping mechanisms by type:

Here is a full list of coping mechanisms:


Death is still an unknown. No one obviously, has ever died and returned to tell us what death is really like. Man naturally fears what he does not understand and can not control



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