Working with Bereavement

A Practical Guide

Janet Wilson

• Publisher: Bloomsbury Academic
• Year: 2014
• ISBN:
  9781350305588
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Apractical guidefor those whowork with the bereaved in a variety of settings, from nurses and social workers to volunteers. Covering ethics, cultural issues and support networks, an essential text for those seeking to build understanding and skills in order to offer better support to the dying and the bereaved.

1	Theories of Bereavement

Introduction

The words, bereavement, grief and mourning are often used interchangeably in relation to death, however, there are distinctive differences in the meanings of these words. Bereavement is the word used to describe the death of someone. A bereaved person is one who has experienced the death of someone close to them. This term is also used more generally to refer to other losses a person experiences in life of things that are important to them. This can be the loss of a job, home, relationship or other aspect of life. Grief is the emotional response to the death, the thoughts, feelings and behaviours a person has as a result of the death. It can include a range of responses including sadness, anger, crying and withdrawal. Mourning involves the actions a person carries out following a death. These can be individual and are often collective and based on cultural and belief systems in terms of the type of funeral and attendance at other events such as a wake, wearing certain clothes and adhering to rituals. Actions can include staying at home for a certain time, not attending social events and dressing in certain colours, or clothing, to identify to others that they are in mourning.

When a person dies it is recognized that there are responses from those known to them. This includes the psychological, biological and sociological aspects of loss and covers a range of issues such as physical, cognitive, behavioural and spiritual aspects of grief (Parkes, 1975). Throughout the twentieth century and into the twenty-first century there have been many theories and views of bereavement and how people may respond when someone close to them dies. Some of these theories have been very specific and looked at the distinct journey or route people are thought to take through grief. A few of these theories may seem prescriptive and they try to fit a person’s response to death into a set of fixed behaviours and feelings. Most of the theories acknowledge that individuals differ and allow for flexibility in responses but this is not always recognized. Some theories actually seem to contradict others and over time ideas and understandings of responses to death and what may be helpful have developed and changed. This chapter contains details of some of the theories of bereavement ranging from Freud (1917) to the present day.

Every individual that experiences bereavement will bring to the situation their past experiences in life, influences from their social and cultural background and their own attitudes and values. All these will impact on how they respond to the death (Katz and Johnson, 2006). Some will have had previous experiences of bereavement and this is likely to influence how they manage their emotions following subsequent deaths.

Freud: mourning and melancholia

Sigmund Freud is well known for his work describing the effects of the conscious and unconscious mind. The conscious mind according to Freud is that which we are aware of at any particular moment including perceptions, memories, thoughts, feelings and fantasies. The unconscious mind includes things not easily available to our awareness such as drives, instincts, memories and emotions associated with past trauma. In his writing on mourning and melancholia Freud stated that mourning is a reaction to the loss of a loved person. It involves a painful frame of mind, loss of both an interest in the outside world and loss of a capacity to adopt any new object of love. The person in mourning also turns away from any activity not connected with thoughts of the dead person (Freud, 1949).

Freud continues that although mourning involves a departure from what are considered normal attitudes to life it is not regarded as a pathological condition. It does not require referral for medical treatment. Freud concluded that individuals overcome the state of mourning themselves after a period of time and that interference with the process is useless and could even be harmful.

Melancholia is viewed by Freud as including all the symptoms associated with grief with the addition of a feeling of low self-worth. The person sees themselves as worthless, incapable of any achievement, and expects to be cast out and punished by those around them. Melancholia can result from the death of a loved one or from the loss of an object or a relationship. The person may be aware of who they have lost but not what they have lost in that person. The person who has died may have been their companion giving emotional support or provided a practical service such as the manager of their finances. Freud’s view was that in melancholia the individual may not be consciously aware of the specific object or feature that has been lost, whereas in mourning, the loss is totally within the conscious mind of the individual.

Freud viewed the personality of an individual as comprising of three parts, the ego, superego and the id. The id he saw as the instincts, wishes and impulses an individual has, the ego as the rational, decision making, logical part enabling a person to distinguish between a wish and reality and the superego as the conscience, judging and representing the internalization of parental and moral values (Gross, 2005). In melancholia Freud believed it was the ego that was affected.

Mourning is a natural process and frees the participant upon its completion. It travels a cycle of adjustment, and a form of rebirth occurs as the bereaved person disengages from the dead person, and re-engages with life to live without the loved one who has died.

Melancholia remains an unnatural open wound that continues within a cycle. There is no detachment from the person who has died or attachment to others that are alive and therefore no moving on to re-engage with life. Melancholia as defined by Freud is an illness requiring treatment.

Lindemann: acute grief and rituals

Eric Lindemann was a psychiatrist who coined the phrase ‘acute grief’ to describe what happens to people when a loved one dies. His study involved people who were survivors of a fire that spread through a nightclub in Boston in 1942 killing 492 people (Lindemann, 1944). He wrote about the importance of rituals surrounding deaths such as funerals, memorials and of group mourning.

As a result of his study Lindemann described grief as being remarkably uniform comprising a common range of symptoms, including:

• Physical (somatic) symptoms: tightness of the throat, choking, shortness of breath, an empty feeling in the stomach, tension.

• Pre-occupation with the deceased: hallucinations, seeing or sensing the deceased’s presence, a sense of unreality.

• Guilt.

• Hostility.

• Changes in behaviour: restless, aimless, loss of concentration.

• Identification with the deceased; assuming traits of the deceased, showing signs of illness of the deceased.

Kübler-Ross: stages of loss

Elizabeth Kübler-Ross worked as a psychiatrist with those who were dying, mostly in a hospice setting. Through this work she identified five stages that terminally ill patients experience. These were denial, anger, bargaining, depression and acceptance. She went on to apply these stages to those who were bereaved (Kübler-Ross, 1973). Below are details of each of the five stages and how they are applied by Kübler-Ross to the terminally ill and to the bereaved.

1. Denial and isolation

For the terminally ill – the diagnosis must be wrong, it is not them who have this illness, it happens to others but not them

For the bereaved – it cannot be their loved one who has died, it must be someone else. The viewing of the body can help people to acknowledge that the death is real and it is their loved one who has died and not someone else. When there is no body it can be very difficult for the bereaved to accept what has happened

2. Anger

For the terminally ill – questioning, why is it happening to me? What have I done to deserve this?

For the bereaved – often aimed at health professionals, family members, work and society. The bereaved person can be very irrational and it can be difficult to deal with someone who is angry in this way. With some, the anger can progress to complaints being made to the hospital, workplace, school, and so forth.

3. Bargaining

For the terminally ill – promising to do anything as long as they can live, that they will live a good life, behave in certain way, give their money away, for example.

For the bereaved – they may try to bargain with God or another higher power they perceive to be in charge of the world. They may promise to do anything as long as the person is not really dead, if they can somehow be brought back to life

4. Depression

For the terminally ill – the reality of their impending death can result in them giving up hope and falling into a deep depression

For the bereaved – they cannot see past their grief as it seems to encompass their whole life. They see no future that would be worth living.

5. Acceptance

For the terminally ill – they feel an acceptance and peace about what is happening

For the bereaved – they accept that death is part of life and that there is life for them after the death of their loved one. They still feel the loss but are able to move on and get involved in aspects of life again.

Although this theory can be viewed as rigid, where the five stages are followed in the given order, in her writings Kübler-Ross states that people revisit the stages and so do not progress systematically from one stage to the next in sequence.

Bowlby: attachment theory

John Bowlby was a psychiatrist who developed attachment theory (1980) to describe the significance and effects of family bonds. He identified that the secure attachment of an infant to a primary carer and others in his sphere of contact is essential for children to grow up into socially competent individuals, able to trust others, achieve things and form healthy relationships. Separation causes anxiety and it is how separation is managed during childhood that determines the child’s capacity for secure attachments in later life.

Adult grief is an extension of the general distress response to separation anxiety observed in young children. With children, when the parent returns the anxiety is resolved. In death there is no return so there needs to be a period of adjustment and reorganization.

Bowlby identified phases that could occur after the death of someone close. The initial phase he reported was that of numbness and disbelief, which can last for hours or weeks and may include outbursts of extreme distress and/or anger. Another phase includes yearning and searching for the deceased accompanied by anxiety and intermittent periods of anger, which can last for months or years

The bereaved person feels to be in a state of disorganization and despair. This can be accompanied by feelings of depression and apathy as old patterns are discarded. As time progresses a reorganization takes place. This results in recovery to a lesser or greater degree and acceptance of what has happened. Bowlby identified that this process, although variable, took on average a period of two years (Holmes, 1993).

Murray Parkes: phases of grief

Colin Murray Parkes worked as a psychiatrist in St Christopher’s Hospice in London and has made a lifelong study of grief and bereavement. He developed a theory of phases of grief and stressed that people move around the four phases in any order repeating the phases until they have finally adjusted to living a life without the person who has died (1975). The four phases are:

1. Shock and despair: this involves disbelief at what has happened and a...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Figures
• Acknowledgements
• Introduction
• 1 Theories of Bereavement
• 2 Working with Bereavement
• 3 Practical and Professional Issues in Supporting the Bereaved
• 4 Culture, Faith and Spirituality
• 5 Differing Perspectives of Grief
• 6 Sudden and Traumatic Death
• 7 Hard to Talk About Deaths
• 8 Unrecognized Grief
• 9 Self-care When Working with the Bereaved
• Sources of Information and Support
• References
• Index