Grief

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Grief

• Daniel Robitshek, MD
• Professor of Medicine
• UC Irvine Medical Center
• Hospitalist Program

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• Death is a fearful thing.
• William Shakespeare
• Death! thou comest when I had thee least in mind!
  
• Unknown
• While grief is fresh, every attempt to divert
  only irritates. You must wait till it be
  digested, and then amusement will dissipate the
  remains of it.
• Samuel Johnson

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Every deathhas a life of its own
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Grief

• Grief is neither a disorder nor a healing
  process it is a sign of health itself, a whole
  and natural gesture of love. Nor must we see
  grief as a step towards something better. No
  matter how much it hurts and it may be the
  greatest pain in life grief can be an end in
  itself, a pure expression of love.
• Gerald May, MD

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The Grieving Process
restoring the fit between the world that is and
the world that should be
(Reference Parkes, Colin M. Mortality Virtual
Themed Issue, 2003)
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Loss Defined 

• Loss is the experience of parting with an object,
  person, belief, or relationship that one values.
• Losses are encountered daily by each of us. 
• The experience of loss must be defined broadly
  and with a clear understanding of the personal
  pain and disruption that can accompany it. 
• Losses can be minor or major.
• The designation of minor or major depends
  upon the perception of the loss by the person
  experiencing the loss.
• The impact of loss depends upon the value the
  person placed on what was lost.

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Language of Loss
Bereavement the state of having experienced
loss Mourning the private and public
processes, rituals and practices to loss
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BEREAVEMENT

• Bereavement is darkness impenetrable to the
  imagination of the unbereaved.
• Iris Murdoch 1919-1999

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Types Of Loss

• Tangible (actual or physical) losses are apparent
  and easily recognized 
• Loss of a body part.
• Changes in physical health.
• Loss of a loved one.
• Intangible (perceived or psychological) losses
  are less obvious
• May be tied to personal perceptions such as ones
  prestige, power, dreams, plans, security, etc.
• Because these losses are less likely to be
  acknowledged, admitting to the accompanying
  feelings of loss can be difficult or
  embarrassing.
• Consequently, emotional support may be inadequate.

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What is Grief?

• Multidimensional result of/response to loss
• Emotional
• Physical
• Cognitive
• Behavioral

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Why Do We Grieve?

• Attachment theory Bowlby
• Attachment occurs in absence of the reinforcement
  of biological needs (e.g. food)
• Based on need for safety and security
• Observed in animals and humans
• Develop early in life, are directed toward a few
  specific individuals and tend to endure
• Grief occurs with the loss of the attachment bond

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Why Do We Grieve?

• Reestablish equilibrium Worden
• Mourning is necessary
• After a loss is sustained, a healing process is
  necessary to re-establish equilibrium

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Surviving the LossThe Grieving Process

• The dual process model (DPM) of coping with
  bereavement lists two types of stressors.
• Loss-oriented stressors- those having to do with
  the loss itself.
• Restoration-oriented stressors- those related to
  adapting to the survivors new life situation.

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Dual Process Model
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Emotional Response to Loss

• Anger
• Frustration with helplessness to change the
  situation
• Regressive experience
• Guilt and self-reproach
• Anxiety
• Fears about not being able to take care of
  oneself after the loss
• Heightened sense of own mortality
• Loneliness
• Fatigue
• Helplessness
• Shock
• Yearning
• Emancipation
• Relief, especially after the dying person has
  suffered during a lengthy illness
• Numbness

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Physical Response to Loss

• Tightness in chest and throat
• Hollowness in stomach
• Heightened sensitivity to noise and light
• Depersonalization
• Breathlessness
• Weakness
• Lack of energy
• Dry mouth

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Cognitive Response to Loss

• Disbelief
• Disorientation
• Confusion
• Preoccupation
• Sense of presence (feeling that the deceased is
  in the room or close by)
• Hallucinations

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Behavioral Response to Loss

• Sleep and appetite disturbances
• Social withdrawal
• Dreams of the deceased
• Avoiding reminders of the deceased
• Searching or calling out for the deceased
• Sighing
• Restlessness
• Crying
• Visiting places or carrying objects that remind
  one of the deceased
• Treasuring objects of the deceased

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Depression and Normal Grief

• Full depressive reaction may accompany normal
  grief response
• Grief does not include the loss of self-esteem,
  overall sense of guilt
• Grief may develop into depression

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What Determines the Intensity and Duration of
Grief?

• Intensity is highly variable may continue for
  months to several years
• Dependant upon
• Type of loss
• Nature of the attachment
• Strength of attachment intensity of grief
  proportionate to the intensity of the
  relationship
• Security of the attachment how necessary was it
  for a sense of well-being of the survivor
• Ambivalence coexisting positive and negative
  feelings
• Mode of loss
• Natural, accidental, sudden/unexpected, expected,
  intentional, traumatic
• Historical antecedents
• Experience of earlier losses
• History of depression
• Previous stresses
• Personality variables
• Coping resources and styles
• Psychological resilience
• Optimism
• Social and cultural factors
• Traditions and rituals social netword

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What are the Tasks of Grief?

• Accepting the reality of the loss
• Denial impedes this task
• Disbelief that the loss has occurred
• Denial of the meaning of the loss
• Denial that death is irreversible
• Acceptance must include understanding that the
  loss has occurred and/or the death is irreversible

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What are the Tasks of Grief?

• Experience the pain of grief
• Social expectation may make resolution of this
  difficult
• Others may try to distract the bereaved from the
  pain
• Ways of not experiencing affect
• Over involvement in work
• Idealizing the loss
• Geographic cure
• Minimizing the significance of the loss

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What are the Tasks of Grief?

• Adjusting to an environment in which the
  loss/deceased is missing
• Taking on new roles, developing new skills
• If not resolved, helplessness may occur
• Survivor may not be aware of all the roles filled
  by the deceased until the loss occurs

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What are the Tasks of Grief?

• Withdraw emotional energy and reinvest it in
  another relationship
• Many people misunderstand this task and are
  unable to work through it
• Some people believe that to reinvest emional
  energy in someone else is to dishonor the dead
• Fear of the prospect of experiencing new loss may
  impede the successful working through to this loss

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What are the Stages of Grief?

• Elizabeth Kubler-Ross (1969) suggested grief be
  seen as occurring in five stages
• Denial and isolation
• Anger
• Bargaining
• Depression
• Acceptance
• Stage concept has been criticized, but framework
  is valuable
• Most people do not progress through the stages in
  a systematic way or in a specific order
• All people will experience a variety of emotions
  which change over time

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NATURAL GRIEF INSTINCTIVE BIOBEHAVIORAL RESPONSE
BEREAVEMENT
Acceptance Positive emotions Forgiveness,
Compassion Meaning-making
PRIMARY GRIEF
Traumatic Distress
INTEGRATED GRIEF
Separation Distress
? 6 months
Guilt
Permanent background state Bittersweet memories
that are accessible and changing
Social withdrawal
Transient, dominant state Painful and preoccupying
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How is Grief Resolved?

• Impossible to place a time limit may be long
  term with close attachment (one year or more)
• A process
• Grief work the mental and behavioral processing
  of the loss
• Gradual evolution of thoughts, emotions and
  experiences toward greater acceptance of the loss
  and emerging ability to resume life

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THE ROLE OF PHYSICIANS

• Educate
• Normal and natural grief processes
• Range of different feelings (positive and
  negative)
• Assess progress and prognosis
• Physical and mental health
• Life context
• Support
• Condolence letter
• Active listening
• Link to local resources (spiritual, support
  groups, counselors)

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• physicians who aid grief-stricken patients are
  afforded the rewarding, quintessentially human
  opportunity of transforming a personal sorry they
  inevitably will experience into sympathetic and
  supportive aftercare.
• Prigerson and Jacobs JAMA 2001

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Nine Ways to Help with Grief

• Increase the reality of the loss
• Allow time and place for the expression of
  feelings
• Normalize feelings
• Reality test
• Help with problem solving as survivor adjusts to
  an environment without the deceased
• Discourage major life decisions too soon
• Encourage healthy reinvestment of emotion
• Allow for individual differences
• Provide continued support

Worden, 1989 Rando, 1984 Cook Dworkin, 1992
Bertman, 1991
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1. Increase the Reality of the Loss

• Talking and traditions help
• Especially important early after the loss
• Provide ways to allow family members to say
  goodbyes at the bedside, before death when
  possible
• Encourage family members to provide care for the
  dying person and recognize their contributions
  (all can say that they were there and did as much
  as was possible)
• Encourage and support the family as they follow
  cultural and social traditions and rituals
• Express sympathy
• Listen to family members talk about the deceased
  and their experiences grieving
• Encourage reminiscing

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2. Allow Time and Place for the Expression of
Feelings

• Provide for a quiet room free of distractions,
  offer tissues
• If appropriate, given the persons culture and
  the social situation, a touch on the shoulder or
  hand may provide a tangible gesture of concern
  and support
• Make telephone available for family members to
  contact significant others
• Verbal permission to grieve or express emotions
  and thoughts
• Listen without judgment

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3. Normalize Feelings

• Especially important when the bereaved feels
  anger or relief with the loss (or other emotion
  that may be perceived as inappropriate)
• Let person know that ambivalent feelings are
  normal and common
• Very important not to minimize feelings

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4. Reality Test

• Help the bereaved person understand difficult
  feelings in the context of the situation
• Example
• 47 yo who expresses feeling of relief and
  resultant guilt after death of parent from long
  illness in which she was the primary caregiver

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5. Help with Problem Solving as Survivor Adjusts
to an Environment Without the Deceased

• Practical discussion of new roles and
  responsibilities for survivor
• Help survivor break down tasks into small steps
  that can be accomplished
• Identify sources of support in community
• Referral to social service, financial advisors,
  counselors

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6. Discourage Major Life Decisions Too Soon

• Making major life decisions early in the grieving
  process may be counterproductive or even harmful
• Moving, marriage, pregnancy, change in employment
• When is it too soon?
• Experience of intense, fresh grief
• Difficulty accepting the paing and reality of the
  loss
• difficulty starting new activities without the
  deceased
• Complicated grieving

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Nine Ways to Help with Grief

• 7. Encourage healthy reinvestment of emotion
• Previous roles and responsibilities
• New activities and relationships
• 8. Allow for individual differences
• Broad range of emotions and other experiences
  during grieving
• Variation in the time needed to grieve
• 9. Provide continued support

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• My wife of 40 years died at a prestigious
  teaching hospitalNeither the hospital management
  nor the attending physician or anyone from the
  house staff ever troubled to write or telephone
  to express sympathy or offer an account of what
  had gone so wrong those last disastrous days. The
  effect of that bizarre silence was to make me
  wonder whether some monumental mistake might have
  been made in preparing the dose that was to end
  her life. The next of kin are entitled to some
  expression of sympathy or concern, even when it
  is not deeply felt. Those close to the deceased
  can only be baffled, resentful, or suspicious
  when no condolences are expressed.
• Lerner A NEJM 345 374-375 2001

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Benchmarks of Grief Resolution

• Survivor is able to talk about the deceased
  without intense affect
• Survivor can reinvest emotions in another

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EVOLUTION OF GRIEF
Major Depression Posttraumatic Stress
Disorder Complicated Grief
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Special Problems

• Failure to Grieve
• Avoidance of Grief
• Chronic Grief
• Delayed Grief
• Exaggerated Grief
• Masked Grief
• Anticipatory Grief

Worden, 1982 Cook Dworkin, 1992
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Failure to Grieve

• Relationship factors ambivalence, narcissistic
  or dependent relationship
• Uncertain losses missing in action(MIA) or
  multiple losses
• Historical factors depressive illness,
  difficult prior experience with bereavement
• Personality factors
• Unable to tolerate intense feelings
• Unable to tolerate dependency feelings
• Social factors
• Death unacceptable to social group suicide,
  death of murderer
• Mourning is not accepted in social group
  abortion, fetal death
• Absence of social support network

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Avoidance of Grief

• Idealization of the deceased
• Chronic anger with the deceased impeding the
  ability to recognize the significance of the loss

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Chronic Grief

• Grief continues for prolonged period without the
  survivor feeling resolved
• Several years after the loss, unrelated events
  trigger intense, fresh grief
• Loss is discussed in daily conversations even
  several years after the loss
• Years after the loss the bereaved has not resumed
  daily activities

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Delayed Grief

• Survivor not able to grieve due to competing
  stressors
• Grief occurs at a date after the death in
  response to another loss or a reminder of the loss

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Exaggerated Grief

• Development of phobias
• Disabling helplessness

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Masked Grief

• Other responses or symptoms are more prominent
  then grief
• Thought to occur when normal grief cannot be
  expressed because of social sanctions, other
  stressors occurring during the loss
• Examples
• Child who acts out
• Headaches emerge at time of loss
• Neglect of health
• Impulsive decision making

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Anticipatory Grief

• Grief occurring in advance of the loss
• Often seen among family members who expect the
  future loss of their loved one
• A dying person can experience anticipatory grief

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Professionals and Family Caregivers Must Attend
to Self Care
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Issues for Health Care Professionals

• Overwork
• Multiple Loss and Grief
• Boundaries
• Burnout

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Overwork

• Occupational realities of working in medicine
• Institutional realities
• Unrealistic self-expectations errors in
  thinking
• If I dont do it, no one will
• I can do it better than anyone, so I should
• Working harder to make up for mistakes
• Helpaholism
• Im in this alone
• Theres no way out of this

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Multiple Loss and Grief

• Stigma of working with the dying
• Professional caregivers not expected to grieve
• Bereavement overload (Kastenbaum, 1969) -
  falling over the edge of hope
• Our early experiences with loss shape our
  approach/response to present-day losses
• Re-living past deaths with each new death
• Letting go, and letting go, and letting go .

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Boundary Issues

• Occupational realities of working with the dying
  multiple roles
• caregiver as health care provider
• caregiver as advocate
• caregiver as primary support person
• caregiver as individual/couples/family therapist
• caregiver as bereavement counselor
• Personal issues involved in becoming a caregiver
  (Berry, C. R., When Helping You is Hurting Me,
  1988, Harper)

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Symptoms of Caregiver Burnout

• Reduced productivity/impaired performance
• Lowered energy/enthusiasm/humor
• Chronic fatigue/insomnia/bodily aches pains
• Less interest in co-workers, clients, families
• Opposition to change
• Failure to manage basic life maintenance
  activities
• Dislike of work environment
• Expressed dislike for recipients of services
• Increases in going by the book

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Self-Care at Work

• Case conference/staff retreats
• Expect (and seek) positive feedback from
  supervisors
• Consult with a back-up expert
• Assignment of specific duties and knowing
  expectations
• Drawing/maintaining clear boundaries on
  professional obligations
• Enlisting help of volunteers
• Time out activities
• Varying tasks
• Building in mental health days

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Self-Care at Home

• Meditation, relaxation exercises
• Therapeutic massage
• Regular exercise!!!
• Nutrition as a self-nurturing activity
• Recreation and pleasant events
• Sharing experiences/feelings with friends
  family
• Professional support group
• Individual therapy

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Reference

• Knight, Sara J., PhD
• Robert H. Lurie Comprehensive Cancer Center Web
  Site

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Case Study Sophia

• 45 yo financial advisor who lost her husband Ben
  1 yr ago after a brief, but aggressive illness
• Married for 20 yrs since graduated college
• No children, but were an extremely close couple
• Spent most of their time together and were each
  others best friend

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Case Study Sophia

• 1 year after Ben's death, Sophia described
  herself as never having gotten over his loss
• Experienced daily panic attacks that limited her
  ability to leave her apt.
• Was considering taking disability leave from work
• Was unable to talk about Ben w/o crying and noted
  that she was having great deal of difficulty
  cleaning Bens closet out
• She felt Ben would have wanted to donate his
  clothes to someone who would use them, but she
  could not decide what to give away and what to
  keep

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Case Study Sophia

• Reflection
• Loss of a spouse is very difficult
• Strong grief responses can be experienced for a
  year or more by bereaved
• Not unusual to have anxiety as they attempt to
  resume their lives
• Common to have difficulty giving up possessions
  of their loved one
• However, Sophia is experiencing severe
  limitations in her ability to take care of
  herself and is still experiencing intense, fresh
  grief when thinking of Ben 1 year later

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Case Study Sophia

• Considerations
• Sophias experience suggests the possibility of
  anxiety and depression
• Should a referral to a mental health professional
  be made?
• What other resources might be helpful for Sophia?

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Grief vs. Depression
Cook Dworkin, 1992
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When is Professional Help Needed?

• Intense fresh grief with discussion of deceased
  long after loss
• Minor event triggers intense grief reaction
• Themes of loss continue long after loss has
  occurred
• Survivor unwilling to move material possessions
  of deceased
• Survivor experiences physical symptoms of
  deceased
• Radical changes in lifestyle
• History of depression, or other psych disorder
• Compulsion to imitated deceased
• Self-destructive impulses
• Unaccountable sadness
• Phobia about illness or death

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Grief Counseling/Support Services vs. Grief
Therapy

• Grief Counseling/Support Services
• Best for individuals who are experienceing grief
  that would not be considered complicated
• Goals
• Support persons as they go through the grieving
  process
• Prevent complicated grief reactions
• Grief therapy for complicated grief
• May have pre-existing issue/disorder that may
  interfere with normal grief
• Invlolves helpf with both pre-existing issues as
  well as the grief process
• Professional help
• Medication may be used