Chapter 10 Grief and Loss

CHAPTER 10: GRIEF AND LOSS

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Chapter 10: Greif and Loss Key Terms: Acculturation: altering cultural values or behaviors as a way to adapt to another culture o o Adaptive Denial: the client gradually adjusts to the reality of the loss, can help the client let go of previous (before (before the loss) loss) perceptions perceptions while creating new ways of thinking about about him or herself, others others and the world Anticipatory Grieving: when people facing an imminent loss begin to grapple with the very real o possibility of the loss or death in the near near future o Attachment Behaviors: affectional bonds with significant others o Attentive Presence: being with the client and focusing intently on communicating with and understanding him or her Bereavement: refers to the process by which a person experiences grief o o Complicated Grieving: a response outside the norm and occurring when a person is void of emotion, grieves for prolonged periods, or has expressions of grief that seem disproportionate disproportionate to the event o Disenfranchised Greif: grief over a loss that is not or cannot be mourned publically or supported socially o Greif: Grieving: o Grieving Tasks: o o Homeostasis: o Mourning: Outcry: o o Recovery: o Spirituality: o Theories of Grieving: Objectives: Identify the types of losses for which people may grieve o ▪ Physiologic Loss: amputation of a lib, a mastectomy or hysterectomy, or loss of mobility; essentially, essentially, it’s the loss of function and/or part of the body ▪ Safety Loss: loss of safe environment is evident in domestic violence, child abuse, or public violence; a person’s home should be a safe haven with trust that family members will provide protection, not harm or or violence; violence; some public public institutions institutions such as as schools and churches churches are often associated with safety as well; feeling of safety is shattered when public violence occurs on campus or in a holy place ▪ Loss of Security and a Sense of Belonging: the loss of a loved one affects the need to love and the feeling of being loved; loss accompanies change in relationships, such as birth, marriage, divorce, illness, and death; as the meaning of a relationship changes, a person may lose roles within a family or group ▪ Loss if Self-Esteem: any change in how a person is valued at work or in relationships or by himself or herself can threaten self-esteem; self- esteem; it may be an actual change or the person’s perception of a change in value; death of a loved one, a broken relationship, loss of job, and retirement are examples of change that represents loss and can result in a threat to self-esteem ▪ Loss Related to Self-Actualization: an external or internal crisis that blocks or inhibits strivings toward fulfillment may threaten person goals and individual potential; a person who wanted to go to college, write books and teach at a university reaches a point in life where it becomes evident that those plans will never materialize; or a person loses hope that he or she will find a mate and have children; these are losses that the person will grieve Discuss various theories related to understanding the grief process o ▪ Kubler-Ross’s Kubler-Ross’s Stages of Grieving: ● Elizabeth Kubler-Ross (1969): attended to clients with terminal illness, a process of dying became apparent to her; observed and worked with dying clients and families ● 5 stages to explain what people experience as they grieve and mourn:

UNIT 3: CURRENT SOCIAL AND EMOTIONAL CONCERNS CONCERNS


Denial: is shock and disbelief regarding the loss Anger: may be expressed toward God, relatives, friends, or health-care workers Bargaining: occurs when the person asks God or fate for more time to delay the o inevitable loss o Depression: results when awareness of the loss becomes acute Acceptance: occurs when the person shows evidence of coming to terms with o death ● Model became a prototype for care providers as they looked for ways to understand and assist their clients in the grieving process Bowlby’s Phases of Grieving: John Bowlby: British psychoanalyst, proposed a theory that humans instinctively attain ● and retain affectional bonds with significant others through attachment behaviors ● Attachment that is maintained is a source of security, an attachment that is renewed is a source of joy ● Bond is threatened or broken, however the person responds with anxiety, protest, and anger ● Four phases: Experiencing numbness and denying the loss o o Emotionally yearning for the loss loved one and protesting the permanence of the loss Experiencing cognitive disorganization and emotional despair with difficulty o functioning in the everyday world o Reorganizing and reintegrating the sense of self to pull life back together Engel’s Stages of Grieving: ● George Engel (1964) ● Five stages of grieving: o Shock and Disbelief: initial reaction to a loss is a stunned, numb feeling accompanied by refusal to acknowledge the reality of the loss in an attempt to protect the the reality of the loss loss in an attempt attempt to protect the the self against against overwhelming stress Developing Awareness: as the individual begins to acknowledge the loss, there o may be crying, feelings of helplessness, frustration, despair, and anger that can be directed at self or others, including God or the deceased person o Restitution: participation in the rituals associated with death, such as a funeral, wake, family gathering, or religious ceremonies that help the individual accept the reality of the loss and begin the recovery process o Resolution of the Loss: the individual is preoccupied with the loss, the loss person or object object is idealized, idealized, and and the mourner mourner may may even imitate imitate the lost person. Eventually, the preoccupation decreases, usually in a year or perhaps more Recovery: the previous preoccupation and obsession ends, and the individual is o able to go on with life in a way the encompasses the loss Horowitz’s Stages of Loss and Adaptation: Adaptation: ● Mardi Horowitz (2001) ● Divides normal grief into 4 stages: o Outcry: first realization of the loss; may be outward, expressed by screaming, yelling, crying, or collapse; can also be suppressed as the person appears stoic, trying to maintain emotional control; either way, these feelings take a great deal of energy to sustain and tend to be short-lived o Denial and Intrusion: people move back and forth during this stage between denial and intrusion; during denial, the person becomes so distracted or involved in activities that he or she sometimes isn’t thinking about the loss; at other t imes, o o

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the loss and all it represents intrudes into every moment and activity, and feelings are quite intense again Working Through: as time passes, the person sends less time bouncing back and o forth between denial and intrusion, and the emotions are not as intense and overwhelming; person still thinks about the loss, but also begins to find new ways of managing life after loss Completion: life begins to feel “normal” again, although life is different after he o loss; memories are less painful and don’t regul arly interfere with day-to-day life; episodes of intense feelings may occur, especially around anniversary dates, but are transient in nature ▪ Stages of Grieving: Comparison of Theorists Table 10.1 pg 166 Describe the five dimensions of grieving ▪ Tasks of Grieving: ● Rondo (1984) describes tasks internet to grieving that she calls the “six Rs”: o Recognize: experiencing the loss, and understanding that it is real, it has happened o React: emotional response to loss, feeling the feelings Recollect and Re-experience: memories are reviewed and relived o o Relinquish: accepting that the world had changed (as a result of the loss), and that there is no turning back o Readjust: beginning to return to daily life; loss feels less acute and overwhelming Reinvest: accepting changes that have occurred; re-entering the world, forming o new relationships and commitments ● Worden (2008) views the tasks of grieving as: o Accepting the reality of the loss: it’s common for people initially to deny the loss; it’s too painful to acknowledge acknowledge f ully; ully; over time the person waivers between relief and denial in grappling with this task; traditional rituals, such as funerals and wakes, are helpful to some o Working through the pain of grief: a loss causes pain, both physical and emotional, that must be acknowledged and dealt with; attempting to avoid or suppress the pain may delay or prolong grieving process; intensity of pain and the way its experienced varies, but needs to be experienced to move on Adjusting to an environment that has changed because of loss: it may take o months for the person to realize what life will be after the loss; when a love one dies, roles change, relationships are absent or different, lifestyle may change, and the person’s sense of identity and self -esteem self -esteem may be greatly affected; feelings of failure, inadequacy, or helplessness at time are common; individual must develop new coping skills, adapt to the new or changed environment, find meaning in new life, and regain control over life to continue to grow; person can be in a state of arrest development and get stuck in mourning if this doesn’t occur o Emotionally relocating that which has been lost and moving on with life: the bereaved person identifies identifies a special place place for what what was lost lost and the memories; memories; the lost person or r elationship elationship isn’t forgotten or diminished; diminished; but relocated in mourner’s life as this person forms new relationships, relationships, friend, life rituals, and moves ahead with daily life ▪ Dimensions of Grieving: ● Cognitive Response of Grief: Loss disrupts if not shatters, basic assumptions about life’s meaning and purpose o o Grieving often causes a person to change beliefs about self and the world, such as perceptions of the world’s world’s benevolence, benevolence, the the meaning of life as as related to justice, justice, and a sense of density or life path



Questioning and Trying to Make Sense of the Loss: ▪ Grieving person needs to make sense of the loss ● Loss challenges old assumptions about life ● Searches for answers to why the trauma occurred ● Goal of search is to give meaning and purpose to the loss Questioning may help the person accept the reality of why someone died ▪ ● Questioning may result in realizing that loss and death are realities that everyone must face one day ● Finding spiritual meaning or explanations can be a source of comfort as people progress through the grieving process that serve to keep the lost one present Attempting to Keep the Lost One Present: belief in an afterlife and the idea that o the lost one has become a person guide are cognitive responses that serve to keep the lost one present Emotional Response of Grief: o Anger, sadness, and anxiety and the predominant emotional responses to loss Feeling of hatred and revenge are common when death has resulted from extreme o circumstances, such as suicide, murder, or war o A common first response to the news of a loss is to be stunned, as though not perceiving reality Eventually reality begins to set in, the grieving person may express irritability, o bitterness, and hostility hostility toward clergy, clergy, medical medical providers, providers, relatives, relatives, comforters, comforters, and even dead person; grieving person may interpret sounds, sights, and smells associated with the lost one as signs of the deceased presence, which may intermittently intermittently provide comfort and ignite hope for a reunion As the bereaved person begins to understand the loss’ s permanence, they o recognize that patterns of thinking, feelings, and acting attached to life with the deceased must change o Eventually, the bereaved person begins to reestablish a sense of personal identity, direction, and purpose for living Spiritual Response of Grief: Closely associated with the cognitive and emotional dimensions of grief are the o deeply embedded personal values that give life meaning and purpose to life o Grieving person may become disillusioned disillusioned and angry with god or other religious figures or members of the clergy Anguish of abandonment, loss of hope, or loss of meaning can cause deep o spiritual suffering o Providing opportunitie opportunitiess for clients to share their suffering assists in the psychological psychological and spiritual spiritual transformation transformation that can can evolve through through grieving Behavioral Response of Grief: Grieving person may function “automatically or routinely without much thought, o indicating that the person is numb- the reality of the loss has not set in o Person actually may call out for the deceased person or visually scan the room for them o Seeking out as well as avoiding places or activities once shared with the deceased, and keeping or wanting to discard valuables and belongings of the deceased illustrate fluctuating emotions and perceptions of hope for reconnection o Drugs or alcohol abuse indicate a maladaptive behavioral response to the emotional and spiritual despair Suicide and homicide may be extreme responses if the bereaved person cannot o move through the grieving process o

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Physiologic Response Response of Grief: Those grieving may complain of insomnia, headaches, impaired appetite, weight o loss, lack of energy, palpitations, indigestion, and any changes in the immune and endocrine systems o Sleep disturbance are among the most frequent and persistent bereavementassociated symptoms Discuss universal and culturally specific mourning rituals ▪ African Americans: deceased viewed in church before curial in cemetery; public prayers, black clothing, decreased social activities ▪ Muslim Americans: five steps of burial procedure including washing, dressing, and position of the body ● First Step: traditional washing of the body by a Muslim if the same gender ▪ Haitian Americans: practice vodun (voodoo) also called “root medicine” the practice of calli ng on a group of spirits whom one periodically makes peace during specific events in life; seen in Alabama, Louisiana, Florida, North Carolina, South Carolina, Virginia, and some communities in New York ▪ Chinese Americans: strict norms for announcing death, preparing body, arranging funeral and burial, mourning mourning after after burial ● Bowls of food on table for the spirt for 1 year after death ▪ Japanese Americans: death as life passage; bathing with warm water and dressing in whit kimono after purification rites ▪ Filipino Americans: black clothing or armbands; wreath on casket; black cloth on home of deceased ▪ Vietnamese Americans: bathing deceases and dressing in black clothing; rice in mouth and money so deceased can buy a drink as the spirit moves on in the afterlife; display of body for viewing in home before burial ▪ Hispanic Americans: novena (9-day devotion, prayers) and Rosary (devotional prayer); luto (mourning) by wearing black or black and white while behaving in a subdued manner ▪ Native Americans: Americans: tribal tribal medicine medicine man or priestly healer; baptism ceremonies ceremonies to help ward ward off depression of the bereaved; end of mourning with ceremony at burial grounds with grave covered with blanket or cloth later given to tribe member ▪ Orthodox Jewish Americans: relative staying with w ith dying person so the soul doesn’t leave the body while the person is alone; alone; body covered covered with sheet; sheet; eyes eyes closed; closed; body should should remain covered and untouched until family, rabbi, or Jewish undertaker can begin rites; organ donation allowed, autopsy isn’t unless u nless required by law; burial with 24 hours of death unless Sabbath; Shivah (7-day period begins on the day of the funeral, represents time for mourners to step out of day-to-day life, and reflect on the change that occurred) Discuss disenfranchised grief ▪ is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially ▪ Circumstances that can result in disenfranchisd grief include: ● A relationship that has no legitimacy. Same-sex relationships, cohabitation without marriage and extramarital affairs o are some examples. ●

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● The loss itself is not recognized. Other losses not recognized or seen as socially significant include prenatal death, abortion, relinquishing a child for adoption, death of a pet, or other losses not involving death such as loss of a job, separation, divorce, and children leaving home. ● ●

The griever is not recognized recognized



Older adults and children expereicen limited social recognition for their losses and the need to mourn. As people grow older, they "should expect" others their age to die. Adults see their children as not understanding or comprehending. CHildren may experience the loss of a "nurturing parental figure" from death, divorce, or family dysfunction such as alcoholism or abuse. ● The loss involves social stigma Death of someone incarcerated or executed for crimes carries a social stigma that o often prevents family members from publicly grieving or receiving receiving support for their loss. Identify factors that increase a person’s susceptibility to complications related to grieving. ▪ Low self-esteem ▪ Low trust in others ▪ A previous psychiatric disorder ▪ Previous suicide threats or attempts ▪ Absent or unhelpful family members ▪ An ambivalent, dependent, or insecure attachment to the deceased person o

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Discuss factors that are critical to integrating loss into life. ▪

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Apply the nursing process to facilitate grieving for clients and families. f amilies. ▪


Chapter 10 Grief and Loss

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