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Module 2: Grief & Coping

Part 1: The Dying Process

Trajectories of Dying (Glaser, Strauss, & Benoleil (1966, 1968)

• Considered caregivers predictions of certainty of death and timing of death

• Four types of death expectation based on certainty and time: • Certain death at a known time • Certain death at an unknown time • Uncertain death but a known time when certainty will

be established • Uncertain death and an unknown time regarding

when the question will be resolved

Awareness Contexts

• Closed Awareness: when the person who is dying doesn’t realize it

• Suspected Awareness: person may begin to suspect their situation

• Mutual Pretense: everyone knows, but no one shares or communicates regarding the knowledge of death

• Open Awareness: willingness to discuss the fact that death is near

Stages of Dying by Kubler-Ross • Example of Western Theory of Dying • Five stages

• Denial – “It can’t be true.” • Anger – “Why me?” • Bargaining – “If you just let me live I promise I will

________.” • Depression – The person is less responsive and

thoughts are pervaded by a sense of loss • Acceptance – A final state of rest and letting go, void

of feelings and emotions

Shortcomings of Stage Theory, Applied to the Stages of Kubler-Ross • The existence of the stages has not been demonstrated • No evidence has been presented that people actually do

move from Stage 1 through Stage 5 • The limitations of the method have not been

acknowledged • The line is blurred between description and prescription • The totality of the person’s life is neglected in favor of the

supposed stages of dying • The resources, pressures, and characteristics of the

immediate environment can also make a tremendous difference

Copyright © Allyn & Bacon 2007

Corr’s Developmental-Coping Model of the Dying Process • Primary focus: empowerment for the dying

person and those who are intimately involved in caregiving

• Four challenges • Physical – satisfy bodily needs, reduce stress) • Psychological – feeling secure and in control • Social – keep attachments to individuals, groups and

causes • Spiritual – meaning, connection, transcendence, and

hope

Phases of Dying • The Pre-diagnostic phase – many will ignore

indicators of dying • The acute phase – try to understand the disease

and cope • The Chronic Phase : managing symptoms,

prevention and management • Recovery Phase- If death does not occur, coping

with the crisis • Terminal Phase-new decisions such as

preparing for death, discontinuing interventions, face ongoing challenges

Partial Models of the Dying Person’s Situation • Restricted Activity • Limited Energy • Damaged Body Image • Contagion • Disempowerment • Attributional

Incompetency • Ineffectuance • Stress Response

Overload • Time Anxiety

• Performance Anxiety • Loss and Separation • Disengagement • Journey • Closing the Book • Endangered Relationship • Struggling Brain • Storying

GRIEF, BEREAVEMENT & MOURNING

Part 2

Defining Terms: Bereavement • An objective fact:

• We are bereaved when someone close to us dies • “Close” is not easily defined

• A change in status: • Such as when a child becomes an orphan, a wife

a widow, a husband a widower • An outcome of a large-scale social phenomena:

• Those surviving a natural disaster or a war

Defining Terms: Grief • Grief is one response to bereavement; how one survives • Grief affects all spheres of life

• On a physical level • Acute grief: tightness in throat, shortness of breath,

lack of muscle power, empty feeling in abdomen • Prolonged stressor: Increased risk of cardiovascular,

infectious, & inflammatory disorders, & weakened immune system

• On a personal and interpersonal level • Confusion, attention, concentration, memory, anxiety,

and rage which may repeatedly return in waves

Defining Terms: Mourning • Mourning is the culturally patterned expression of the

bereaved person’s thoughts and feelings • Can reflect local, regional, national, ethnic, and

religious cultures at particular points in history • Examples:

• During World War I widows dressed in black with veils covering their heads

• During World War II families put a gold star in their window if they had lost a loved one

Types of Grief • Normal Grief – stays within the bounds of a particular

culture • Complicated Grief – once called “pathological” or

“abnormal,” the most common feature is that the bereaved person does not move from the shock and pain of loss toward a return to a fulfilling life

• Traumatic Grief – severe and disabling responses to sudden and often violent death

• Anticipatory Grief – how people cope with expected loss

Types of Grief • Resolved Grief – movement toward recovery from the

most debilitating effects of grief • Unresolved Grief – the debilitating effects of grief have

continued longer than would be expected (difficult to define)

• Hidden Grief – hiding any signs of grief in order to appear as “normal” as possible

• Disenfranchised Grief – occurs when society does not recognize a person’s right to grieve. Examples: health care professionals, foster parents, gay partner

Examples of Disenfranchised Grief • The grieving individual is not regarded as having the

right to grieve (at this time or under these circumstances) and must keep the sorrow hidden • When at work, school, or in public places • Nurses and caregivers • Lover or companion of an AIDS victim • When the lost companion was an animal • When the loss was a stillborn baby • When the bereaved person or the individual who died is

developmentally disabled

Freud’s Grief-Work Theory • Grief is an adaptive response to loss • The work of grief is difficult and time-consuming • The basic goal is to accept the reality of death and

thereby liberate one’ self from the strong attachment one had to the “lost object”

• Grief-work is carried out through a long series of confrontations with the reality of the loss

• The process is complicated by the survivor’s resistance to letting go of the attachment

• Failure results in continued misery and dysfunction

Interpersonal Applications of Grief-Work Theory • Bowlby’s Attachment Theory

• Our basic goal is to maintain the security provided by the significant relationship

• Stress comes as we try to re-establish the lost relationship

• In grief-work we must overcome our attachment • Parkes’ Three Basic Components of Grief-Work

• Preoccupation with thoughts of the deceased person • Repeatedly going over the loss experience • Attempts to explain the loss

Other Theoretical Approaches • Rando’s Task Theory

• Accept the loss • React to the separation • Remember and re-experience the lost person and

relationship • Give up the attachment to the person and the life

that used to be • Move into the new life but remember the old • Reinvest emotions and energies in other

relationships and activities

Other Theoretical Approaches • Stage Theories (such as Kubler-Ross)

• Most agree on the beginning and ending points, but the middle stages vary by theory

• Little independent evidence to verify the application of universal stages to the grieving process

• Dual-Process Model (Stroebe and Schut) • Must work on both:

• Emotional working through the grief • Adapting to roles and situations in the altered world

Other Theoretical Approaches • Integrated Individual-Family Model (Moos)

• Considers symptoms of family grief, such as family isolation, confusion in family roles, changes in who talks to whom, and cut-off, reconnection or overprotection of certain family members

• Evolutionary Biology Model of Grief (Archer) • Views grief in all mammals and social birds • Views social bonds as advantageous for survival, but

grief as maladaptive

How Do People Recover? Spousal Bereavement • Immediate Impact of Spousal Bereavement

• Most women experienced anticipatory grief • After the death women felt a sense of abandonment • After the death men felt a sort of dismemberment

• Emotional & Physical Reactions Soon After Bereavement • Physical symptoms lingered for weeks (pains, poor

appetite, loss of stamina, headaches, dizziness) • Women had trouble at night, wanted someone to rely on,

and felt the situation was “not fair” • Men felt guilty and were less likely to express emotions

How Do People Recover? Spousal Bereavement • Leave-Taking Ceremonies

• Women found them important and helpful • Men found them less important and too expensive

• Grief and Recovery: The Widow’s Response • Obsessional reviews of the circumstances • Tendency to idealize the husband • Strong sense that he is still with her

• Grief and Recovery: The Widowers’ Response • Cuts off obsessional reviews quickly • Faster social recovery, slower emotional recovery

How Do People Recover? Spousal Bereavement • Types of Recovery

• People who did not have the opportunity to prepare for the spouse’s death suffered more distress

• Time by itself will not facilitate recuperation • Those who were most disturbed a few weeks after the

death usually were the ones who continued to be disturbed a year later

• The quality of the marital relationship influences the grief and recovery process

How Do People Recover? Spousal Bereavement • Three Types of Unresolved Grief

• The unexpected grief syndrome (when death comes without warning, leaving disbelief and intense anxiety)

• The conflicted grief syndrome (when death occurs in a troubled relationship)

• The chronic grief syndrome (marked by dependency on deceased spouse)

• Psychosocial Transition • Vulnerable place of change • Rites of passage can be helpful

The Family That Has Lost a Child: Perinatal Death • Perinatal death – 20 weeks after conception to one month

after birth • Health care systems are more responsive • Shadow grief – stays with parents for years (like a shadow) • Contact the “inner representation” of the dead child may be

experienced for years (keeps parents’ worldview intact) • Memories, hallucinations, a presence or incorporation of

the child’s characteristics into their own personalities • Most surviving parents do not divorce • Grandparents grieve as well

Bereavement in Later Life • Most older adults cope as well as anyone • Some deal with bereavement overload

• Accumulation of experience with many losses (family, friends, pets, lifestyle)

• Risk of illness and death increases following the death of a loved one (often within 6 months) • Risk is greater for widowers than widows • Risk is greatest for young adult widowers • Higher risk for violent death and suicide • Stress of grief can weaken immune system

Meaningful Help for Bereaved People • Silverman established the Widow-To-Widow Program

prior to the development of professional grief counselors or peer-support groups • Grief does not have a final outcome • Grief can most usefully be regarded as a life transition • People can help each other

• Helpful things to say to the bereaved • “He/she will always be alive in your memories.” • “I’m here if you need somebody to talk to” • “Tell me how you are feeling”

COPING WITH DEATH

Part 3:

What is coping?

• Emotional reactions to stressful situations • Cognitive and behavioral efforts to manage

external or internal demands

Types of Coping

• Appraisal-focused coping: how one understands a stressful situation

• Emotion-Focused Coping: Trying to control one’s emotional reactions to the stressful situation

• Problem-Focused Coping: Managing or remedying the distressing situation

• Religious-based coping: Using God or a higher power to help understand and react to stressful situations (ie turning to God, working through with God’s help)

Who Copes?

• The dying person • Family members and friends • Caregivers