Bereavement

Question 1

Definition: Bereavement

Answer 1

• State of loss resulting from death

Question 2

Definition: Grief

Answer 2

• Emotional response associated with loss

Question 3

Definition: Mourning

Answer 3

• Process of adaptation to loss, including the cultural and social rituals prescribed as accompaniments

Question 4

Definition: Anticipatory Grief

Answer 4

• Grief that precedes the death and results from the expectation of the loss

Question 5

Definition: Pathological grief

Answer 5

• Abnormal outcome involving psychological, social, or physical morbidity, including complicated grief

Question 6

Definition: Disenfranchised grief

Answer 6

• Hidden sorrow of the marginalized where there is less social permission to express many dimensions of loss

Question 7

Attachment Theory and Grief

Answer 7

• Development of close affectionate bonds to particular others generates security and survival potential
• Spouse eventually replaces parents as the recipient of the strongest bonds
• In grief, the bonds of close relationships are severed

Question 8

Psychodynamic Theory and Grief

Answer 8

• Emphasis on the development of the person, with childhood and early life influences, that lays down a template to guide the emotional experience of future relationships
• Mourning recognised as a lifelong mechanism of adaptation to cope with trauma in life

Question 9

Interpersonal Theory and Grief

Answer 9

• Relational influences from the past influence grief

- Schemas of ‘who the self is’ establish a role for the individual in relationships, which is then altered in loss

Question 10

Psychosocial Transition Theory

Answer 10

• Loss results in changed assumptive world view

- Meaning-making and reconstruction of a continuing bond help to reconfigure world view after loss

Question 11

Sociological model of bereavement

Answer 11

• Breaking of the bonds of a relationship is socially determined, and the ‘continuing bonds theory’ results in a sustained, ongoing relationship with the deceased

Question 12

Family Systems Theory of bereavement

Answer 12

• Family are the main source of support, with groups and networks there to counteract the social isolation following bereavement
• Family functioning determines outcome

Question 13

Characteristics of normal grief

Answer 13

• Somatic distress with numbness
• Preoccupation with sad memories of the deceased
• Guilt
• Anger
• Loss of the regular patterns of conduct
• Identification with symptoms of the deceased
• Emotional distress that occurs in waves

Question 14

Anticipatory Grief Presentation

Answer 14

• May be in anticipation of death of a family member, loss of function (and hence work, leisure activities, sense of certainty, etc.)
• Typically draws supportive family into a configuration of mutual comfort and closeness
• Periods of grief interspersed with phases of contentment and happiness
• Marker of risk for complicated grief

Clinician role:

• Encourage open sharing of feelings
• Saying goodbye as a process
• Create opportunities for reminiscence, celebration of life, expressions of gratitude, completion of unfinished business

Question 15

Role of the ‘death bed’

Answer 15

• Gathering of loved ones around a dying person may provide support for the patient and ease their own subsequent adjustment
• Ensure sensitivity and respect provided to family
• Clinicians can provide guidance and information regarding the dying process
• Facilitate religious rituals
• Offer time spent alone with the patient once deceased
• If indicated, consider discussion of autopsy

Question 16

Acute grief and time course of bereavement

Answer 16

1. Initial numbness and sense of unreality
2. Waves of distress as the bereaved suffer intense pining and yearning
3. Phase of disorganization as loneliness sets in
4. Phase of re-organization and recovery as nostalgia replaces sadness, morale improves, and altered world view is constructed

Time course is generally proportional to the strength of the attachment

Question 17

Complicated Grief

Answer 17

• Termed “Persistent Complex Bereavement Disorder” In DSM-5
• Lasts at least 12 months following death of a close individual
• Intense yearning or longing for the deceased
• Intense sorrow and preoccupation with the deceased more days than not
• Out of proportion with cultural norms
• Significant impairment in social, occupational, or other important functioning
• Not better explained by another mental disorder
• Also associated with non-acceptance of death, intense anger, diminished sense of self, feeling that life is empty, indecisiveness about the future

Identification with “Inventory of Complicated Grief”

Question 18

Risk factors for development of complicated grief

Answer 18

• History of childhood neglect or abuse
• Traumatic or unexpected loss
• Intimate relationship with deceased
• Limited support following death

Question 19

Chronic grief

Answer 19

• Often related to an overly dependent relationships in which a sense of abandonment is avoided by memorialization and maintenance of continuing bonds
• Fantasy of reunion via suicide
• Social withdrawal and depression

Question 20

Comorbid complications of grief

Answer 20

• Depressive disorders (peaks in first 2 months, 16-50%)
• Anxiety disorders (adjustment disorder, GAD, phobic states, up to 30%)
• EtOH or substance abuse (typically exacerbation of pre-existing disorder)
• PTSD (mostly with unnatural deaths, causes felt to interfere with dignity, profound disfigurement, inability to say goodbye)
• Psychotic disorders (may precipitate relapse of Bipolar DO or schizophrenia)

Question 21

Risk factors for pathologic grief

Answer 21

1. Nature of the death
   - Untimely (e.g. childhood death)
   - Sudden and unexpected
   - Traumatic
   - Stigmatised (e.g. suicide, AIDS)
2. Strengths and vulnerabilities of the carer/bereaved
   - History of psych disorder
   - Personality and coping style
   - Cumulative experience of losses
3. Nature of relationship with the deceased
   - Overly dependent
   - Ambivalent (e.g. angry, insecure, EtOH abuse, infidelity)
4. Family and support network
   - Dysfunctional (poor cohesiveness, high conflict)
   - Isolation (new migrant, new relocation)
   - Alienation (perception of poor support)

Question 22

Bereavement follow up by the team

Answer 22

1. Expression of condolences via telephone, sympathy card, visit by RN or GP, staff attendance at funeral, subsequent family invitation to periodic commemorative service
   - Normalises grief
   - Provides encouragement and support
2. Further follow up for those felt to be at greater risk
   - Bereavement coordinator follow up
   - GP follow up

Question 23

Types of bereavement therapiest

Answer 23

1. General supportive aids
   - Assistance in expression of feelings, sharing of photo albums or letters
   - Children may make a scrap/photo book
2. Supportive-expressive therapy
   - Sharing of distress in the context of a supportive relationship
   - Acknowledgement that some shift in cognitive appraisal of life has occurred
   - Requires acceptance of loss, working through pain of grief, adjusting to new environment without the deceased, and establishing a collection of positive memories for future references
3. Interpersonal psychotherapy
4. CBT
   - Behavioural approaches to regulate exposure to cues inducing sadness, optimizing socialisation, cognitive reframing
5. Family-focussed grief therapy
   - Invites family to identify and agree to work on aspects of family life that is recognised as a cause of concern
   - Enhances cohesion and adjustment