Bereavement

Question 1

How is grief made sense of in the context of attachment?

Answer 1

The defining characteristic of grief is pining for a loved, but now absent, person

It arises in the course of the attachment to a parent figure, usually the mother, in the first year of life in the form of separation distress

It can best be seen as the emotional accompaniment of an urge to search for the lost person - continuing even after death and other permanent losses despite the cognitive awareness that the search is forlorn

Although separation distress is evident in all social animals, it is modified by learning from the outset and influenced by parenting, gender, and other social and cultural influences - this explains the wide variation in the expression of grief

Question 2

What is the dual process theory of grief? (Stroebe & Schut, 2002)

Answer 2

Two processes:

1) Loss process - episodic ‘pangs’ of grief = bereaved person preoccupied with memories of the loss event + the person - experiencing intense separation distress; triggered by reminders of the loss and peak within a few hours of bereavement, though they can be delayed
2) Restoration process - longer periods of ‘calm’ when bereaved individual can function; in time, person begins ‘psychosocial transition’ as they become aware of those aspects of their ‘assumptive world’ (the world they assume exists) that must change and those that remain

Individuals grieving oscillate between these two processes, each with reduced frequency and duration as time progresses

Problems arise if either process is carried out to the exclusion of the other e.g. when grief is intense, prolonged and continuous or inhibited, avoided and delayed

Question 3

How does grief present?

Answer 3

Separation distress
Feelings of tension, anger and self reproach

A comforting sense of the presence of the lost person, dreams of reunion, hypnagogic hallucinations of the deceased - these illusions do not necessarily decline with time, memories may even become more clear

The sense of a ‘continuing bond’ - not regarded as denial; only damaging if these perceptions are prioritised over the persons daily existence e.g. care of their children

Negative feelings tend to decline with time

The majority of people are sufficiently resilient to cope without the need of specialist input outside the need of family and friends

Question 4

What neurophysiological changes are apparent in grief?

Answer 4

Brain areas activated by grief triggers (names/photos):

• Posterior cingulate gyrus
• Cerebellum
• Medial/superior frontal gyrus

Therefore grief is mediated by a distributed neural network serving:

• Visual imagery
• Autonomic regulation
• Memory retrieval
• Affective processing of familiar faces
• Modulation/coordination of these functions

Question 5

What immune changes are seen in grief?

Answer 5

Transient impairment of the function of B and T lymphocytes and natural killer cells

Question 6

How does bereavement impact on physical health?

Answer 6

General:

• Increased visits to doctors
• Increased hospital admissions
• Increased costs of health care
• Increased mortality esp. in first 6/12 after loss of spouse/child, due to expediting of CV disease deaths, more marked in men

Specific: increased risk of

• Cancers
• Cardiovascular disease
• Hyperthyroidism
• Psychosomatic disorders

Question 7

How does bereavement impact on mental health?

Answer 7

Non-specific:

• Anxiety disorders (23-39%)
• Major depression (14-45%) +/- increased risk of suicide
• Panic disorders (6-13%)
• Alcoholism

Specific:

• Complicated grief disorders (10-15%)
• PTSD (most often from deaths where feelings of intense fear/helplessness/horror arise)
• Diagnosis + treatment is no different in these circumstances than in any other
• Recovery is expected and many people eventually become more caring and emotionally mature following bereavement

Question 8

What is a prolonged grief disorder?

Answer 8

A type of complicated grief reaction:

• Typical features of grief reaction - sense of self as empty/confused, trouble accepting loss as real, avoidance of reminders of the loss, inability to trust others since the loss, extreme bitterness or anger relating to loss, difficulty moving on, pervasive numbness, feeling that life is empty, feeling stunned or shocked by loss
• Lasting at least 6/12
• Causing significant impairment across multiple areas
• Most common complicated grief reaction to be met in clinical practice
• May come on immediately after the death or onset might be delayed
• Distinct from major depression but highly comorbid (up to 56% of cases) + increased alcohol consumption, poor sleep, suicidal ideation, increased risk of CV events and cancer

Question 9

What are some other potential features of complicated grief reactions?

Answer 9

Hypochondriacal disorders where bereaved develops symptoms resembling illness of person who has died = identification reactions

Reactions of anger or guilt that are disproportionate to the facts of the situation and may approach delusional intensity

Question 10

What demographic factors affect someones reaction to bereavement?

Answer 10

Age:

• Children who lose a parent are at an increased, lifetime risk of problems
• Most elderly people cope very well - including with the sudden but timely deaths of their peers; though the elderly also are at greater risk of loneliness/depression

Gender:

• Women are more likely to seek help and are more likely to return to baseline psychosocial functioning sooner compared to men
• Men are often the ones to inhibit their expressions of grief e.g. not crying

Culture:

• Some religions and cultures have specific ‘acceptable’ methods of grieving that might be helpful or detrimental to recovering
• At time of war and in a culture where soldiers are expected to be ‘strong’ - grief tends to be inhibited
• In the West - loss of a child usually gives rise to the most intense and lasting grief (especially mothers of young children); in other societies with larger families where children are more likely to die, grieving isn’t as intense

Question 11

How does attachment affect the grief response?

Answer 11

Attachment bonds are not easily relinquished - security here protects against effects of trauma and loss

Severe reactions to the loss of a spouse often reflect intense, dependent or ambivalent attachments

Inhibited or delayed grief reflects avoidant attachment styles

Loss of a parent is most traumatic aged 1-5 years and in adolescence

Question 12

How does mode of death affect grief response?

Answer 12

Adults sought more psychiatric help when death was:

• Unexpected/sudden
• Multiple deaths
• Other factors e.g. witnessing violence/mutilation, continuing treats to life and situations where no body has been discovered, self-blame involved
• Suicide
• Murder

Question 13

What are some personal factors affecting grief response?

Answer 13

• Childhood attachment problems
• Dependent or interdependent relationships
• Ambivalent relationships
• Emotional inhibition
• Insecurity - low trust in self and others
• Previous mental illness/suicidal ideation
• Perceived lack of support from family (but also more likely to benefit from external support)

As grief reflects a loss of attachment - childhood (and thus adulthood) attachment styles will impact ability to manage the loss e.g. insecure attachments - separation anxieties in childhood and then adulthood - prolonged grief disorders following bereavement

Question 14

What is disenfranchised grief?

Answer 14

Doka, 1989

Bereaved people whose needs are easily overlooked:

• Children
• People with learning difficulties
• People in stigmatised or illicit relationships
• People with difficulties in expressing feelings

Question 15

What is does theories explain the components of the dual process model of grief?

Answer 15

Attachment theory:
- Can help explain the loss component of the dual process model

Constructivism and psychosocial transition theory:

• Can explain the restoration component
• Assumptive models of how the world works have to be reconstructed and assumptions replaced or new, more mature meanings discovered
• Therapists can be useful here to assist in this creative process

Question 16

Who is most likely to benefit from formal bereavement service input?

Answer 16

Most people are thankful for the help of bereavement services but it usually does little to improve mental health outcomes - family and friends are better/sufficient sources of support for most

Individuals with previous symptoms of psychiatric disorders + those with complicated grief processes have been shown to benefit more from services

Question 17

What types of help are available for bereavement?

Answer 17

Prevention:

• Bereavement support services e.g. in hospices, Cruse Bereavement Care
• Mutual help groups e.g. Compassionate Friends, Survivors of Bereavement by Suicide, Stillbirths and Neonatal Deaths Society, Support After Murder and Manslaughter
• Help lines e.g. Hope Again

Therapy:

• Individual psychotherapies (e.g. Shear’s complicated grief therapy)
• Family therapies (family-focused grief therapy)
• Group therapy
• Internet based services

Question 18

How is CBT used in grief?

Answer 18

• For any co-occuring diagnosable mental illnesses e.g. anxiety, depression (these will also respond to antidepressants but grief will not)
• CBT has been shown to be better than IPT for treating the ‘trauma-like symptoms’ of prolonged grief disorder

Question 19

What is the general function of individual therapies in grief?

Answer 19

A combination of the facilitation of emotional expression and co-construction of a new world view

• Emotional expression might be more relevant in those that are avoidant, including (typically) men - can bring important objects e.g. photos and carry out ‘unfinished’ conversations in role play

Question 20

What is the function of family therapy in grief?

Answer 20

As bereavement is usually felt by multiple people in one household - either directly relating to the loss of the deceased or more indirectly relating to the ‘loss’ of a family member to their grieving process e.g. a child might become neglected or a caregiver themselves

Particularly important for already dysfunctional families - but can be challenging/not work if members are hostile or avoidant

Aims to increase cohesiveness, open communication and problem solving - members encouraged to discuss the family as they see it, explore problems and emphasise assets and strengths