Theories relating to the grief process

Theories relating to the grief process Most theories of grieving derive from the works of Sigmund Freud and Eric Lindemanns understanding of mourning and include two assumptions: A / Grieving is time limited. The process should be completed or resolved after a year or two. B / The main task of grieving is to achieve decathexis (one should detach oneself from emotional ties to the deceased so as to be able to form new relationships.). Horacek, (1991). There are two complex processes taking place within this topic that we call Grief. Firstly there is the emotional side (grief) and can take on many obvious and subtle forms. Secondly there is the process or grieving stage as it is more commonly indentified. It is within this second stage that the bereaved is called upon and to allow them selves to make a raft of choices and decisions such as the funeral arrangements or when at some point do they allow themselves to decide what to keep as mementos and what not to. Often these sides can become entwined into one and the bereaved may end up in a state of confusion and stagnant response. This may lead to a third state in which the bereaved becomes dysfunctional within their grief processing and literally becomes stuck in whatever position or state they are in and cannot allow themselves release from that state and to move forward. Grief does not exist within the world of death only. Grief may come from many physical and psychological changes that are totally unrelated to death. Loss of a limb; incapacitation of body use as a result of an accident; loss of a boyfriend or girlfriend; loss of a marriage; bankruptcy; loss of a personal business. I could list more but the point is to say that grief covers an extremely wide and complex area of understanding and acceptance. For the purposes of this essay, I will concentrate upon the subject of death and how does one handle the situations of that death. I will cover various models as they relate to a child (0 11) and to that of an adolescent. Then, we will look at those of an older person and also take into account the elderly. How do the various models of grief and the process of grieving change with age? Are there stages of recovery or is the recovery a process that may never be finally finished? Either way, grief and grieving is a personal experience and will vary among ages, culture and background. It would become too involved for the purpose of this topic to introduce culture and background, so I will therefore keep this essay to the more general form of models of grief and their relationship to those of age. Does a child have the capacity to experience grief and to mourn as do adults? Bowlby (1963), and Fusman (1964), sees a child as capable of suffering major bereavement particularly with a close family member and probably with other close significant losses as well. In that reference, there were no given age ranges so I will take the point of a child being of 0 11 yrs of age. Lindemanns seminal study in 1944 on the Symptomatology and Management of acute grief is similar to Freuds understanding. But how does that apply to a child? Whilst Bowlby recognised a similarity to Freuds point of view, he also recognised that a young child is capable of suffering major bereavement as mentioned. But these responses can come from many influences. Obviously, they are different to those of an adult but none the less they (adults) do have an influence upon the childs perception and response to their ability to handle grief and grieving. It is suggested that a child will copy to the best of their ability, the grieving patterns of their remaining significant parent or even that of an older sibling (Bowlby, 1980; Kubler-Ross, 1983; Schumacher, 1984). Other factors can also have an influence on the childs response such as the nature and intensity of their attachment to the deceased; their developmental level; the capacity to understand what has happened (the conceptualisation of death and what explanations are given to them); and the nature and circumstances of the death. It is reasonable to assume that a child can experience a bereavement response, probably in an attenuated form death of a grandparent, parent, uncle, teacher, playmate, family pet or even the loss of a favourite toy. Ambivalence and dependence are core themes of a childs relationship with family members and a childs grief may be influenced by this aspect of their attachment to the deceased. Childrens conception of death closely parallel Piagets (1952) successive levels of cognitive development (Berlinsky Biller, 1982). For example, during the sensorimotor period (birth 2yrs), the childs concept of death is non-existent or incomplete (Kane, 1979). Most workers agree that the younger childs response, particularly to the death of a parent, is likely to be indistinguishable from that of separation response. For a child of 2 or younger, they do not have the concepts of time, finality or of death itself but they may show, if for instance their mother dies, typical phases of denial, protest, despair, and eventually detachment (Kastenbaum, 1967; Berlinsky Biller, 1982). During Piagets pre occupational period (2 6yrs), a childs cognitive development is dominated by magical thinking and egocentrism. Consequentially at this stage, they believe that death can be either avoided or reversed (Melear, 1973; Anthony, 1971; Stillion Wass, 1979). Furman (1963) believes that from 2 2 Â ½ years onwards a child is able to conceptualise death to some degree and to mourn. Melear found that children within this age group viewed the dead as having feelings existing in a life like state. Because of their thinking, the child may feel responsible for causing the death and consequently feel shame and guilt. Progressively, through the period of concrete operations (6 7yrs through to 11 or 12 years), children begin to understand the reality of death but do not realise that death is universal and that those around them, including their loved ones, will die some day (Berlinskey Biller, 1982). Anthony, (1971) suggested that children conceptualise death in concrete terms and view death as distant from themselves. Gradually, from ages 9 or 10, children acquire a more mature understanding of death; that death is irreversible in nature and that they themselves will eventually experience it (Anthony, 1971; Melear, 1973; Stillion Wass, 1979). A child will experience the developmental nature of death associations which progress from no understanding toward an abstract and realistic understanding of the concept of death (McCown, 1988). Within the years of adolescence, the persons understanding of death and what has happened; closely approximates that of an adult and their grief may take on similar forms. But because they are in that realm halfway between childhood and adulthood, their responses may fit neither mould. If they cry, they may be accused of being babyish. Equally, if they dont, they may seem cold and uninvolved. With so many conflicting areas and so many stressful situations of this age group, they may neither express their emotions directly nor verbalise them. They may instead, act out within their personal environment, indicating their need for care, their anger, their guilt and their longing. Although privy to increased knowledge about death through instant communication and increasing exposure to death, adolescents do not have the social or emotional maturity to fully incorporate and process those experiences into a coherent world view (Rowling, 2002). Adolescents tend to be more extreme in their risk taking and it seems to be the closer to the edge that they go, the greater the thrill of cheating death. Living life to the fullest inherently has some risks. Consciously or otherwise, they may pursue this ambiguity more than others, due to their cognitive development and the need for excitement (Spear, 2000). Emotional reactions to a loss can be devastating to the adolescent, whether the loss is the perceived detachment from parents, actual losses that are literal deaths such as the suicide of a friend; or metaphorical deaths such as the breaking up with a boyfriend or girlfriend. Meshot Leitner (1993), have observed that the extent of grief is often much stronger in teenagers than in adults. There is evidence that adolescents are constantly grappling with life and death contrasts as a normal part of their development (Noppe Noppe, 1991). These years help to construct a personal stamp with their understanding of death as they are engaging in both life affirmation and death acknowledgement. They are questioning and assuming different belief systems regarding death and the after life prior to settling onto a more permanent value system as well as incorporating the very reality of personal mortality into their evolving sense of identity. Adolescent grief experience is profoundly personal in nature. Although they grieve more intensely than adults (Christ et al. 2002; Oltjenbruns, 1996), their grief may be expressed in short outbursts, or there may be concentrated efforts to control emotions. They can often believe that their experiences are completely unique unto themselves (Elkind, 1967). The adolescent grief pattern may follow a life long developmental trajectory. That is, the loss may be continued to be felt throughout their life span as they graduate from college, their work, marriage and so on. This can be accentuated as they grow older than the parent, sibling or friend who has died (Silverman, 2000). Adolescents are more sophisticated than children in their understanding and response to death, but neither is their mourning adult like. The overall nature of the adolescents response is intimately tied to their developmental issues. The consideration of ones own death, as part of the treads of the totality of the life cycle, cannot be a comfortable notion for an adolescent to accept. Creating a unified sense of identity must be reconciled with this consideration. Adolescents encounter this dilemma in the context of a system of values, philosophy of life and particular spiritual or religious beliefs. Sterling and Van Horn (1989) found that adolescents who were at the peak of their struggle with identity formation, had the highest levels of death anxiety. With regard to personal characteristics or the adolescent, self esteem was found to be important in adolescents response to loss. Balk (1990) and Hogan and Greenfield (1991) found that adolescents with lowered self concept scores s howed more problems with their grief. More adolescent males than females die suddenly and violently, via accidents, homicides and suicides (Corr et al., 2003). However, no one knows if, as a consequence, teenage males grieve more than females over the loss of their same sex best friend. Parallels between the socialization of males into hiding emotions, being independent and displaying aggressive behaviour when upset are reflected in adolescent males grief reactions (Adams, 2001). Bereaved adolescent girls may express more adjustment difficulties (Servaty Hayslip, 2001), but this may be consistent with the latitude afforded women to talk of their feelings. Reaching out to others seems to be easier for females than males (Noppe et al., 2003). As mentioned earlier and in closing of this section, the myriad of adolescent tasks serve as a framework for how the adolescent is affected by grief and their response to loss is intimately tied to their developmental issues. Adolescents do not grieve in the same way as do adults and their grief processes may be more intermittent, intense and overwhelming. We began this essay with the generally accepted theory of mourning from the work done by Freud and Lindemann as cited by Horacek (1991). Whilst Freud did not officially modify his theory, he did modify it in a letter written to Swiss psychiatrist Ludwig Binswanger in 1929. In this letter he reflected on the death of his daughter in 1920 from influenza and the death of his grandson in 1923. He stated that although we know that after such a loss the acute stage of mourning will subside, we also know we shall remain inconsolable and will never find a substitute. Freud realised that some losses can never be fully resolved and that grieving can continue indefinitely for such potentially high grief deaths such as the loss of a child or a grandchild. Gorer (1965), described eight styles of grieving that fall into three categories based on the length of the grieving process. The first category includes grieving styles that demonstrating little or no mourning, such as the denial of mourning, the absence of mourning, anticipatory grieving and hiding grief. The second category is time limited mourning, which includes a period of intense grief followed by a return to the pre grief status. His third category is unlimited mourning, a continuing grief that does not radically interfere radically with everyday living; mummification, in which the mourner makes a room or a whole house as a shrine for the deceased; and despair, a never ending, deeply painful process. Adults view death through the lens of wisdom gained through the myriad of life experiences associated with expanded interactions with different people, work settings and family relationships. Whilst studies on parental and sibling grieving challenge the assumption that grieving is time bounded and that decathexis can and should be accomplished. In his interviews of some 155 families, Knapp (1986, 1987), found six significant similarities in the way in which families responded to the deaths of their children. The sixth was what he called shadow grief, a lingering, emotional dullness of affect that continues indefinitely, indicating that grief such as this is never totally resolved. He called shadow grief a form of chronic grief that moderately inhibits normal activity, yet it is an abnormal form of mourning that it was quite normal, perhaps even routine. In support of this finding, Lund (1989) stated that there is considerable evidence that some aspects of bereavement and subsequent r eadjustments may continue throughout a persons life and it might be appropriate to question the use of conceptualizing grief as a process which culminates in resolution, because there may never be a full resolution. Though death separates the mourner from the deceased, a relationship with the deceased continues. It is largely agreed that particularly with adults and the more elderly, the bereaved should regain everyday functioning within a two to three year period, but, also, that grief may never come to an end and can still be considered normal. Fulton (1978), produced a model that began to reflect the complicated reality of the grieving process. He put forward that in a high grief situation, three sets of reactions can be delineated: 1. Initial reactions. These can include numbness, shock and disbelief. These reactions could last for days, weeks or even months. 2. Grief tasks. These reactions may include such tasks as dealing with anger, guilt, emptiness, depression, ambivalent relationships and life reviewing. Working through these tasks can take months or years and in some cases can continue indefinitely. 3. Adjusting to the loss and continuing grieving. In addition, this model recognises that the three sets of reactions overlap and can recur and that the mourner could deal with one specific grief task such as resolving excess guilt and then face another grief task months later. Most important, this model recognises that the basic loss does not disappear like a wound that heals in time, but rather that the loss continues like an amputation or dismemberment. Likening grieving to amputation denotes the mourner must continually adapt and adjust to the loss. Although the griever can reach a new everyday functioning status, the loss and its concomitant reactions, for example shadow grief, continue indefinitely. In final conclusion, both the grief and grieving process is complicated and has many variable aspects to how one deals with the bereavement. Probably the most obvious is that the ability to handle bereavement lies in the cognitive developmental stage of the bereaved. This is probably more pronounced within the child and adolescent stages of life due to the aspects already discussed earlier. It is also of note that the elderly are more likely to experience multiple losses, such as the deaths of a spouse, friends, or relatives or the loss of roles, health, or income, over relatively short periods of time. At the same time, many older grievers are quite resilient and exhibit strong and effective coping abilities (Lund, 1989). An aspect of grief that was only briefly touched upon, was that of anticipatory grief. Such would occur during the period of extended terminal illness. Whether this type of grief assists the survivor or not, has not been really established. In some cases it can lea d also to confusion and subsequently, to a dysfunctional grief. In dealing with and assisting the bereaved caregivers need to be aware of the need to adjust their understanding of the grieving process relative to the age, gender and the situation with which the bereaved is finding them selves. Grieving is a complex emotional and active process and there are no simple answers nor are there simple repairs.