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Grief
Daniel Robitshek, MD
Professor of Medicine
UC Irvine Medical Center
Hospitalist Program
Death is a fearful thing.
William Shakespeare
Death! thou comest when I had thee least in
mind!
Unknown
While grief is fresh, every attempt to divert only
irritates. You must wait till it be digested, and
then amusement will dissipate the remains of it.
Samuel Johnson
Every death
has a life of its own…
Grief
“Grief is neither a disorder nor a healing
process: it is a sign of health itself, a whole and
natural gesture of love. Nor must we see grief as
a step towards something better. No matter
how much it hurts – and it may be the greatest
pain in life – grief can be an end in itself, a pure
expression of love.”
Gerald May, MD
The Grieving Process
“…restoring the fit
between the world that
is and the world that
should be…”
(Reference: Parkes, Colin M. Mortality: Virtual Themed Issue, 2003)
Loss Defined
Loss is the experience of parting with an object,
person, belief, or relationship that one values.
Losses are encountered daily by each of us.
The experience of loss must be defined broadly and with a clear
understanding of the personal pain and disruption that can accompany it.
Losses can be minor or major.
The designation of “minor” or “major” depends upon the perception
of the loss by the person experiencing the loss.
The impact of loss depends upon the value the person placed on what
was lost.
Language of Loss
Bereavement – the state of having experienced loss
Mourning – the private and public processes, rituals
and practices to loss
BEREAVEMENT
“Bereavement is darkness
impenetrable to the imagination
of the unbereaved.”
Iris Murdoch 1919-1999
Types Of Loss
Tangible (actual or physical) losses are apparent and
easily recognized:
Loss of a body part.
Changes in physical health.
Loss of a loved one.
Intangible (perceived or psychological) losses are less
obvious:
May be tied to personal perceptions such as one’s prestige, power, dreams, plans,
security, etc.
Because these losses are less likely to be acknowledged, admitting to the
accompanying feelings of loss can be difficult or embarrassing.
Consequently, emotional support may be inadequate.
What is Grief?
Multidimensional result of/response to loss
Emotional
Physical
Cognitive
Behavioral
Why Do We Grieve?
Attachment theory – Bowlby
Attachment occurs in absence of the reinforcement
of biological needs (e.g. food)
Based on need for safety and security
Observed in animals and humans
Develop early in life, are directed toward a few
specific individuals and tend to endure
Grief occurs with the loss of the attachment bond
Why Do We Grieve?
Reestablish equilibrium – Worden
Mourning is necessary
After a loss is sustained, a healing process is
necessary to re-establish equilibrium
Surviving the Loss:
The Grieving Process
The dual process model of coping with
bereavement (DPM) lists two types of stressors.
Loss-oriented stressors- those having to do with the
loss itself.
Restoration-oriented stressors- those related to
adapting to the survivor’s new life situation.
Dual Process Model
Restoration
Loss Oriented
Oriented
Dealing with the
Involves the many life changes
emotional and and new roles that
reactive processing are brought about by
of the loss the loss
Oscillating between these stressors
(Reference: Stroebe and Schut, 1999)
Emotional Response to Loss
Anger
Frustration with helplessness to change the situation
Regressive experience
Guilt and self-reproach
Anxiety
Fears about not being able to take care of oneself after the loss
Heightened sense of own mortality
Loneliness
Fatigue
Helplessness
Shock
Yearning
Emancipation
Relief, especially after the dying person has suffered during a lengthy illness
Numbness
Physical Response to Loss
Tightness in chest and throat
Hollowness in stomach
Heightened sensitivity to noise and light
Depersonalization
Breathlessness
Weakness
Lack of energy
Dry mouth
Cognitive Response to Loss
Disbelief
Disorientation
Confusion
Preoccupation
Sense of presence (feeling that the deceased is in
the room or close by)
Hallucinations
Behavioral Response to Loss
Sleep and appetite disturbances
Social withdrawal
Dreams of the deceased
Avoiding reminders of the deceased
Searching or calling out for the deceased
Sighing
Restlessness
Crying
Visiting places or carrying objects that remind one of the
deceased
Treasuring objects of the deceased
Depression and Normal Grief
Full depressive reaction may accompany normal
grief response
Grief does not include the loss of self-esteem,
overall sense of guilt
Grief may develop into depression
What Determines the Intensity and
Duration of Grief?
Intensity is highly variable; may continue for months to several years
Dependant upon
Type of loss
Nature of the attachment
Strength of attachment – intensity of grief proportionate to the intensity of the relationship
Security of the attachment – how necessary was it for a sense of well-being of the survivor
Ambivalence – coexisting positive and negative feelings
Mode of loss
Natural, accidental, sudden/unexpected, expected, intentional, traumatic
Historical antecedents
Experience of earlier losses
History of depression
Previous stresses
Personality variables
Coping resources and styles
Psychological resilience
Optimism
Social and cultural factors
Traditions and rituals; social netword
What are the Tasks of Grief?
Accepting the reality of the loss
Denial impedes this task
Disbelief that the loss has occurred
Denial of the meaning of the loss
Denial that death is irreversible
Acceptance must include understanding that the loss
has occurred and/or the death is irreversible
What are the Tasks of Grief?
Experience the pain of grief
Social expectation may make resolution of this
difficult
Others may try to distract the bereaved from the pain
Ways of not experiencing affect
Over involvement in work
Idealizing the loss
Geographic cure
Minimizing the significance of the loss
What are the Tasks of Grief?
Adjusting to an environment in which the
loss/deceased is missing
Taking on new roles, developing new skills
If not resolved, helplessness may occur
Survivor may not be aware of all the roles filled by
the deceased until the loss occurs
What are the Tasks of Grief?
Withdraw emotional energy and reinvest it in
another relationship
Many people misunderstand this task and are unable
to work through it
Some people believe that to reinvest emional energy
in someone else is to dishonor the dead
Fear of the prospect of experiencing new loss may
impede the successful working through to this loss
What are the Stages of Grief?
Elizabeth Kubler-Ross (1969) suggested grief be seen as
occurring in five stages
Denial and isolation
Anger
Bargaining
Depression
Acceptance
Stage concept has been criticized, but framework is
valuable
Most people do not progress through the stages in a systematic way or in a
specific order
All people will experience a variety of emotions which change over time
NATURAL GRIEF: INSTINCTIVE
BIOBEHAVIORAL RESPONSE
BEREAVEMENT
Acceptance
PRIMARY GRIEF Positive emotions
Traumatic Distress Forgiveness, Compassion
Meaning-making
INTEGRATED
Separation Distress
GRIEF
Guilt ? ~ 6 months
Social withdrawal Permanent background state
Bittersweet memories that are
accessible and changing
Transient, dominant state
Painful and preoccupying
How is Grief Resolved?
Impossible to place a time limit: may be long
term with close attachment (one year or more)
A process
Grief work – the mental and behavioral processing
of the loss
Gradual evolution of thoughts, emotions and
experiences toward greater acceptance of the loss
and emerging ability to resume life
THE ROLE OF PHYSICIANS
Educate
Normal and natural grief processes
Range of different feelings (positive and negative)
Assess progress and prognosis
Physical and mental health
Life context
Support
Condolence letter
Active listening
Link to local resources (spiritual, support groups,
counselors)
“…physicians who aid grief-stricken patients are
afforded the rewarding, quintessentially human
opportunity of transforming a personal sorry
they inevitably will experience into sympathetic
and supportive aftercare.”
Prigerson and Jacobs JAMA 2001
Nine Ways to Help with Grief*
1. Increase the reality of the loss
2. Allow time and place for the expression of feelings
3. Normalize feelings
4. Reality test
5. Help with problem solving as survivor adjusts to an
environment without the deceased
6. Discourage major life decisions too soon
7. Encourage healthy reinvestment of emotion
8. Allow for individual differences
9. Provide continued support
*Worden, 1989; Rando, 1984; Cook & Dworkin, 1992; Bertman, 1991
1. Increase the Reality of the Loss
Talking and traditions help
Especially important early after the loss
Provide ways to allow family members to say goodbyes at the
bedside, before death when possible
Encourage family members to provide care for the dying person
and recognize their contributions (all can say that they were there
and did as much as was possible)
Encourage and support the family as they follow cultural and
social traditions and rituals
Express sympathy
Listen to family members talk about the deceased and their
experiences grieving
Encourage reminiscing
2. Allow Time and Place for the
Expression of Feelings
Provide for a quiet room free of distractions, offer
tissues
If appropriate, given the person’s culture and the social
situation, a touch on the shoulder or hand may provide
a tangible gesture of concern and support
Make telephone available for family members to
contact significant others
Verbal permission to grieve or express emotions and
thoughts
Listen without judgment
3. Normalize Feelings
Especially important when the bereaved feels
anger or relief with the loss (or other emotion
that may be perceived as inappropriate)
Let person know that ambivalent feelings are
normal and common
Very important not to minimize feelings
4. Reality Test
Help the bereaved person understand difficult
feelings in the context of the situation
Example
47 yo who expresses feeling of relief and resultant
guilt after death of parent from long illness in which
she was the primary caregiver
5. Help with Problem Solving as Survivor Adjusts
to an Environment Without the Deceased
Practical discussion of new roles and
responsibilities for survivor
Help survivor break down tasks into small steps
that can be accomplished
Identify sources of support in community
Referral to social service, financial advisors,
counselors
6. Discourage Major Life Decisions
Too Soon
Making major life decisions early in the grieving process
may be counterproductive or even harmful
Moving, marriage, pregnancy, change in employment
When is it “too soon”?
Experience of intense, fresh grief
Difficulty accepting the paing and reality of the loss
difficulty starting new activities without the deceased
Complicated grieving
Nine Ways to Help with Grief
7. Encourage healthy reinvestment of emotion
Previous roles and responsibilities
New activities and relationships
8. Allow for individual differences
Broad range of emotions and other experiences
during grieving
Variation in the time needed to grieve
9. Provide continued support
My wife of 40 years died at a prestigious teaching
hospital…Neither the hospital management nor the attending
physician or anyone from the house staff ever troubled to
write or telephone to express sympathy or offer an account of
what had gone so wrong those last disastrous days. The effect
of that bizarre silence was to make me wonder whether some
monumental mistake might have been made in preparing the
dose that was to end her life. The next of kin are entitled to
some expression of sympathy or concern, even when it is not
deeply felt. Those close to the deceased can only be baffled,
resentful, or suspicious when no condolences are expressed.
Lerner A NEJM 345: 374-375 2001
Benchmarks of Grief Resolution
Survivor is able to talk about the deceased
without intense affect
Survivor can reinvest emotions in another
EVOLUTION OF GRIEF
Problems
+ 30%
Major Depression
Posttraumatic Stress
Disorder
Complicated Grief
Adaptive
+ 70%
Special Problems*
Failure to Grieve
Avoidance of Grief
Chronic Grief
Delayed Grief
Exaggerated Grief
Masked Grief
Anticipatory Grief
*Worden, 1982; Cook & Dworkin, 1992
Anticipatory Grief
Grief occurring in advance of the loss
Often seen among family members who expect
the future loss of their loved one
A dying person can experience anticipatory grief
Professionals and Family Caregivers Must
Attend to Self Care
Issues for Health Care Professionals
• Overwork
• Multiple Loss and Grief
• Boundaries
• Burnout
Overwork
• Occupational realities of working in medicine
• Institutional realities
• Unrealistic self-expectations & errors in thinking :
“If I don’t do it, no one will”
“I can do it better than anyone, so I should”
Working harder to make up for mistakes
“Helpaholism”
“I’m in this alone”
“There’s no way out of this”
Multiple Loss and Grief
• Stigma of working with the dying
• Professional caregivers not expected to grieve
• “Bereavement overload” (Kastenbaum, 1969) - falling over the
edge of hope
• Our early experiences with loss shape our approach/response to
present-day losses
• Re-living past deaths with each new death
• Letting go, and letting go, and letting go ….
Boundary Issues
• Occupational realities of working with the dying: multiple roles
caregiver as health care provider
caregiver as advocate
caregiver as primary support person
caregiver as individual/couples/family therapist
caregiver as bereavement counselor
• Personal issues involved in becoming a caregiver (Berry, C. R.,
When Helping You is Hurting Me, 1988, Harper)
Symptoms of Caregiver Burnout
• Reduced productivity/impaired performance
• Lowered energy/enthusiasm/humor
• Chronic fatigue/insomnia/bodily aches & pains
• Less interest in co-workers, clients, families
• Opposition to change
• Failure to manage basic life maintenance activities
• Dislike of work environment
• Expressed dislike for recipients of services
• Increases in “going by the book”
Self-Care at Work
• Case conference/staff retreats
• Expect (and seek) positive feedback from supervisors
• Consult with a back-up expert
• Assignment of specific duties and knowing expectations
• Drawing/maintaining clear boundaries on professional obligations
• Enlisting help of volunteers
• “Time out” activities
• Varying tasks
• Building in mental health days
Self-Care at Home
• Meditation, relaxation exercises
• Therapeutic massage
• Regular exercise!!!
• Nutrition as a self-nurturing activity
• Recreation and pleasant events
• Sharing experiences/feelings with friends & family
• Professional support group
• Individual therapy
Reference
Knight, Sara J., PhD
Robert H. Lurie Comprehensive Cancer Center Web
Site
Case Study: Sophia
45 yo financial advisor who lost her husband
Ben 1 yr ago after a brief, but aggressive illness
Married for 20 yrs since graduated college
No children, but were an extremely close couple
Spent most of their time together and were each
other’s best friend
Case Study: Sophia
1 year after Ben's death, Sophia described herself as
never having gotten over his loss
Experienced daily panic attacks that limited her ability
to leave her apt.
Was considering taking disability leave from work
Was unable to talk about Ben w/o crying and noted
that she was having great deal of difficulty cleaning
Ben’s closet out
She felt Ben would have wanted to donate his clothes
to someone who would use them, but she could not
decide what to give away and what to keep
Case Study: Sophia
Reflection
Loss of a spouse is very difficult
Strong grief responses can be experienced for a year or more
by bereaved
Not unusual to have anxiety as they attempt to resume their
lives
Common to have difficulty giving up possessions of their
loved one
However, Sophia is experiencing severe limitations in her
ability to take care of herself and is still experiencing intense,
fresh grief when thinking of Ben 1 year later
Case Study: Sophia
Considerations
Sophia’s experience suggests the possibility of
anxiety and depression
Should a referral to a mental health professional be made?
What other resources might be helpful for Sophia?
Grief vs. Depression*
UNCOMPLICATED GRIEF CLINICAL DEPRESSION
LOSS Recognizable and current Loss may be symbolic/not recognized
REACTIONS Initially intense, then variable Intense and persistent
MOOD Labile, acute heightened when thinking Consistently low, pervasive, chronic,
about loss absence of emotion
BEHAVIOR Variable, shifting Refusal of most previously enjoyed
activities
ANGER Often expressed Thought to be self-directed
SADNESS Periodic weeping or crying Little variability (inhibited or uncontrolled)
COGNITION Preoccupied with loss, confusion Preoccupied with self, worthlessness, self-
blame, hopelessness
HISTORY Little history of psych disorder Previous history of depression or other
SLEEP Periodic difficulties falling asleep and early Regular early morning awakening
am awakening
IMAGERY Vivid dreams, capacity for imagery and Self-punitive imagery
fantasy
RESPONSIVENESS Responds to warmth and assurance Hopelessness and helplessness limit
responsiveness to others
*Cook & Dworkin, 1992
When is Professional Help Needed?
Intense fresh grief with discussion of deceased long after loss
Minor event triggers intense grief reaction
Themes of loss continue long after loss has occurred
Survivor unwilling to move material possessions of deceased
Survivor experiences physical symptoms of deceased
Radical changes in lifestyle
History of depression, or other psych disorder
Compulsion to imitated deceased
Self-destructive impulses
Unaccountable sadness
Phobia about illness or death
Grief Counseling/Support Services
vs. Grief Therapy
Grief Counseling/Support Services
Best for individuals who are experienceing grief that would
not be considered “complicated”
Goals
Support persons as they go through the grieving process
Prevent complicated grief reactions
Grief therapy for complicated grief
May have pre-existing issue/disorder that may interfere with
normal grief
Invlolves helpf with both pre-existing issues as well as the
grief process
Professional help
Medication may be used
