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BEREAVEMENT PROCESS.
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Definition, models, stages, (shock, confusion, acceptance), moderating factors (age of deceased, relationship, cause of death, religious faith), healing interventions. Table.... More...
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Paper Abstract:
Definition, models, stages, (shock, confusion, acceptance), moderating factors (age of deceased, relationship, cause of death, religious faith), healing interventions. Table.
Paper Introduction:
DEATH, DYING AND BEREAVEMENT: THE HEALING PROCESS
Introduction
This paper examines the process of bereavement. The paper begins with a description and discussion of the general symptoms associated with bereavement; this is followed by an examination of several factors contributing to variance in both the duration and intensity of the bereavement process. The review then examines psychotherapeutic interventions designed to facilitate the healing process. The final section of the review consists of a series of conclusions about the process formulated on the basis of the reviewed studies.
Bereavement: General Description
Bereavement is the emotional experience undergone by a person in reaction to the death of another who was significant in
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Stage 4. Dying, Death, and Bereavement. It can be concluded that one factor that moderates the intensityand/or duration of the bereavement process is the relation of theindividual who died to the bereaved; and that bereavement is more intenseif the death was of a child or a spouse or a parent. Stage 2. Stage 5. (Barocas, Reichman & Schwebel, 1993, p. Farberow, N.L., Gallagher-Thompson, D., Tilewski, M. It can be concluded that a number of personal characteristics ofthe bereaved can either intensify and/or prolong the process or they cansoften it. The role of social supports in the bereavement process of survivingspouses of suicide and natural deaths. DeathStudies, 16(5), 387-399. However, 3 percent of the survivors who had not initially requestedthe educational materials did so around eight months later. Death Studies, 13(5), 465-483. (1992). Bereavement in older adults. 6. (3rd ed.) Boston: Allyn & Bacon. Abrahm, Cooley and Ricacho (1995) developed a bereavement program forfamilies of veterans with cancer. Children. Goldstein, Alter and Axelrod (1996) discussed a psychoeducationalbereavement support group for families whose loved ones were dying ofcancer. These include: depressedmood (often expressed through crying behavior, heavy sighing, andcommunications of sadness); difficulties sleeping, concentrating, andremembering things; difficulty eating; tiredness or fatigue; and feelingsof hopelessness. Mabe, P.A. Most survivors felt the letters and what-to-expect sheethad been helpful. According to Zisook and DeVaul (1985), oftenthese are individuals dealing with unresolved grief. Lohnes and Kalter (1994) describe time-limited psychotherapeuticintervention groups for parentally bereaved children of elementary schoolage (6-12 years). The next section ofthe paper examines research on these moderating factors and their effectson the bereavement process. (1996). Sormanti, M. (1994). However, survivors of suicide experienced greaterfeelings of shame and had experienced more life events after the death thandid accident survivors. Children were also helped to deal with theirfears regarding the death of the surviving parent. Journal of Psychology and Theology, 19(4), 334-343. Conway, K. (3rd edition) NY: St.Martin's Press. al (1989), their findings supportedthe view that open communication between dying children and the adults whocare for them benefits the children. In this regard, Morgan(1994) reported that there can be health-related difficulties associatedwith the stress of bereavement. (199 ). Noting that the experience involvesseparation and loss, feeling of failure and guilt, and an undermining ofbasic beliefs, they report that the Christian has five important sources ofcomfort available based on religion. Relief---may be difficult for mourner to acknowledge andopenly adjust. It can be concluded that a second factor that moderates theintensity and/or duration of the bereavement process is the age of thebereaved. Second, most models characterize thestages following this period of shock as involving a process of expressingand dealing with grief. All of these women had been in treatment elsewhere and felt theyhad been "pressured to get on with living." The program ran for one yearand focused on supporting patients' defenses and avoiding any implicationsof extended grief as pathological. A psychotherapeutic approach to bereavement difficulties wasdescribed by Lawrence (1992). & Chu, L. One yearafter the program's inception, its efficacy was assessed with a chart andtelephone audit. This finding was observed in a study conducted by Graham-Pole,Wass, Eyberg and Chu (1989) who investigated factors influencingcommunication between parents, dying children, and their siblings, usingretrospective questionnaire data obtained from the parents of 77 children(mean age at death 12.4 years). (1995). Journal of Cancer Education, 11(4), 233-237. Miscarriage is another way in which bereavement can occur. Lawrence, L. Lohnes and Kalter (1994) report that children do not reallyhave a complete understanding of the permanence of death; nor do they havethe cognitive structures and reasoning processes to fully understand whathas occurred. The major models of bereavement are presentedin Table 1. However, differences in general perceptions of deathwere found between urban and suburban adolescents. Regarding dissimilarities between psychological models ofbereavement, models differ in terms of the number of stages utilized and intheir characterizations of certain key elements marking the transition intoand out of a particular stage. Grief & bereavement in AIDS & aging. Recovery from bereavement among mothers was correlated withreligious faith and with better emotional adjustment among children.Degree To Which Death Was Anticipated Bereavement can happen suddenly or, as in cases where a loved one hasbeen ill for a long time, it can be expected. (1995). When a child dies: The impact of beinga Christian. It can be concluded that the degree to which the death wasexpected or anticipated also moderates the bereavement process.Bereavement appears to be less intense and/or prolonged in those caseswhere family members expected death to occur, e.g. One of the most helpful strategies wassaid to be the use of personal videotapes and photographs in thebereavement process. In this regard, genderappears to be factor interacting with the social support variable suchthat, despite impediments associated with bereavement due to suicide,females are likely to receive more social support than males. It was led by a family therapist who was a member of apsychosocial services team. Reorientation and recovery---person reorganizes the symbolicworld and gives the deceased a new identity outside the world of thesurvivor._________________________________________________________________*Source: L.R. In their study, the authorsspecifically examined for ways in which the bereavement process followingsuicide differed from other types of bereavement. Reestablishment---friends become important at this stage.Hardt's (1978-1979) Model Stage 1. Seguin, M., Lesage, A. Others may continue to feel the presence of the deceased or have daily visions of him or her. According to the Graham-Pole et. (1989). Talking and listening as comfortingstrategies were found to have been used by both groups of adolescents about66.7 percent of the time. Loss and loneliness---may be the most painful stage. Understanding behavior disorders.Boston: Houghton-Mifflin. Both kinds of programs arediscussed below. Generations,13(4), 8 -82. Dying, death and bereavement. Fourth, most models state that it is not necessaryfor a given individual to experience all stages. & August, J. Barocas, H., Reichman, W. It is noted that the answer to these questions -both verbal and nonverbal - will help identify unresolved grief, whenpresent, and may be a guide to specific interventions. Mothers who talked more freely withdying children also did so with siblings, and communication was more openwith older children. In terms of treatment considerations, Zisook and DeVaul (1985) reportthat when these symptoms are identified it is useful to ask the patient whohe has lost, how he has lost them, how he felt about the loss, whether hefelt that he grieved, whether he still cries or feels the need to cry, andwhether he has adjusted. (1994). Concentration directed toward the deceased. Communication, religious faith and level of emotional adjustment canbe factors that moderate the duration and intensity of bereavement infamilies. However, Zavasnik (1992) notes that it is generally very difficultfor the survivors to recognize, accept, and express---a fact that can slow-down the bereavement process, making it last much longer than normal.Indeed, if survivors do not go through a phase where they recognize andvent their anger and aggression toward the person who committed suicide,Zavansnik states that the bereavement process should not be consideredcompleted. Adolescence, 31(123), 585-595. Still others may feel pain, anger, and guilt for years after the death. Reorganization/acceptance (8 months and longer)Stephenson's (1985) Model Stage 1. Some of their grief work is done in advance of death. Disorganization and reorganization---reality sets in;bereaved is disappointed and the loss cannot be recovered. & Kiely, M.C. Suicide and Life-Threatening Behavior, 25(4), 489-498. Unresolved grief. Intense grief (several months)---periodic crying, confusion,and inability to understand what has actually happened. According to Sormanti and August (1997), about38 percent of parents losing children will have some experiences ofcontinued connection to their death child (e.g., visions, physicalsensations, dreams). For some, identification syndromes continue. Preventive intervention groups forparentally bereaved children. Following such discussions, siblings showedsignificantly more sadness, anger, denial, and fear than did dying children---however, it was felt that these findings were positive in that therecognition and expression of these emotions helped siblings begin theirgrief work. Stage 4. Riskfactors are said to include the risk of internalized homophobia and theabsence of institutional recognition of the relationship. American Journal ofPsychoanalysis, 45(4), 37 -379.----------------------- 6 & Schwebel, A.I. Steele, L. 8. 37 ) There have been a number of programs developed to help individualsthrough the bereavement process. "Till death do us part": The application ofobject relations theory to facilitate mourning in a young widows' group.Special Issue: A hospital social work department's 4 th anniversary. Aggression as a natural part of suicidebereavement. (1991). In research conducted on factors that moderate bereavement, Seguin,Lesage and Kiely (1995) found clear differences in the bereavement processdepending upon differences in cause of death. 149) Barocas et. Denial (from time of death up to one month) Stage 2. Study participants were parents, 3 of whom were bereaved followingtheir offsprings' suicide and 3 of whom were bereaved following theinvolvement of their offspring in a car accident. Shock--physical and emotional shock; real and unreal worldscollide. Morgan, J.P. In this regard,they state that: Most, if not all, people never totally resolve their grief; significant aspects of the bereavement process go on for years after the loss, even in otherwise normal patients. The results of analyzes conducted on questionnaire data completed byfamily members three months after their group experience revealed thatgroup members found the group experience beneficial, especially regardingthe opportunity to talk with others who had experienced similar losses,learning about the reactions one would expect in the grieving process, anddeveloping new strategies to deal with the grief associated with the loss. The authorsconcluded that the program was beneficial for the vast majority ofsurvivors, and they planned to modify it to respond to the deficienciesidentified. 7. & Sue, S. For example, in a study conducted by Steele (1992), it was foundthat age, sex, socioeconomic status, and the quality of relationship to thedeceased were related to specific high-risk bereavement behaviors. It can be concluded that despite certain stable patternsassociated with the bereavement process, there are a number of factors thatmoderate its intensity and/or duration. The finalsection of the review consists of a series of conclusions about the processformulated on the basis of the reviewed studies. Stage 2. (1997). Barocas, Reichman andSchwebel (1993) state that the latter cases almost always involve theanticipation of the loss or anticipatory grief. Morin, S.M. Adolescents' perceptions andexperiences of death and grieving. Moderating Factors and their Impact on the Bereavement ProcessRelation to the Bereaved According to Barocas et. Personaladjustment and growth: A life-span approach. Despair, withdrawal, and general disorganization. Stage 3. In general, these programs are of two types: (1)psychoeducational; and (2) psychotherapeutic. Parental bereavement: Spiritualconnections with deceased children. Third, although there are a few exceptions, most models do not settemporal limits on the amount of time an individual will require to movethrough any one stage. & Axelrod, R. As can be seen from examination of this table, there arecertain similarities and dissimilarities in these models.Table 1Major Psychological Models of Bereavement*_________________________________________________________________Bowlby's (1966) Model Stage 1. Parental bereavementafter suicide and accident: A comparative study. Through thesesources of comfort, it is said that a bereaved parent can profit by theChristian faith. (3rd ed.) Boston:Allyn & Bacon. A psycho-educationalbereavement-support group for families provided in an outpatient cancercenter. Parental bereavement after suicide differed in several ways fromother types of bereavement and appeared to happen more often in vulnerablefamilies. The authors also report that some studies have suggested that perhapsunresolved grief is a somewhat overly simplistic concept. Depression (from 3 to 8 months) Stage 5. Conclusions This paper examined the literature on the bereavement process. al (1993), the duration and intensity of thebereavement process will differ depending upon the relationship of theindividual who died to the bereaved with the deaths of children and spousesbeing associated with the strongest levels and duration of grief followingby the death of a parent. For example, Mabe and Dawes (1991) discussed the impact of beinga Christian on the loss of a child. Lohnes, K.L. Guilt---mourner feels guilty and depressed. Suicide and Life-Threatening Behavior, 22(1), 1 7-124. Volatile emotion---mourner unleashes volatile emotions,upsetting those around him or her. Kaufman, P.A. Regarding similarities, almost every model asserts that bereavement(as an emotional response) begins with a sense of shock which can vary inlength from individual to individual. 2. The authors also attempted to examine adolescents' generalperceptions of death. Aiken (1994). It was also observed that the most distasteful aspect of death to thesuburban students was suffering (31.6 percent), while it was loss of lovedones to urban youths (25 percent). Bereavement: General Description Bereavement is the emotional experience undergone by a person inreaction to the death of another who was significant in his or her life(Aiken, 1994). (1994). Efficacy of aneducational bereavement program for families of veterans with cancer.Journal of Cancer Education, 1 (4), 2 7-212. Miscarriage experience and the role of supportsystems: A pilot study. Negligent disruption of the bereavementprocess: Post-traumatic stress disorder. Some of these programs are aimed atindividuals with unresolved grief while others are designed to prevent thisproblem from occurring. 4. However, there arecertain mystical or spiritual experiences of connectedness that can softenthe intensity in such situations. Most had not used the bibliographies, and half had notneeded the support group listings. Zisook, s. Moreover, for those working with olderpeople, distinguishing between normal bereavement depression and clinicaldepression is often difficult with older persons whose depression is oftenmasked by age-related physical complaints. Of all age groups, older adults are often most at riskof complications associated with bereavement. Stage 3. Interventions That Promote Healing There are many cases in which individuals seek help in going throughthe stages of bereavement. & Dawes, M. 3. Farberow, Gallager-Thompson, Tilewski and Thompson (1992) report thatone of the factors that can increase the difficulty of bereavement in caseswhere the loved one committed suicide is that relatives and friends areless likely to provide the kind of social support needed---perhaps becausethey have their own confusions about the nature of the death and don't feelthey can adequately help in such situations. These sources of comfort are said to be: faith in a good and powerfulGod, knowledge of God's word, a relationship with Jesus Christ, anindwelling of the Holy Spirit, and a fellowship of believers. Forexample, Zavasnik reports that suicide is associated with intense anger insurvivors. Stage 7. Special Issue: Suicide and the olderadult. cases of seriousillness, or cases where a spouse went off to fight a war. In herstudy of bereavement due to miscarriage, Conway (1995) reported that, basedon her interview and questionnaire data, the psychological sequelaefollowing miscarriage appear to be similar to the bereavement process forother types of death. Most theoretical models of bereavement are stage models which is tosay that they characterize the bereavement process as a series of steps, orphases that people undergo. Anger or hostility toward the deceased or others. Reaction---period of initial shock when news of death isencountered, shock followed by numbness and a dazed lack of feeling,bewilderment, anger, and attempts to make sense of loss. According to Sue, Sue and Sue (1994), there are a number ofsymptoms typically associated with bereavement. These include: the patient who suffers from unexplainabledepression, chronic illness behavior, or symptoms similar to those of adeceased relative or friend. It isalso stated that these children, need to maintain an emotional attachmentto internal representations of the deceased parent and that the extent towhich they are able to achievement this is an important component of thebereavement process. It is noted that this typeof advanced grief work is sometimes done by individuals whose spouses aregoing into extremely dangerous situations such as war. False acceptance (from 1-2 months) Stage 3. Initial shock (first few days)--characterized by loss ofself-control, reduced energy, lack of motivation, bewilderment,disorientation and loss of perspective. However, it is also noted that Christian counselorsworking with bereaved individuals, if they are to maximize their success,should strive to have a full understanding of the bereavement process. Goldstein, J., Alter, C.L. Also, there appears to be problems in those bereaved through suicidereceiving the available social support they need. Risk factor profile for bereaved spouses. American Journal of ForensicPsychology, 8(3), 3-18. (1993). & Kalter, N. There was also a greater history of loss in parents bereaved bysuicide. & Ricacho, L. Once the program had been developed, the authors telephoned bereavedsurvivors and sent letters, a "what-to-expect" sheet, bibliographies, andlistings of support services available to them at specified times. Family members and friends of recently deceasedpatients were invited to participate by letter and phone call. Disorganization---person feels totally out of touch withordinary proceedings of life. Stage 3. Stage 2. It was also found that while social support frompartners, relatives and friends was helpful, the women did not perceivethat support from professionals and the wider community was alwaysadequate.Personal Characteristics of the Bereaved Sometimes, there are certain sociodemographic and personality factorsthat place people at risk for difficulties working through the bereavementprocess. (1996). According to Barocas, Reichmanand Schwebel (1993), factors that moderate bereavement include: personalcharacteristics of the bereaved; the relation of the individual who died tothe bereaved (e.g., spouse, child, friend, parent, etc.); the age of thebereaved at the time the death occurred; the degree to which the death wasexpected or anticipated; and even the type of death. This can lead to health carepersonnel failing to provide treatment that supports grief work in olderpopulations, thereby lengthening and intensifying the bereavement process.Cause of Death According to Zavasnik (1992), the type of death experienced by theloved one can influence the duration and intensity of bereavement;moreover, it can intensify certain components of the experience. The program consisted of a support group forrecently widowed young women who sought help at a hospital's psychiatricclinic. Although, as just noted, certain symptoms of bereavement are stableacross individuals, the process in general can vary in both duration andintensity depending upon several factors---indeed, in some casesbereavement can grow so intense that individuals disrupt the processpurposely, an action that can sometimes result in a number ofpsychoemotional problems(Kaufman, 199 ). DEATH, DYING AND BEREAVEMENT: THE HEALING PROCESS Introduction This paper examines the process of bereavement. Because ofthe need to work through these death issues and identity matterssimultaneously, adolescents will often experience a longer period ofwithdrawal from others than will adults or children. Journal of MentalHealth Counseling, 16(3), 318-326. & DeVaul, R. The research indicated that factors which can moderate theprocess in either direction are: religious faith, age, sex, socioeconomicstatus, the quality of the relationship with the deceased, the degree ofopen and frank communication engaged in concerning the death, and theperson's general level of emotional adjustment. (1992). Religion is another personal factor that can moderate the bereavementprocess. Morin and Welsh (1996) state that adolescents will oftenexperience a difference in bereavement reactions when compared to eitheradults or children; this is believed to be related to the fact that inaddition to the turmoil associated with the death adolescents are alsoexperiencing turmoil associated with forming their identity. Reorganization and direction of self toward a new loveobject.Gorer's (1967) Model Stage 1. (1985). (1992). The authors do note that ifthe bereaved is female it is likely that she will receive more help than amale. al (1993) go on to point out that this advance acceptanceis highly protective against the acute grief experienced in cases where theloss of the loved one is quick and unexpected. Mental Health, 13(2), 65-69. Basedon the reviewed articles, the following conclusions can be formulated: 1. Subjects were interviewed twice, once at six months, and once at ninemonths after the death; they were also administered a number ofstandardized questionnaires to measure depression and grief reaction.Measures of shame, social support, family adaptation, psychologicaldistress, and prior losses were also obtained during the second interview. Appeals to others for support and help. It can be concluded that regardless of differences in thecircumstances associated with bereavement there are certain stablecharacteristics: depressed mood; difficulties eating and/or sleeping;extreme tiredness; and feelings of hopelessness. 5. References Abraham, J.L., Cooley, M. The authors reportthat there are certain identifying signals that a client is suffering fromthis problem. Program goals involved normalizing children's reactionsto and experiences of the death of a parent, clarifying their thoughtsabout the death, and helping them to cope with troubling feelings andfamily and peer dynamics. O'Neil, M. Zavasnik, A. (1995). Stage 3. The authors note that such groups can assist family members andfriends in coping with their feelings of grief, thereby reducing thepossibility of complicated grief reactions. The review then examines psychotherapeuticinterventions designed to facilitate the healing process. Results indicated that suicide survivors were more depressed thanaccident survivors at the first measure but this difference disappeared atthe second measure. O'Neil (1989) reports that individuals who lose a significant otherdue to AIDS are often at higher risk for dysfunctional grieving. In almost every case, these experiences will shorten the length ofbereavement and soften the intensity. (1994). The authors note that insuch cases, the actual bereavement process can be shortened and reduced inintensity because: Just as dying patients reach the stage of acceptance and rest, so too may their family come to terms with the death. Sue, D., Sue, D. American Journal of Orthopsychiatry, 64(4),594-6 3. (p. Older Adults. Children, adolescents, and elderly people will all experiencebereavement differently due to maturational factors and the impact of thesefactors on their ability to process and emotionally bear the death. Gradual reawakening of interest---acceptance of reality ofloved one's death and all it means.Kavanaugh's (1974) Model Stage 1. Based on the Cause of Death research, it can also be concluded thatpeople whose loved ones died of AIDS are at increased risk for a prolongedand problematic bereavement process. The authors reason that suchexperiences have these effects because of several features including thefact that they: perpetuate parents' perceptions of their children's uniquequalities; maintain their identity as parents of that child; providereassurance, hope, and a sense of peace amid the confusion and despair oftheir grief; help them manage better on a day-to-day basis by expandingtheir tolerance of the uncertainty and ambiguity of life and death.Age of the Bereaved Adolescents. For this reason, the authors report that youngsters continueto struggle with death-related stress well beyond the time of loss. It can be concluded that a third factor moderating the intensityand/or duration of the bereavement process is the cause of death withsuicide being one of the most difficult types of death to deal with,especially because of its association with a good deal of anger andaggression on the part of the bereaved, feelings which if left unexpressedcan produce dysfunctional grief. Stage 5. (1989).Communicating with dying children and their siblings: A retrospectiveanalysis. The paper beginswith a description and discussion of the general symptoms associated withbereavement; this is followed by an examination of several factorscontributing to variance in both the duration and intensity of thebereavement process. There can also be feelings of intenseshame, and more negative experiences following the death. They found that most teens said they were aware ofdeath by age nine. Stage 2. Stage 6. Pseudoreorganization (from 2-3 months) Stage 4. The program was constructed usinginformation available about the process of grieving, its psychological andphysical manifestations, the most stressful times for the bereaved, and themost helpful interventions. British Journal of Medical Psychology, 68(3), 259-267. The program itself, provided in an outpatient cancer center,consisted of an eight-session psychoeducational group that providedpsychosocial support and information aimed at assisting in the bereavementprocess. All survivors wereparents who had lost a son aged between 18 and 35 years. SocialWork in Health Care, 16(3), 67-81. Aiken, L.R. In this regard, urbanadolescents' perception of death involved reference to violence (25 percentof sample) or religion (16.6 percent) in contrast to the suburban youthswho referred far less frequently to violence ( percent) and/or to religion(5.3 percent). & Thompson, L.(1992). Graham-Pole, J., Wass, H., Eyberg, S.M. & Welsh, L.A. Unfortunately,research also indicates that it is the psychologically and emotionallyvulnerable families that are most likely to experience bereavement due tosuicide. Finally it can be concluded that healing from both normal anddysfunctional grief can be facilitated through psychoeducational andpsychotherapeutic programs. American Journal of Orthopsychiatry,67(3), 46 -469.
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