Bereavement Care for the Adult

by: Elizabeth J. Clark, PhD, ACSW, MPHs
Executive Director
National Association of Social Workers

American society is uncomfortable with death and with open displays of grief, and prefers that individuals hide their feelings and emotions. Added to this is the organizational approach to grief that often allows an employee less than one week to bury a loved one and mourn the loss before returning to work. As a result, bereaved individuals persons are forced to hide their grief in public and act as though they have completed grieving and are "back to normal." Denial of the significance of the loss makes grief harder, and an inability to be open about grief may extend the grief process.

Bereaved persons need to know that despite society’s response to death, they have a right to grieve openly and to observe religious and social mourning rituals according to their individual wishes and customs. They also have the right to expect health and mental health professionals to understand the process and characteristics of grief and to have this knowledge education available to them (Table 1).

Normalizing the Grief Process

It is important to note that manifestations of grief vary in different age groups, and that childhood grief is quite different from the grief of adulthood. This article primarily deals with adult grief.

The characteristics of "normal" grief were documented in 1944 when psychiatrist Erich Lindemann conducted his classic study of relatives who had lost loved ones in the tragic Coconut Grove fire in Boston.’ (Lindemann, 1944). His findings have been labeled "the symptomatology of acute grief."

Depending on a variety of factors, including whether the death was expected or sudden, grief may include a state of shock or numbness and an inability to fully grasp what has happened for the first two weeks or so after the death. It is followed by expressions of intense emotional and bodily distress that occur in waves lasting from 20 to 60 minutes. There is a feeling of tightness in the throat, a choking feeling with shortness of breath, an empty feeling in the abdomen, a need for sighing, a lack of muscular power, and intense "mental pain." Other physical expressions of acute grief include crying and sobbing, restlessness, loss of appetite and sexual drive, and sleep disturbances. These physical responses are combined with feelings of depression and sadness and an inability to concentrate.

Two other important and normal aspects of grief should be mentioned. The first is preoccupation with thoughts of the deceased. This is called searching behavior, and it may be accompanied by responses similar to auditory or visual hallucinations in which the bereaved are certain they briefly see their loved one in a crowd or hear their voice or hear the car pull into the garage at the usual hour. These thoughts are caused by psychological cues and will decrease with time. The second aspect is the use of linking objects that make the bereaved feel connected to the deceased. Wearing or sleeping with a piece of clothing or item belonging to the deceased may bring great comfort. This, too, is normal grieving behavior, and the need for the linking object will decrease over time.

Many people ask how long grief lasts. Others ask if it ever ends. Death ends a life; it does not end a relationship. However, after the death, this relationship must change. That change involves four major tasks: (1) accepting the reality of the loss, (2) experiencing the pain of grief, (3) adjusting to a changed environment in which the loved one is missing, and (4) relocating the loss emotionally and moving forward. Researchers estimate that it takes at least one year to move through the grief process (Worden, 1991). (Note: They do not use terms like "finish grieving," "resolve the grief," or "get over the loss.") Two to three years may be a more realistic estimate. A full year is considered a minimum, because it takes a year to experience all of the anniversary dates with the loved one missing. During these anniversary periods, the acute grief syndrome may resurface, and the bereaved should recognize that this is normal.

Bereavement Resources

Many bereavement resources are available in the community, but the bereaved may need assistance in finding them. Social workers, clergy and funeral directors are excellent resources with which to start.places begin. They frequently have lists of support groups and counselors who specialize in grief. Also, many hospice programs offer support groups, and these frequently are open to all persons regardless of whether the deceased was cared for by that hospice.

Bibliotherapy, or using books, writings, and poems to resolve problems, is a common grief intervention. By reading about the experiences of others, the person who is bereaved may better understand grief and gain personal and relevant insights. Journaling, or regularly writing about personal feelings and circumstances, may increase self-awareness about coping strategies and ways crises were resolved in the past (Graves, 1994). Similarly, creative arts, such as drawing, may stimulate repressed memories and identify patterns of reaction to loss developed in childhood (Wadeson, Durkin, & Perach, 1989). Unhealthy patterns may be changed when identified. Selected resources for understanding personal grief are presented in Table 2.

Internet interventions are a new avenue open to the bereaved. Many Web sites include "chat" rooms where an individual may speak with others who have experienced similar losses. Although it may be quite comforting for the bereaved person to talk with others who understand his or her pain, it must be emphasized that each grief is individual. What works for one person may not be useful to another, and it should be recognized that persons frequenting the chat rooms speak from personal, rather than professional, perspectives. In addition to chat rooms, valuable information about grief and about community services can be found on the Internet (Table 3). Many public libraries provide Internet access to those who do not have computer resources in their homes.

Conclusions

As mental health professionals, we ourselves must have a thorough understanding of the grief experience. Next, we must provide grief education for those families experiencing a loss, so they know their rights as bereaved individuals and so their grief may be normalized. Finally, we need a good grasp of community resources and innovative ways of finding these resources to better direct the family to available and appropriate services.

References

Clark, E. J. (1987). Bereaved persons have rights that should be respected. In A. Kutscher, A. Carr, & L. Kutscher (Eds.), Principles of thanatology. New York: Columbia University Press.

Graves, S. (1994). Expressions of healing: Embracing the process of grief. North Hollywood, CA: Newcastle.

1. Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 1944;101,:141-–148.

Wadeson, H., Durkin, J., & Perach, D. (Eds.). (1989). Advances in art therapy. New York: John Wiley & Sons.

2.Worden, J. W. (1991). Grief Ccounseling and Ggrief Ttherapy. New York: Springer. Publishing Co.; 1991.

3.Graves S. Expressions of Healing: Embracing the Process of Grief. North Hollywood, CA.- Newcastle Publishing; 1994.

4.Wadeson H, Durkin J, Perach D. (eds). Advances in Art Therapy. New York: John Wiley & Sons; 1989.

5.Clark EJ. Bereaved persons have rights that should be respected. In Kutscher A, Carr A, Kutscher L (eds.) Principles of Thanatology. New York, NY: Columbia University Press; 1987

Table 1. Rights of the Bereaved

1. The bereaved have a right to expect optimal and considerate care for their dying loved one.

2. The bereaved have the right to a compassionate pronouncement of the death and to respectful and professional care of the body of their loved one.

3. The bereaved have the right to view the body and to grieve at the bedside immediately following the death, if this is their wish.

4. The bereaved have the right to expect adequate and respectful professional care (both physical and emotional) for themselves at the time of their loved one’s death.

5.The bereaved have a right (except when contraindicated legally) not to consent to an autopsy, without coercion, regardless of how interesting or baffling the patient’s disease.

6.The bereaved have the right to an adequate explanation of the cause of their loved one’s death and to answers regarding the illness, treatment procedures, and treatment failures.

7. The bereaved have the right to choose the type of funeral service most consistent with their wishes and financial means and not to be coerced into those services of which they aren’t supportive.

8. The bereaved have the right not to be exploited for financial gain nor for education or research purposes.

9. The bereaved have a right to observe religious and social mourning ritual according to their wishes and customs.

10. The bereaved have a right to express their grief openly regardless of the cause of the loved one's death, suicide and violent death included.

11. The bereaved have a right to expect health professionals to understand the process and characteristics of grief.

12. The bereaved have a right to education regarding coping with the process of grief.

13. The bereaved have a right to professional and lay bereavement support, including assistance regarding insurance, medical bills, and legal concerns.

Adapted from Clark, E. (1987)., Bereaved persons have rights that should be respected. In Principles of Thanatology, edited by A. Kutscher, A. Carr, & and L. Kutscher (Eds.), Principles of thanatology.1987 © Columbia University Press. Reprinted with permission of Columbia University Press.

Table 2. Selected Resources for Personal Awareness About Grief

Crossing the Bridge: Creating Ceremonies for Grieving and Healing From Life’s Losses by S. B. Metrick. Berkeley, CA: Celestial AM;, 1994.

Grieving.: How to Go On Living When Someone You Love Dies by T. A. Rando. Lexington, MA: D.C. Heath and Company;, 1988.

How to Survive the Loss of a Love by M. Colgrove, H. Bloomfield, and P. McWilliams. Los Angeles, CA: Prelude Press;, 199 1.

Life After Loss. A Personal Guide to Dealing with Death, Divorce, Job Change and Relocation by B. Deits. Tucson, AZ: Fisher Books;, 1992.

Making It Through the Toughest Days of Grief by M. Woodson. Grand Rapids, MI: Zondervan Publishing House;, 1994.

Mending the Torn Fabric: For Those Who Grieve and Those Who Want to Help Them by S. Brabant. Amityville, NY: BaywoodPublishing Company, Inc,.; 1996.

What to Do When a Loved One Dies.-— A Practical and Compassionate Guide to Dealing with Death on Life’s Terms by E. Shaw. Irvine, CA: Dickens Press, 1994.

Table 3. Internet Resources for Grief

This article is adapted from Clark, E. (1997). The end of the continuum: Bereavement care for the adult. Cancer Practice, 5, 252–254. © xxxxxxxxxxxxxx. Reprinted with permission.