Bereavement Care for the Adult
by: Elizabeth J. Clark, PhD, ACSW, MPHs
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 societys 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.
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.
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.
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
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 patients disease.
6.The bereaved have the right to an adequate explanation of the cause of
their loved ones 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 arent 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
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
Crossing the Bridge: Creating Ceremonies for Grieving and Healing From Lifes
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 Lifes 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, 252254. © xxxxxxxxxxxxxx.
Reprinted with permission.