Understanding bereavement and how to cope with it
View(s):PBy Prof. Raveen Hanwella All that lives must die, Passing through nature to eternity. —William Shakespeare, Hamlet
The death of a loved one is a special type of loss and leads to mourning or bereavement. How do we cope, or help others to cope with bereavement?
Bereavement brings friends and family together but can also isolate a mourner. We may avoid a bereaved individual or family, because we do not know quite what to say. This is especially so, if the death was sudden, tragic or that of a child. An understanding of loss and its aftermath will enable us to be more empathic when there is bereavement among friends and family.
Grief or bereavement is not a disease and most people recover or adjust to normal life without professional help but for a few, grief may become abnormal. They may need help. It is important to recognise when this is necessary. Swiss American psychiatrist Elizabeth Kübler-Ross made the study of terminally ill patients her life’s work. In her book Death and Dying, published in 1969, she describes five stages that people go through when faced with the prospect of dying. Though she based her theory by observing dying patients, later she expanded it to include bereavement.
The five stages known by the acronym DABDA are: Denial, anger, bargaining, depression and acceptance. In denial, people are in shock and may appear to act as if nothing has happened. This may surprise relatives who may be critical of the person for not mourning. But this is a protective mechanism, and helps people attend to practical aspects such the funeral arrangements.
In the stage of anger, people become angry with themselves and others, especially those close to them. They may also become angry with health care personnel who last treated the dead person. The bereaved person will become difficult to care for during this period. It is important to remain detached and non-judgemental during this stage.
The stage of bargaining is more common in the case of a terminal illness where the person hopes to negotiate a longer period of life, usually with a higher power, by change of lifestyle. In the stage of depression, the reality of the loss begins to sink in and the person becomes withdrawn, avoids visitors and spends much of their time crying. They feel sadness, regret, fear, and uncertainty. These emotions are normal during this stage and shows that the person has begun to accept the reality of the situation.
In the last stage of acceptance, individuals come to terms with the death of their loved one and their own mortality. The mood becomes calm and stable.
The process of normal bereavement usually lasts up to six months but may become reactivated during anniversaries of the death. The work of Kübler-Ross is helpful in understanding the behaviour of people in bereavement. People can be helped to progress from one stage to another at the appropriate time, rather than getting stuck in one or, moving around from one unresolved stage to another. But most people do not go through the neat stages as described by Kübler-Ross. Her work was mainly with dying people and the findings were extrapolated to the bereaved.
Colin Murray Parkes, a psychiatrist whose specialty is the study of bereavement, divides bereavement into four phases:
- Numbness
- Pining
- Disorganisation and despair
- Reorganisation
The first phase lasts from hours to days and is soon followed by the second phase. Here there is an intense feeling of longing for the dead person accompanied by intense anxiety. These pangs of grief are transient and in-between the person appears to function normally. There is loss of appetite and weight with loss of concentration and short term memory. The bereaved person is often irritable and depressed.
This is followed by the third phase where there is grieving, disorganisation and despair. Often the person repeatedly goes over the events that led up to the death looking to find a reason and even now to correct it. Some report the voice of the dead person talking to them. This is usually when they are about to fall asleep. This is normal and not a sign of impending madness.
A sense of the dead person being near at hand is also common. After some time the intensity and frequency of grief is reduced but may recur during anniversaries. The phases of grief do not go in a strict sequence and the bereaved person may oscillate between pining and despair several times before the final phase of reorganisation.
Most bereaved people do not need expert help. The traditional rituals of our culture are helpful in this regard. However, a few may get stuck in one of the stages and may need help to move on. This is more likely when the death is sudden and untimely, while the bereaved person is vulnerable (previous psychiatric disorder, unsupportive family) or where there is an abnormal attachment (ambivalent, dependent or insecure) to the deceased.
For example, people may become locked in the stage of denial. Here they continue to act as if the deceased is still alive. They retain the belongings of the dead person expecting them to come back any moment. This process is called mummification. Such persons can be helped by a process called guided mourning where they are helped to accept the reality of the loss.
The bereaved are asked to bring photos or other objects associated with the dead persons. They are invited to talk about those items, and write a ‘diary’ reminiscing about the deceased. Many need to go over and over in their minds the circumstances of the death before they become fully aware of the loss. This takes time, sometimes as long as three months.
Shakespeare recognised the importance of talking about loss when he had Macbeth say, “Give sorrow words; the grief that does not speak knits up the o’erwrought heart and bids it break.” The bereaved persons could also be encouraged to visit the graveside or the place where the remains were scattered.
When a loved one dies it is common to feel angry. Some may continue to feel angry and are unable to move on. This state is more likely if the relationship with the deceased was ambivalent. Anger, if directed outwards, is not towards the deceased but deflected on to other people such as the doctor and the hospital staff or a family member. Sometimes the anger is turned inward and the person experiences depression, guilt and lowered self-esteem. People will not admit to angry feelings if asked directly.
There are also cultural sanctions against speaking ill of the dead. However, it is important for bereaved persons to acknowledge some of their negative feelings. It is also important to help them get in touch with existing positive feelings even though at times they may be few in number. This will help in the resolution of anger.
Sometimes the bereaved person gets stuck in the stage of depression and refuses to stop mourning. Here the therapy is to facilitate the person to stop grieving.
The most serious complication of bereavement is depression and risk of suicide. This is not common, but, if present, needs immediate intervention. Many years ago Sigmund Freud pointed out the fundamental difference between what he called mourning (normal grief) and melancholia (depression). He said, in grief the world looks poor and empty, whereas in depression the person feels poor and empty.
The second difference is that persons with depression experience profound loss of self-esteem, but the self-regard of persons engaged in a mourning process is not diminished. Therefore, if a mourner feels worthless and expresses a strong sense of general guilt and ideas of dying, it is time to seek professional help.