Loss is an inevitable experience that may arise from the demise of a loved one as well as other life events. In most cases, individuals respond through grief, a normal process that leads to acceptance of loss. Normal or uncomplicated grief typically does not require formal treatment although grieving persons need to find the support and information they need (Zisook & Shear, 2013). However, there are individuals who experience prolonged and debilitating grief, referred to as complicated grief. Social workers play an integral role in helping individuals through the grief process by assessing for related needs as well as providing or bridging them to appropriate interventions.
Problem Overview
Each year, 2.5 million deaths occur in the United States (Shear, 2012). In 2011, over one million, or close to 40%, of those who died had a terminal illness and received hospice care (Metcalf, 2013). The deceased are survived by between one and five close family members resulting in 2.5-12.5 million bereaved persons every year. Uncomplicated grief from the loss of a loved one occurs 90% of the time while 10% involves impaired functioning and the development of psychiatric disorders that are hallmarks of complicated grief (Zisook & Shear, 2013). However, the proportion of complicated grief is higher at 30% among persons with mental health problems (Lichtenberg, 2010).
Affected Populations and Systems
No one is immune to loss and consequent grief. The literature identifies different segments of the population experiencing grief. HHealth care professionals, including social workers, who care for dying patients have been noted to experience grief (Boyle, 2011). Grief following the sudden and violent death of a loved one, for instance by murder, and grief among survivors of suicide are two groups of bereaved individuals also studied. Bereaved children and teenagers is another population in studies. In addition, there have been studies of grief among persons with mental health problems or mental disabilities.
In the workplace, grief arising from a coworker’s death is another area of research. Caregiver grief involving loved ones with long-term conditions including dementia and Alzheimer’s is often anticipatory, as is grief involving persons with cancer and other terminal illnesses (Waldrop, 2007; Jones, 2010). Grieving patterns in this population have been studied as well and includes parental grief over a terminally-ill child. Moreover, researchers have examined the spousal grief in older adults who have cared for a husband or wife with a long-term illness. The grief experience among parents who lost a newborn and women who had abortions or miscarriages also sparked research interest. Finally, the grief experiences of veterans of war have been studied (Ober, Granello & Wheaton, 2012)
In complicated grief, persons at high risk for this grief trajectory are those with a history of multiple trauma, anxiety or mood disorder, and insecure attachment in childhood (Shear, 2012). Several types of loss also increase the likelihood of complicated grief, namely those concerning a child and a spouse or partner and losses caused by homicide or suicide. The circumstances of death can further contribute to complicated grief such as when the loved one died or hostility from other family members (Shear, 2012). Hence, segments of the bereaved population presenting with these risks may need additional interventions, both formal and informal.
In addition, hospice, long term, perinatal, and obstetric care are some of the settings wherein grief-related needs must be considered in relation to caregivers, families, parents, women, and health and non-health care providers. Mental health care and senior care settings must also consider how they can assist grieving clients. Schools, workplaces and institutions serving persons with mental disabilities will inevitably have to support students, employees, and clients deal with their losses as well (NASP, 2010; Duke University, 2013). Finally, communities must have support systems for bereaved persons especially for deaths by homicide or suicide. This is especially true with the incidences of mass shootings.
Definition
Grief is defined as the range of normal physical, cognitive, emotional, behavioral, and spiritual responses to loss (Zisook & Shear, 2013). For instance, low levels of energy, indecision, inability to concentrate, distress, lack of appetite, insomnia, and anger are common during acute grief or the immediate aftermath of loss (Wolfelt, 2013). There are several tasks that bereaved individuals need to navigate to adapt effectively and include accepting the reality of the death. The bereaved must work through and experience the range of negative emotions that accompany loss including shock, sadness, anger, regret, fear, and guilt (Smith & Segal, 2012). Subsequently, they must learn to adjust to life without the physical presence of the deceased but still establishing enduring bonds with the dead person referred to as integrated grief (Howarth, 2011).
While bereavement is the state of having lost someone, grief is a complex process where different persons experience different types of distress with varying intensities and durations (American Cancer Society, 2013). The grief trajectory that follows bereavement depends on several factors relating to the circumstances of death, the relationship of the person with the deceased, attributes of the grieving person, his or her social and health situation, impact of the loss, and cultural influences (Grebin & Vogel, 2007). For most people, grieving never ends as they continue to remember the deceased years after the death.
Grief is unique from depression despite their common association (Boelen & van den Bout, 2005). In major depression, there is a persistent loss of pleasure or interest but in complicated grief, this relates to missing the deceased. While there is a persistence of dysphoric mood in depressed individuals, strong grief emotions are precipitated by reminders that the loved one is gone (Shear, 2012). Clinical depression involves a preoccupation with shame, guilt, or low self-esteem whereas, in grief, preoccupation and guilt relate to the dead person (Shear, 2012). Whereas depression is characterized by social withdrawal, this is in relation to bereavement among grieving persons. Yearning or longing for and intrusive images of the deceased, while common among grieving persons, are not typical symptoms in major depression.
Grief is also similar yet different from post-traumatic stress disorder (PTSD) (Shear, 2012). Both states are a reaction to a major event in a person’s life. Grieving persons, as mentioned above, experience the intrusion of images of the dead loved one, withdraw from others, and feel isolated. Reports of sleep disturbances or attention problems are also common in grief. However, bereaved persons do not typically develop a fear of physical danger and hypervigilance as what happens among persons with PTSD (Shear, 2012). Rather, most manifestations are connected to the demise of a loved one.
Complicated grief, on the other hand, is a reaction to loss that impedes grieving adaptation. Through numbing and avoidance, persons with complicated grief are able to insulate themselves from the feelings of distress linked with the death (Howarth, 2011). In addition, they may feel so overwhelmed and devastated that they experience disorientation (Grebin & Vogel, 2007). They become stuck in grief as they avoid coming to terms with the reality of death. Symptoms include excessive attention to the loss, intense yearning for the dead loved one, inability to accept the death, detachment, profound sadness, difficulty performing normal daily routines, and inability to enjoy daily life (Howarth, 2011). In addition, complicated grief can lead to depression that reinforces the symptoms of the former.
Consequences of Grief and Loss
In general, grief and loss are painful and difficult experiences but facilitate adaptation through major and minor changes at the individual, family, and community levels. For example, the death of a loved one may precipitate moving to a new home, starting a new job, or engaging in new activities. In communities, collective grief such as in the aftermath of mass killings can lead to the identification of preventive actions (Rettner, 2012). For this reason, grief can precipitate change and growth. However, ineffective adaptation among individuals, such as in complicated grief, is a negative consequence of loss.
Impact on Individuals, Families, and Communities
At the individual level, grief and loss can negatively affect performance at work and in school. The physical, emotional, and cognitive manifestations of grief may hinder the satisfactory fulfillment of tasks or the capacity to learn. Among employees, grief especially when coupled with lack of support in the workplace may be a reason for finding a job elsewhere (Duke University, 2011). Among nurses and social workers who witness death and dying as a common occurrence in the workplace, their grief for the patient may largely be unacknowledged. The lack of support and interventions can lead to burnout or compassion fatigue wherein the professional becomes apathetic because of the depletion of the capacity to show compassion (Boyle, 2011).
In some studies, bereavement and grief resulted in the deterioration of familial bonds (Breen & O’Connor, 2011). One reason is unmet individual expectations of how other family members should grieve. Other family members may also be expected to take on roles, e.g. keeping the family together, that lead to a heavier burden. Clearly, support must be extended not only to the individual but to the family as well using family-centered models of care (Kovacs, Bellin & Fauri, 2006). At the community level, experiences of mass losses can lead to greater solidarity through public gatherings. The need to prevent future tragedies often motivates the creation of ordinances including a limit on the purchases of gun magazines and other precautions (Dinzeo, 2014).
The Impact of Systems on Grief
Social support includes acts or situations wherein the bereaved feel they are cared for and valued (Breen & O’Connor, 2011). These may be informational wherein the bereaved benefit from advice and guidance. Social support may also be instrumental and means giving financial assistance, services, and goods. Moreover, support could be emotional in nature through the mere presence of others, empathy, and warmth. Social support must be adequate, available, and extended to the bereaved by social networks including the family, workplace, and community (Breen & O’Connor, 2011). A good understanding of grief should frame the provision of social support for it to be regarded as helpful and appropriate.
Informational support is one intervention that health and social care institutions are in the best position to provide. A survey of caregivers of terminally-ill persons revealed an overwhelming perception of being unprepared for the eventual death arising from a lack of reliable information and support (Hebert et al., 2008). However, researchers found that grief care takes place only when individual members of the staff had an interest in it and took the initiative (Montgomery & Campbell, 2012). There were few institutionalized processes for the assessment of grief care needs and assigning the most capable professionals to provide services. This study validates earlier findings that 54% of complaints pertaining to health and social care facilities was in relation to dissatisfaction with dying, death, and bereavement-related care (Stephen et al., 2008). Moreover, it is estimated that 80% of support for bereaved persons is provided by volunteers and voluntary groups rather than the health and social care system. The absence of social support in this system may contribute to suboptimal grief experiences.
At the same time, a qualitative study of bereaved individuals shows a general lack of appropriate emotional support from social networks primarily because of the predominant misconceptions about grief. One is the belief that grief, no matter the manner of loss, follows a similar, predefined, and linear pattern among all bereaved persons (Duke University, 2013). Consequently, bereaved persons are expected to grieve in proper ways and any deviation, like not openly expressing emotional distress, is abnormal and met with suggestions about seeking treatment.
Another is that grief is a finite and short-term experience so that a few days or weeks after the death, the bereaved are expected to be over it (Manns & Little, 2011). For example, participant were told that they will be okay or that they should get over it because the death was months ago. Further, employers may expect the same level of performance from a grieving employee (Duke University, 2013). Still another misconception is that grieving persons should remain strong as reflected in comments such as “chin up” (Breen & O’Connor, 2011). This scenario created pressure to be strong among persons experiencing grief leading to the perception that signs of weakness sometime after the initial period of the death are inappropriate.
Lastly, there is also the misconception that the bereaved must severe any attachments with the deceased so that holding on to photographs and other tangible reminders are considered abnormal although refuted in the literature (Manns & Little, 2011). For instance, one participant in the study was told by co-workers to remove her deceased child’s photo from her work desk. Misconceptions in the workplace, health and social care systems, schools, families, and communities hinder the provision of appropriate social support that can ease the process of uncomplicated grieving or help prevent complicated grief. That related education and training is inadequate in health and social care curricula does little to correct false beliefs (Ober, Granello & Wheaton, 2012).
The Etiology of Grief
Grief is caused by loss. Although bereavement is the most common loss, there are other types of losses including divorce, retirement, ill health, illness of a loved one, loss of a job and financial security, demise of a pet, and the inability to achieve a dream (Smith & Segal, 2012). Losing something or someone that one loves or values evokes pain, sadness, and a host of other negative emotions that affect other areas of functioning. The dual process model of grief suggests that individuals deal with loss by oscillating between strategies of coping. When individuals adopt loss-orientation, it entails mentally processing the primary loss, accepting the attendant suffering, and grieving (Wright & Hogan, 2008). On the other hand, restoration-orientation involves the individual sorting through the changes or secondary losses brought about by the primary loss including financial and familial consequences (Wright & Hogan, 2008). This manifests in individuals as alternating periods of avoiding the loss and dwelling in grief. Moving from loss-orientation to restoration-orientation has a protective effect on mental health in that it provides a respite from anguish that a person may not withstand when continuously experienced. Thus, it facilitates uncomplicated grief.
Competing Theories
A theory of grief was proposed by Kubler-Ross wherein individuals are thought to go through several distinct stages – denial, anger, bargaining, depression, and acceptance (Prigerson & Maciejewski, 2008). Some models expanded the stages to include pain and guilt before anger, and upward turn and reconstruction prior to acceptance (Wright, 2011). Stages are useful in describing the typical course of grief although Kubler-Ross originally applied the theory to dying and not bereaved persons. At the same time, some also see the stages incapable of encompassing the range of experiences by grieving persons.
An alternative theory deemed more applicable to the bereaved is the transtheoretical model of change consisting of the following stages: “pre-contemplation, contemplation, preparation, action, and maintenance” (Calderwood, 2011, p.109). Pre-contemplation is parallel to the denial stage of Kubler-Ross’s theory wherein an individual is unable to comprehend and accept the impact of the loss. In contemplation, the bereaved individual starts to realize that the loss entails an internal transformation and one that is lengthy and difficult (Calderwood, 2011). The preparation stage is when the individual acknowledges the need to move on and takes initial steps forward. Examples of actions taken during this stage are memorializing the person through a video, scrapbook, or photo album and creating commemorative rituals. These activities facilitate letting go of the past.
In the action stage, the individual comes to terms how the death has changed his or her personal identity and seeks new meanings through actual changes such as engaging in new hobbies, having new friends, dating, or having another baby (Calderwood, 2011). However, reminders of the deceased including birthdays or anniversaries will continue to trigger strong emotions even after transformations were made, and the bereaved has moved on. The maintenance stage is when individuals establish ways of coping with the resurgence of grief in order that it will not interfere too much with daily life (Calderwood, 2011). For many, it does not mean closing a chapter in one’s life never to be revisited again. Rather, it means being able to put memories and the feelings they evoke aside to be entertained by the person when desired.
Another perspective of grief is through the multiple trajectories model. Following a study that aimed to determine individual adjustment to loss, findings revealed five unique trajectories that captured the experiences of the majority of participants. In order of prevalence, these are resilience of stable and low levels of distress; chronic grief; recovery or common grief; depression and improvement; and chronic depression (Hall, 2011). The level of distress was highest among persons who were dependent on the deceased spouse. Incidentally, grief responses were highly influenced by dependency level.
Distress level was also influenced by suddenness of the death and the consequent lack of psychological preparation (Hall, 2011). On the other hand, chronic depression was associated with relationship conflict with the deceased. Individuals who experienced chronic grief processed the loss and searched for meaning more than persons who were chronically depressed (Hall, 2011). The trajectories model emphasizes that there are no uniform stages and tasks that bereaved persons must go through or fulfill in order to successfully adapt to the loss of a loved one. Different samples of bereaved individuals may result in varying strategies of adaptation or grief trajectories.
In addition, the elements facilitating or hindering the process of grieving are also important variables and have been studied in populations of caregivers of terminally-ill cancer patients (Dumont, Dumont & Mongeau, 2008). The findings that there are multiple and often unique elements that shape the grieving process further support the multiple trajectories model. The presence and helpfulness of social support certainly can be a barrier or facilitator to uncomplicated grieving as described in a qualitative study by Breen & O’Connor (2011). In complicated grieving, the type and co-occurrence of risk factors also determine the trajectory (Hebert et al., 2008).
Conclusion
Grief is a universal occurrence brought on by bereavement and other types of loss. It entails suffering from physical, emotional, and other manifestations distinct from major depression and PTSD. It consists of an acute and integrated phase. The uncomplicated type of grief proceeds without treatment typically resulting in adaptation and moving on whereas complicated grief is incapacitating and requires formal intervention. Adaptation entails change at the individual, family, and community levels. There are many theories providing different perspectives of grief as a state and process. Bereaved persons benefit much from different forms of social support. However, support is sometimes unavailable, inappropriate, and unhelpful because of prevailing misconceptions about grief and the lack of systematic ways for service delivery. Social workers can help enhance social support systems to ensure that persons in grief effectively cope with their situation.
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