Susan Delaney, Bereavement Services Manager with the Irish Hospice Foundation, presents a model of how different people respond to bereavement and how GPs might respond to the needs of bereaved patients
Normal grief (Level 1) can be defined as the state that occurs when a person is affected by the death of a significant person in their life. Typically, the symptoms include intense yearning or intrusive thoughts and images, and/or dysphoric emotions.
In early bereavement, people may describe changes in eating and sleeping patterns, bouts of crying, difficulty concentrating and feeling low. However, these symptoms subside over time and interest and engagement in daily activities are renewed.
This movement towards adaptation can be noticed from about three months after the loss, as natural resilience promotes a return to equilibrium. As this integration occurs, painful feelings lessen and thoughts of the deceased person cease to dominate the mind of the bereaved.
The symptoms can reoccur on important dates such as birthdays and anniversaries, but the bereaved person will report that overall they are coping better.
Most people find their own way through bereavement with the help of supportive family and friends. Current bereavement thinking indicates that there are no set stages or patterns to grief; rather it is an individual process and will follow its own course and rhythm.
In this author’s clinical experience, some of the typical worries that people express are, ‘Is what I am experiencing normal?’ and ‘Why am I still feeling so low?’. They may be surprised that grief can be so physical and concerned that they are not grieving the ‘right’ way. Sometimes, reassurance that their grief is within normal limits and a validation of the impact of the loss can be the only intervention needed from professionals.
Suggestions for responding to patients presenting with Level 1 bereavement needs would include: to acknowledge the loss; and provide information on the grief process.
A model of bereavement that this author has found useful when working with clients is the Dual Process Model by Strobe & Strobe. Briefly, this model describes how in bereavement, a person needs to attend to their grief while also getting on with life.
Styles of grieving can differ, and some patients who can easily talk about their loss and be open with their emotions may struggle with the practical challenges that the death brings to their daily life.
Similarly, a more action-oriented person may cope by keeping themselves busy, but might need a reminder to also allow themselves time to grieve. Bereaved people can typically relate to this model and grasp the concept of balancing these two processes: moving towards grief, and moving away from grief.
l Bereavement leaflets are available in hard copy form from the Irish Hospice Foundation (IHF) or they can be downloaded from www.hospice-foundation.ie;
l The HSE (www.hse.ie) and the Citizen’s Information Board (www.citizensinformationboard.ie) both provide information on bereavement;
l The IHF lending library is available to professionals and the general public. This includes books that give further information on bereavement and stories of people who have faced bereavement. Call (01) 679 3188 for further information.
Level 2 bereavement
Some bereaved patients, while presenting with a ‘simple’ bereavement, do not have the network of family and friends to support them through bereavement. This may be because their family does not reside in Ireland, they are estranged from their family or everyone in the family is struggling to cope with the loss.
In this case, a service that can provide a listening ear, or internet-based support, may be an appropriate intervention. Bereavement support groups are typically run by volunteers who have been trained in listening skills and have been bereaved themselves.
When it comes to offering suggestions for responding to patients presenting with Level 2 bereavement needs, bear in mind the suggestions for Level 1 and also provide information on community and web-based resources. Useful resources would include:
l Hospices (and some hospitals) provide bereavement support for those bereaved in their care. The individual social work departments will have details;
l Bereavement counselling services: phone (01) 839 1766 for a listening service run by trained volunteers in several centres around Dublin;
l Bethany Bereavement Support Groups: call 087 9905299 for a parish listening service run by trained volunteers;
l Rainbows (01 4734175): a national peer-support programme to assist bereaved children and adults;
l Console (01 8685232): a national support service for those bereaved by suicide;
l Living Links (067 43999) offers outreach support to those bereaved by suicide;
l Isands (01 872 6996) provides help and support to parents whose baby has died or is expected to die;
l Barnardos, at (01) 473 2110, offers a helpline regarding bereaved children. It also offers counselling services for bereaved children.
Some useful web resources would include: www.anamcara.ie (a resource for bereaved parents and siblings run by bereaved parents); crusebereavementcare.org.uk; and griefnet.org.
Level 3 bereavement
A minority of people (10-20 per cent) experience difficulty in adjusting to their loss and may present at the surgery either with ongoing grief symptoms, or physical symptoms that relate to the loss. Emotional support alone does not ameliorate the presenting symptoms and they may report a worsening of symptoms as time goes on.
Frequently, there is a sense of persistent and disturbing disbelief regarding the death. There are often feelings of anger, bitterness and resistance to accepting the reality of the death.
Intense yearning and longing for the deceased continue, along with frequent pangs of intense, painful emotions.
Thoughts of the deceased person continue to dominate and preoccupy their day. Interest and engagement in ongoing life, including hobbies and family events, is limited or absent, and there may be avoidance of a range of situations and activities that serve as painful reminders to the loss.
This presentation is often called complicated grief. It is likely that it will be listed as a disorder in the new DSM V, which is due for publication in 2013, with the title ‘prolonged grief (PG)’. While most practitioners seem to agree that there is a qualitative difference in the presentation of this minority group, and this is backed up by fairly robust research (see Prigerson, 2006), there is mixed feeling in the bereavement field about moving bereavement to the status of an axis 1 disorder.
The risk factors for developing a prolonged grief include:
l Deaths that are sudden, unexpected or perceived as preventable can put someone at risk of developing PG;
l People who have previously had difficulty coping with change or loss, or who have a history of emotional difficulties, can be at risk of developing prolonged grief;
l Also at risk are people who suffer several losses contemporaneously or have been at risk of death themselves;
l Finally, those who have, or perceive themselves to have, limited social support are vulnerable to developing PG.
There is no single circumstance that leads to PG, but when the above factors are present, the likelihood of developing prolonged grief rises.
Some practitioners find it useful to employ a checklist to diagnose PG; others question this method of information gathering and stress the need to engage the bereaved person in any assessment of bereavement.
Two factors that have been found to reduce the risk of PG are advance preparation for the death and a strong network of support. Interventions geared towards preparing caregivers for an imminent death, as well as building up a strong natural network, can reduce the likelihood of PG developing. Traditional, person-centered counselling has been shown to be minimally effective in treating PG.
Patients appear to respond better to interventions that enhance coping skills, and specific therapies that conceptualise grief as trauma also appear to be useful, but there is little currently published on intervention efficacy.
While PG may have some overlapping symptoms with depressive illness, drugs that have been found useful in treating depression have not been found to be particularly effective in treating PG.
Suggestions for responding to patients presenting with Level 3 include bereavement therapy, which aims to resolve the deeper emotional issues that can be created or revived by a significant loss, and specific therapies that conceptualise grief as trauma, which have been shown to be the most effective to date.
Early studies (such as Shear, 2005) are confirming the efficacy of this approach, with PG patients reporting improvements in symptoms of depression, anxiety and general impairment.
For resources and referrals, see those listed under Levels 1 and 2. Also:
l Refer patients to well-trained and accredited practitioners who have specialised training in the area of prolonged grief;
l If the death was through a hospice or hospital, there may be appropriate services available;
l The Psychological Society of Ireland (01 4749160) can provide a list of qualified psychologists;
l The Irish Association of Counselling and Psycho-therapy (01 2723427) can supply a list of qualified therapists;
l Counselling training courses often offer reduced-rate services for their students. This can be a good resource for patients on a limited budget.
l Susan Delaney, Psy.D. is a clinical psychologist and the Bereavement Services Manager with the Irish Hospice Foundation.
l Prigerson, H and Maciejewski, P. (2006). A call for sound empirical testing and evaluation of criteria for complicated grief proposed for DSM-V. Omega: The journal of death & dying, 52, 1-7.
l Shear, K. (2006). The treatment of complicated grief. The Australian journal of grief and bereavement. Vol. 9: 20, 39-42.
l Shear, K, Frank, E, Houck, P and Reynolds, C. (2005) Treatment of complicated grief. JAMA, Vol. 293, No. 20.
l Stroebe, MS, Hansson, R, Stroebe, W and Shut, H. (2001) Handbook of Bereavement Research: consequences, coping and care. APA, Washington.
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