GRIEF and LOSS

Life is series of experiences and challenges. Loss is a human experience and a challenge we all must face. Loss requires that we give up something familiar, comfortable, and personal. The more intense the attachment, the more deeply felt the sense of loss. Loss of a person includes death, separation, divorce, moving, and changes in mental or physical status. We can also lose aspects of ourselves such as self-esteem, health, roles in life, and dreams. We are vulnerable to loss of objects such as possessions or pets. As we go through our life span we experience developmental losses associated with life transitions, such as grown children leaving the home or retirement from a career (Klebanoff and Smith, 1997).

The meaning of loss is subjective, as is the process of responding to a loss. The more significant the loss, the more intense the reaction we experience. Unresolved losses in the past influence how we manage current losses in the past influence how we manage current losses. Factors such as guilt, financial issues, ambivalence, age, culture, number of current stressors, and available support system determine how we react to loss and express our grief (Gorman, Sultan, and Raines, 1996).

Bereavement is the feelings, thoughts, and responses that loved ones experience following a death of a person with whom they have shared a significant relationship. Mourning or grieving is the active process of learning to adapt to the loved one’s death. Mourning is a progression through a series of phases that include recognition and acceptance of the death, the experience of emotional and physical pain, and the rebuilding of a life without the loved person. Grieving also occurs with any significant loss experience, as mentioned above, and is a process of learning to live with our feelings as we struggle to re-establish our self-esteem or self-confidence in the face of these personal losses. The process of grieving is essential for our mental and physical health as it allows us to cope with the loss gradually and to accept it as part of reality. Mourning and grieving are influenced by our families, our religious believes, and our cultural customs. It is a social process and is the best shared and carried out with the help of others. None of us grieves predictably or uniformly. As caring nurses, we must always respect individuality in the way persons grieve and mourn (Attig, 1996.



Culture and the Grieving Process
• The culture in which each of us is raised and the culture in which each of us lives partially determine what is acceptable in terms of the grieving process.
• Families also have general rules of behavior and expressions of feelings during grief.
• Family coping strategies include re-establishing a stable equilibrium, realigning family roles, and communicating clearly.
• Disenfranchised grief means that the loss cannot be openly acknowledged, socially validated, or publicly mourned.
• Complicated grief occurs when there is enormous social, psychological, and medical morbidity.

LOSS

Type of Loss

An individual may experience various types of loss throughout a lifetime. Depending on the significance of the loss, negligible or intense responses will be generated. Logically, multiple loss experiences will intensify the overall response. Four types of loss exist that individuals will experience singularly or collectively at any time.
Loss of external objects (physical or material loss) is, perhaps, the most common loss experience. External objects, or material loss, can be tangible, such as the loss of money, house, pets, or possessions, or it can be intangible, as in leaving one’s country or homeland or moving from one city to another.

A second type of loss that all individuals experience is maturational loss. Losses of this type occur throughout the life span. This loss begins with weaning the infant from the mother’s breast and continues with loss of baby teeth; loss of position in the family as more siblings arrive; loss of relationship, such as first love; going off to college; marriage; and changes in the body with the normal process of aging.

Every individual has an overall mental image of his body and persona. When events occur that alter a person physically or psychologically, a third type of loss is evident: loss of body image or some aspect of self (symbolic loss). Loss of body image can be initiated by physical assaults, such as the surgical removal of the breast, ovaries, or uterus; or the loss of an extremity through an accident or surgery. Psychological losses include loss of ideas one holds dear and feelings about one’s attractiveness, lovableness, confidence, and worth. Loss of positive attitudes, such as independence and control, and loss of social role, such as mother, father, or breadwinner, are also examples of this type of loss.

When familiar symptoms of disease are eliminated after medical or surgical intervention, the secondary gains that may have served a particular function for an individual are lost, and that person becomes uncomfortable and may grieve over their loss.
Loss of a loved one or a significant other is perhaps the most difficult loss a person experiences, especially if it is caused by death. This type of loss is the most difficult for nurses and other health care professionals to handle, because they also are confronted with their own mortality and vulnerability.

Each loss carries with it a threat of additional or future losses and secondary losses. The initial loss of health can, for example, precipitate the loss of a job (some aspect of self), money (material objects), family role, self-esteem, or body part. As one begins to assimilate and understand the concept of loss, it becomes increasingly apparent that loss plays a peripheral, as well as a central, role in both the start and outcome of illness and disease. Experiencing a major loss, such as the death of a spouse, may trigger psychosomatic illness or a variety of symptoms in a person, because loss is such a serious body stressor.
Regardless of the kind of loss, it is an integral part of the human experience and can be a stimulus for growth. The discomfort felt when a loss occurs stimulates a need to do something about it or to explore new avenues to lessen the discomfort or make it go away. The response one has or exhibits as a result of loss depends on one’s previous loss experiences, the meaning attached to the loss, one’s methods of coping, cultural dictates, the means available for handling the loss, environmental factors, and messages from parents and peers. Jackson similarly applied these factors to loss by death. He identified individual personality, social roles, one’s personal value structure, and the perceived relative importance of a loss as factors that affect the response to loss and the potential for growth.

Life Transitions as Loss
• Separation and divorce may be a child’s first significant loss.
• Adolescents must give up their dependence on their parents and form interdependent relationships with their peer group.
• Middle adults must respond to losses in physical status as well as managing dependent parents.
• Older adults deal with many losses, such as the loss of work roles, body image, relationships, control, material possessions, and death.

Psychiatric Disability as Loss
• Individuals who are psychiatrically disabled experience many losses in areas such as ADLs, social interactions, school, employment, housing, and community participation.
• Families of people with mental illness experience losses such as family roles, expectations of an ideal family life, and social stigmatization.

GRIEF

Grief is a natural response to loss. It’s the emotional suffering you feel when something or someone you love is taken away. You may associate grief with the death of a loved one – and this type of loss does often cause the most intense grief.

But any loss can cause grief, including:
a. A relationship breakup
b. Loss of health
c. Losing a job
d. Loss of financial stability
e. A miscarriage
f. Death of a pet
g. Loss of a cherished dream
h. A loved one’s serious illness
i. Loss of a friendship
j. Loss of safety after a trauma

The more significant the loss, the more intense the reaction we experience. However, even subtle losses can lead to grief. For example, you might experience grief after moving away from home, graduating from college, changing jobs, selling your family home, or retiring from a career you loved.

Everyone Grieves Differently
Grieving is a personal and highly individual experience. How you grieve depends on many factors, including your personality and coping style, your life experience, your faith, and the nature of the loss. The grieving process takes time. Healing happens gradually; it can’t be forced or hurried – and there is no “normal” timetable for grieving. Some people start to feel better in weeks or months. For others, the grieving process is measured in years. Whatever your grief experience, it’s important to be patient with yourself and allow the process to naturally unfold.

Are there stages of grief?

In 1969, psychiatrist Elisabeth Kubler-Ross introduced what became known as the “five stages of grief.” These stages of grief were based on her studies of the feelings of patients facing terminal illness, but many people have generalized them to other types of negative life changes and losses, such as the death of a loved one or a break-up.

The five stages of grief:

• Denial: “This can’t be happening to me.”

• Anger: “Why is this happening? Who is to blame?”

• Bargaining: “Make this not happen, and in return I will ____.”

• Depression: “I’m too sad to do anything.”

• Acceptance: “I’m at peace with what happened.”

If you are experiencing any of these emotions following a loss, it may help to know that your reaction is natural and that you’ll heal in time. However, not everyone who is grieving goes through all of these stages – and that’s okay. Contrary to popular belief, you do not have to go through each stage in order to heal. In fact, some people resolve their grief without going through any of these stages. And if you do go through these stages of grief, you probably won’t experience them in a neat, sequential order, so don’t worry about what you “should” be feeling or which stage you’re supposed to be in.

Kubler-Ross herself never intended for these stages to be a rigid framework that applies to everyone who mourns. In her last book before her death in 2004, she said of the five stages of grief, “They were never meant to help tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss, as there is no typical loss. Our grieving is as individual as our lives.”

Common symptoms of grief

While loss affects people in different ways, many people experience the following symptoms when they’re grieving. Just remember that almost anything that you experience in the early stages of grief is normal – including feeling like you’re going crazy, feeling like you’re in a bad dream, or questioning your religious beliefs.

• Shock and disbelief – Right after a loss, it can be hard to accept what happened. You may feel numb, have trouble believing that the loss really happened, or even deny the truth. If someone you love has died, you may keep expecting them to show up, even though you know they’re gone.

• Sadness – Profound sadness is probably the most universally experienced symptom of grief. You may have feelings of emptiness, despair, yearning, or deep loneliness. You may also cry a lot or feel emotionally unstable.

• Guilt – You may regret or feel guilty about things you did or didn’t say or do. You may also feel guilty about certain feelings (e.g. feeling relieved when the person died after a long, difficult illness). After a death, you may even feel guilty for not doing something to prevent the death, even if there was nothing more you could have done.

• Anger – Even if the loss was nobody’s fault, you may feel angry and resentful. If you lost a loved one, you may be angry at yourself, God, the doctors, or even the person who died for abandoning you. You may feel the need to blame someone for the injustice that was done to you.

• Fear – A significant loss can trigger a host of worries and fears. You may feel anxious, helpless, or insecure. You may even have panic attacks. The death of a loved one can trigger fears about your own mortality, of facing life without that person, or the responsibilities you now face alone.

• Physical symptoms – We often think of grief as a strictly emotional process, but grief often involves physical problems, including fatigue, nausea, lowered immunity, weight loss or weight gain, aches and pains, and insomnia.

COPING WITH GRIEF AND LOSS

Support for Grieving and Bereavement

Losing someone or something you love is very painful. After a significant loss, you may experience all kinds of difficult and surprising emotions, such as shock, anger, and guilt. Sometimes it may feel like the sadness will never let up. While these feelings can be frightening and overwhelming, they are normal reactions to loss. Accepting them as part of the grieving process and allowing yourself to feel what you feel is necessary for healing.
There is no right or wrong way to grieve — but there are healthy ways to cope with the pain. You can get through it! Grief that is expressed and experienced has a potential for healing that eventually can strengthen and enrich life.

1. Get support
The single most important factor in healing from loss is having the support of other people. Even if you aren’t comfortable talking about your feelings under normal circumstances, it’s important to express them when you’re grieving. Sharing your loss makes the burden of grief easier to carry. Wherever the support comes from, accept it and do not grieve alone. Connecting to others will help you heal.

Finding support after a loss

• Turn to friends and family members – Now is the time to lean on the people who care about you, even if you take pride in being strong and self-sufficient. Draw loved ones close, rather than avoiding them, and accept the assistance that’s offered. Oftentimes, people want to help but don’t know how, so tell them what you need – whether it’s a shoulder to cry on or help with funeral arrangements.

• Draw comfort from your faith – If you follow a religious tradition, embrace the comfort its mourning rituals can provide. Spiritual activities that are meaningful to you – such as praying, meditating, or going to church – can offer solace. If you’re questioning your faith in the wake of the loss, talk to a clergy member or others in your religious community.

• Join a support group – Grief can feel very lonely, even when you have loved ones around. Sharing your sorrow with others who have experienced similar losses can help. To find a bereavement support group in your area, contact local hospitals, hospices, funeral homes, and counseling centers.

• Talk to a therapist or grief counselor – If your grief feels like too much to bear, call a mental health professional with experience in grief counseling. An experienced therapist can help you work through intense emotions and overcome obstacles to your grieving.

2. Take care of yourself
When you’re grieving, it’s more important than ever to take care of yourself. The stress of a major loss can quickly deplete your energy and emotional reserves. Looking after your physical and emotional needs will help you get through this difficult time.

• Face your feelings. You can try to suppress your grief, but you can’t avoid it forever. In order to heal, you have to acknowledge the pain. Trying to avoid feelings of sadness and loss only prolongs the grieving process. Unresolved grief can also lead to complications such as depression, anxiety, substance abuse, and health problems.

• Express your feelings in a tangible or creative way. Write about your loss in a journal. If you’ve lost a loved one, write a letter saying the things you never got to say; make a scrapbook or photo album celebrating the person’s life; or get involved in a cause or organization that was important to him or her.

• Look after your physical health. The mind and body are connected. When you feel good physically, you’ll also feel better emotionally. Combat stress and fatigue by getting enough sleep, eating right, and exercising. Don’t use alcohol or drugs to numb the pain of grief or lift your mood artificially.

• Don’t let anyone tell you how to feel, and don’t tell yourself how to feel either. Your grief is your own, and no one else can tell you when it’s time to “move on” or “get over it.” Let yourself feel whatever you feel without embarrassment or judgment. It’s okay to be angry, to yell at the heavens, to cry or not to cry. It’s also okay to laugh, to find moments of joy, and to let go when you’re ready.

• Plan ahead for grief “triggers”. Anniversaries, holidays, and milestones can reawaken memories and feelings. Be prepared for an emotional wallop, and know that it’s completely normal. If you’re sharing a holiday or lifecycle event with other relatives, talk to them ahead of time about their expectations and agree on strategies to honor the person you loved.

WHEN GRIEF DOESN’T GO AWAY
It’s normal to feel sad, numb, or angry following a loss. But as time passes, these emotions should become less intense as you accept the loss and start to move forward. If you aren’t feeling better over time, or your grief is getting worse, it may be a sign that your grief has developed into a more serious problem, such as complicated grief or major depression.

THE NURSING PROCESS

Assessment

Assessment of client in the grieving or mourning process includes an accurate perception of the loss from their viewpoint. You begin by identifying the loss, be it a person or a relationship or a change in health status, roles in life, or dreams and aspirations for the future. Seek to understand the nature of the attachment to the lost person, object, or expectation. Assess past experiences with loss and the impact those have on the present experience. Assess cultural rituals and rules about mourning to understand the unique experience of grieving individuals.

Diagnosis

Possible nursing diagnoses for survivors of a family member who has died include Anticipatory grieving, Dysfunctional grieving, Social isolation, Altered role performance, Risk for altered parenting, Ineffective family coping: compromised, and Family coping: potential for growth. Nursing diagnoses for children of divorce include Altered family processes, Risk for caregiver role strain, and Family coping: potential for growth. For adolescents who lack a peer group, nursing diagnoses might be Impaired social interaction and Self-esteem disturbance. Nursing diagnoses for middle adults experiencing loss might be Impaired adjustment, Self-esteem disturbance, and health-seeking behaviors. Nursing diagnoses in late adulthood include Spiritual distress, Social isolation, and Hopelessness. Nursing diagnoses for families experiencing loss through mental illness include Impaired social interaction, Social isolation, Caregiver role strain, Ineffective family coping: compromised, Family coping: potential for growth, and Ineffective community coping.

Nursing Interventions

Behavioral: Coping Assistance

Grief Work Facilitation

Assisting individuals and families to progress through the grief process is an important nursing intervention. Encourage people to express their feelings about the loss and help them identify their greatest fears concerning the loss. Help them recognize that all these feelings are a normal part of grieving. Discuss the active process of grieving as they meet new challenges in coping. Let them know that you understand grieving takes a great deal of time and energy.
As new skill are identified and implemented, support those which are most effective. If appropriate, suggest alternative ways of dealing with challenges while supporting them in following their own choices. An important aspect of grieving is establishing autonomy and direction in their own lives. (Attig, 1996; McCloskey and Bulechek, 1996)

Discuss potentially difficult times such as holiday seasons or anniversary dates. Role playing may be helpful as they anticipate these painful events. Assist survivors to identify goals that are unattainable because of the loss while encouraging realistic goal setting. Explore the ways in which social support system have changed as a result of the loss or death. Refer to appropriate self-help groups for survivors of death, families of mentally ill persons, and individuals who are psychiatrically disabled (Klebanoff and Smith, 1997)
Spiritual care includes helping grieving person to seek new meanings in both life and death. Encourage them to implement religious beliefs and rituals surrounding death. Guide them through the process of self-reflection as they think about what has happened to them. As grieving progresses, you can provide a listening ear while they recover old and discover new goals and purposes in life (Attig, 1996; McCloskey and Bulechek, 1996)

If children are involved in the grieving process, answer their questions associated with the loss. Use clear words, such as dead or died, rather than euphemisms, such as passing on or gone to sleep. Clear up any misunderstanding the children may have. Use play, art, or journal therapy to help children identify and work through their feelings. Refer to community resources designed to help children cope with the loss of a family member (McCloskey and Bulechek, 1996).
Families have specific needs as they address losses associated with having a member who is psychiatrically disabled. Assist them in redefining roles, responsibilities, and functions within the family. Teach them how to navigate the mental health system to obtain treatment and locate sources of emotional and financial support. If necessary, help them locate respite care to prevent caregiver burnout. Teach them locate respite care to cope with deficit behaviors and intrusive or acting out behaviors by their loved one. Discuss stigma and ways to respond to prejudice from individuals, from communities, and from state and federal legislative branches as health care resources are allocated. Act as an advocate in preventing family exclusion as a member of the team, all of whom work together to support the individual in living the fullest life possible.

Evaluation

Living with losses is a normal but very stressful part of life. When coping with loss through grieving or mourning, people may respond in adaptive or maladaptive ways. Some never lose their sense of despair. In the face of this overwhelming negativism, family and friends often avoid the despairing person. Others are able to move though the process and focus on positive achievement and celebrate the relationship that was or is now. Family and friends find delight in sharing this positive process.

Some nurses have difficulty dealing with loss and death since they view the essence of caring as supporting life process. To accept death as a process of life enables other nurses to support people through this final stage of growth. To be effective caregivers, nurses must be willing to talk openly about death as well as accept their own mortality. As Hoff (1989 p. 418) states: “A healthy attitude toward our own death is our powerful asset in assisting the dying through this final life passage and comforting their survivors.

References:
Barry, Patricia D. 1998. Mental Health and Mental Illness. New York, Philadelphia: Lippincott.
Clinton & Nelson. 1996. Mental Health Nursing Practice, Australia: Prentice Hall Pty Ltd.
H & CS. 1996. Mental Health Service Directory. Melbourne: Health and Community.
Hunsberg & Abderson. 1989. Psychiatric Mental Health Nursing. Philadelphia: W. B. Saunders Company.
http://helpguide.org/mental/grief_loss.htm