BEREAVEMENT, MOURNING AND GRIEF

Bereavement is the state of having lost something or someone.

The experience of someone who is grieved or bereaved is entirely individual. The way a person grieves depends on a number of factors such as one’s personality and coping style, life experience, faith, and the nature of the loss grieving process takes time.

Grief: is a process of emotional, cognitive, functional behavioral responses to loss or death

Grief is the emotional and psychological experience activated by loss of something dear.

Grief is a natural response to loss. It is the emotional suffering you feel when something or someone you love is taken away. It is felt by an individual, family or community brought about by loss; most intensely with the death of a loved one (HAU, 2011).

Mourning is the period of time it takes to grieve

Periods of mourning vary according to:

The manner of death (long illness, sudden death or traumatic death such as car accident, murder, medical mistake)
The age of the person who dies (a child’s death often feels out of place; an older person has often had longer relationships)
The age of the bereaved (child development affects reaction; life stage is relevant)
Gender (women are often allowed more emotional expression than men)
Previous experiences of loss and their impact
Support systems
Personal coping styles
Family and cultural

Stages of Grief/Grieving

Peoples’ experiences of grief may go through stages as described below. These stages may not be orderly always as some may be missed out sometimes. These include

Stage One: Denial – refusal to believe that death would be likely outcome of this illness. No, not me ‘The tests must be wrong. God would not allow this to happen to me. There has been some mistake.’
We deny that the trauma or loss has occurred. We begin to use;
- Magical thinking: believing that by magic, this memory will go
- Regression: Believing that if we act child-like, others will reassure us that nothing is
- Withdraw: Believing that we can avoid facing the losses and the truth
- Rejection: Believing we can reject the truth and avoid facing the loss
Stage Two: Anger – questioning ‘Why me?’ It’s not fair!’ Who or what can I blame for this illness?’
- We become angry with God, it ourselves, or with others over our pain.
- We pick out a scapegoat on which to vent our anger e.g. the doctor, nurse, hospital,
- We begin to use;
- Self-blaming believing we should blame ourselves for the blame of our trauma.
- Switching blame believing we should blame others
- Aggressive anger believing we have a right to vent out the blame rage aggressively.
- Anger is a normal stage; it must be expressed to be If it is suppressed and help in, it will become locked away or replaced leading to depression that further drains away our emotional energy.
Bargaining – attempt to delay the disaster, ‘Yes, but. . .’‘If I give money to the church or pray and fast every day then I will recover.’
- We bargain or strike a deal with God or others to make the pain go away.
- We promise to do anything to make this pain go.
- We agree to take extreme measures in order to ask this pain disappears.
- We lack confidence in our attempts to deal with the pain looking elsewhere for answers.
- We begin to;
- Shop around believing we look for a cure for our pain.
- Take risks believing we can put ourselves in a jeopardy way to get an answer for our pain.
- Take more care for others believing we can ignore out our needs.

4. Depression – reaction to existing and impending ‘It’s me! ’‘What is the point of struggling on; it is all meaningless.

We become over whelmed by the anger, pain and hurt of our. We are thrown into the depth of our emotional response.
We can begin to have uncontrollable spells of crying, sobbing and weeping.
We can begin to into spells of deep silence, Morose, thinking and deep melancholy.
We begin to experience;
Guilt believing, we are responsible for our loss.
Loss of hope believing we have no hopes or being able to return back to order in life and calm.
Loss of faith believing that because of this loss, we can no longer trust.

5. Acceptance – peaceful resignation it’s part of life. I have to get my life in order. We begin to reach a level of awareness and understanding of the nature of our loss

We can now;
Describe the terms and conditions in our loss
Cope with our loss
Handle the information surrounding this loss in a more appropriate way.
We begin to use;
Adaptive behavior, believing we can begin to adjust our lives to the necessary changes
Appropriate emotion, believing we begin to express our emotional responses freely and are better able to verbalize the pain, hurt, and suffering we have experienced
Patience and self-understanding, believing we set a realistic time frame in which to learn to cope with our changed lives.

Types of grief

Normal/uncomplicated grief: It is the ability of a person to progress satisfactorily through the stages of grieving to achieve resolution.
Anticipatory grief: is the type of grief before an expected loss.
Maladaptive grief: it is the inability to progress satisfactorily through the stages of grieving to achieve resolution i.e. the following types of maladaptive include:
1. Delayed: is the type of grief not experienced immediately after a loss possibly postponed.
2. Inhibited grief: the type of grief experienced by people who have great difficulty in expressing their emotions i.e. children
3. Chronic grief/prolonged grief: It’s a situation where the grieved person continues to feel the effects of loss which extends for a long time and behaves in an abnormal way which may manifest as:
  - Frequent visits to the grave
  - Low self esteem
  - Crying whenever he/she learns of other deaths
  - Speaking and over focusing on the dead person
  - Loss of libido
  - Vague aches
Disenfranchised grief: the type of grief that occurs when a loved person or item losses some of its adorable characteristics through still present i.e. one experiences loss when a loved there is decline in physical abilities in a dementia person through still present/alive
Cumulative grief: the type of grief that occurs when multiple loses are experienced often in a short period of time i.e. it can be stressful because one does not properly grieve one loss before the other
Masked grief: it is the type of grief converted into physical symptoms or other negative behaviours that are out of character i.e. someone experiencing masked grief is unable to recognize that these symptoms or behaviors are connected to loss.
Distorted grief: it presents with extreme feeling of guilt or anger, noticeable changes in behavior, hostility towards a particular person plus other self-destructive behaviors.
Exaggerated grief: it is the intensification of the normal stages of grief as the time moves on.

Factors that can make grief more challenging, harder and prolonged.

Relationship with the deceased: The nature of the relationship you had with the person who passed away can affect the intensity and duration of grief. Having a close and positive relationship can make it harder to let go compared to a difficult or distant relationship.
Circumstances of death: The circumstances surrounding the death can impact the grieving process. Factors such as whether the death was due to natural causes, accident, suicide, or homicide, as well as whether it occurred close to or far from home, can influence the grieving experience.
Personal history: Past experiences of loss and separation, such as the early loss of a parent, can affect how an individual processes and copes with grief.
Individual personality and beliefs: Each person has unique personality traits and belief systems that can influence how they experience and handle grief. These factors can vary greatly from person to person.
Social factors: The social context surrounding the loss can play a role in the grieving process. If the loss is socially stigmatized or not openly acknowledged, such as in the case of AIDS or suicide, it can add additional challenges to the grieving individual. Lack of social support can also make the grieving process more difficult.
Unacknowledged grief: Certain groups, such as gay men, lesbians, and children, may experience grief that is not fully acknowledged or recognized by society. This lack of validation can make the grieving process more complicated for individuals in these groups.

Common reactions in bereavement

Physical Reactions	Emotional Reactions	Social Reactions	Spiritual Reactions
Aches and pains	Disbelief	Needing to say goodbye	Questioning why this has happened
Nausea and/or vomiting	Numbness	Interaction with people at public gathering, funeral	Challenging the belief system (strengthening, decrease or change in beliefs)
Headaches	Sadness	Selecting and undertaking rituals	Bargaining with a higher power
Confusion, weakness and numbness	Crying, even sobbing	Self-absorption and anti-social behaviour	Talking to the deceased
Change in sexual needs (loss/increase of libido)	Unexpected thoughts and feelings, often painful	Needing to talk of the deceased	Dreams that may have significance about the deceased
Vulnerability to infections, cold, illness (low immunity)	Guilt	A sense of isolation from the world (‘in a bubble’)	Review of the meaning of life
Changes in eating and sleeping patterns	Panic and fear	Attempting to carry on as usual (social face)
Shortness of breath	Appearing distracted	Needing to be alone or need to be with others
Dry mouth	Feelings of helplessness
Sweating	Anger (at self and others)
Frequent urination	Blame
	Regret

Grief Counseling

Grief counseling and bereavement support play a crucial role in helping individuals and families navigate the challenging journey of loss. By implementing effective principles and strategies, counselors can provide compassionate care and assist in the healing process.

Principles of Effective Grief Counseling

Convey Support and Compassion: Show empathy and understanding towards the grieving individual, offering a safe space for them to express their emotions.
Acknowledge the Loss: Validate the significance of the loss and create an environment where the person feels heard and understood.
Accept the Inability to Control: Help individuals recognize that grief is a natural process and that they cannot control or hasten its course.
Validate Feelings, Thoughts, and Behaviors: Acknowledge and normalize the range of emotions, thoughts, and behaviors experienced during grief, providing validation and reassurance.
Channel Energy to Adapt and Reestablish Equilibrium: Assist individuals in redirecting their energy towards adapting to life without the deceased, finding new routines, and establishing a new equilibrium.
Encourage Access to Supportive Networks: Emphasize the importance of seeking support from helpful individuals, such as friends, relatives, or support organizations, to foster a sense of community and connectedness.

Bereavement Counseling for Individuals Facing AIDS/Cancer

Help Acceptance of Death: Work towards helping the patient and their family accept the finality of death, while addressing fears and finding ways to ease them.
Reflect on Achievements and Past Time: Encourage patients to reminisce about their accomplishments and meaningful moments, while identifying sources of support, such as friends and relatives.
Provide Information on Symptom Management: Offer guidance on managing distressing symptoms associated with the illness, helping alleviate discomfort and improve quality of life.
Explore Religious and Cultural Beliefs: Respect and explore the patient’s religious and cultural beliefs, assisting in connecting them with appropriate sources of spiritual support.
Discuss the Future for Family: Facilitate discussions about the patient’s concerns regarding their family’s well-being after their death, encouraging open dialogue and planning for the future.

Bereavement Counseling After Death

Encourage Presence and Farewells: Support family members in spending as much time as needed with the deceased, allowing them to say their goodbyes in their preferred manner.
Sensitivity in Language: Use the deceased person’s name instead of impersonal terms like ‘the body,’ and provide detailed information if the family was not present at the time of death.
Repeat the Story of Illness and Death: Encourage family members to share and repeat the story of the illness and death, allowing them to process their experiences and emotions.
Involve Children and Explain the Situation: Include children in discussions, explaining what is happening in an age-appropriate manner to help them understand and cope with their grief.

Continuous Counseling After Death

Use Reminders for Memories: Encourage the bereaved to use photographs or other reminders to remember the deceased and cherish memories.
Involve Extended Support Network: Engage extended family members, friends, or volunteers to continue visiting and providing emotional support to the bereaved.
Encourage Open Communication: Foster an environment where family members can openly express their feelings, including guilt, relief, pain, or anger, promoting mutual understanding and support.
Active Listening: Prioritize active listening over excessive talking, allowing the bereaved person to share their emotions and experiences without interruption.
Discourage Major Life Decisions: Caution against making significant life decisions during the immediate grieving period, as emotions may cloud judgment and practical considerations may be overlooked.
Support Rituals and Grieving Processes: Acknowledge and support the use of rituals that can aid in the grieving process, respecting the bereaved person’s cultural and religious customs.
Self-Awareness of the Counselor: Maintain self-awareness of personal losses and emotions, ensuring that the counselor remains empathetic and focused on the needs of the bereaved.
Remember Special Dates: Make an effort to remember important dates such as birthdays and death anniversaries, reaching out to offer support and remembrance.
Encourage Emotional Well-being: Promote self-care, relaxation, and socialization, reminding the bereaved of the importance of taking care of themselves during the grieving process.

Complications of Grief

Chronic Depression: Prolonged and persistent feelings of sadness, hopelessness, and lack of interest in previously enjoyed activities.
Substance Abuse: Turning to drugs or alcohol as a way to cope with the pain of grief, leading to dependence and addiction.
Suicidal Behavior: Expressing thoughts or engaging in actions that indicate a desire to end one’s life. Immediate intervention and professional help are essential.
Prolonged Grief: Experiencing intense and persistent grief symptoms beyond what is typically expected, with difficulty adjusting to life without the deceased.
Chronic Physical Symptoms without Medical Reasons: Developing persistent physical symptoms such as headaches, stomachaches, or fatigue without an identifiable medical cause.
Severe Disease: The onset or worsening of chronic or severe health conditions as a result of the stress and emotional toll of grief.
Risk-Taking Behavior: Engaging in reckless or dangerous activities, potentially as a means to escape from or numb the pain of grief.
Persistent Sleep Disorders: Experiencing ongoing sleep disturbances, such as insomnia or nightmares, that significantly impact daily functioning.
Persistent Denial: Refusing to accept or acknowledge the reality of the loss, often avoiding discussions or reminders of the deceased.
Identification with the Deceased: Developing symptoms or behaviors similar to those exhibited by the deceased, as a way of connecting or holding onto their memory.

The role of the nurse in grief and bereavement

Provide Active Listening: Nurses listen attentively and non-judgmentally to individuals experiencing grief, creating a safe space for them to express their emotions and concerns.
Support Future Exploration: Nurses encourage patients to gently explore what the future may look like without the deceased, helping them envision possibilities and find hope amidst their grief.
Assess and Foster Social Support: Nurses assess the patient’s social support systems and help them develop and strengthen connections with family, friends, or support groups, recognizing the importance of a strong support network during the grieving process.
Facilitate Time with the Deceased: Nurses respect the desires of the bereaved to spend time with the body of the deceased at the time of death, creating opportunities for final goodbyes and closure.
Respect and Validate Feelings: Nurses honor the emotions of grieving individuals without judgment, recognizing that each person’s experience of grief is unique and valid.
Identify and Normalize Grief Manifestations: Nurses assist in identifying the various manifestations of grief, such as emotional, physical, and cognitive symptoms, helping patients understand that these reactions are normal and part of the grieving process.
Aid in Identifying Meaning of Loss: Nurses help survivors explore and identify the practical implications and meaning of their loss, supporting them in navigating the challenges and adjustments that come with bereavement.

Grief and Bereavement in Children:

Introduction:

School-going children require special attention following the death of their parents compared to preschoolers.
The experience of grief varies and is influenced by factors such as age, past experiences, and personality.
Children may express grief through crying and seeking solitude.
Bereaved children may experience deep sadness and a sense of something missing.
Even if their reactions are not visible, the pain of loss remains consistent.
Many children are not encouraged to grieve initially, but as they grow older, they may feel a sense of loss that can be expressed in different ways, even into adulthood.

Concept of Grief and Loss in Children:

Children’s ability to cope with death depends on their age and cognitive development.
They encounter death through various means like seeing dead animals, watching it on TV, or hearing about it in their homes, schools, and communities.
Children living with HIV may contemplate their own mortality and may have experienced multiple losses.
After a death, children need information, reassurance, and a safe space to express their feelings and participate in counseling.

Common Reactions of Bereavement in Children:

Children’s reactions to grief vary based on their age, personal development, and environment.
Understanding of death changes as children grow older:
- Children aged 0-2 years: Experience the loss of physical contact, security, and comfort when a primary caregiver dies. Show upset through changes in sleeping or eating patterns, crying, irritability, and withdrawal.
- Children aged 3-6 years: Unable to comprehend death as permanent and may expect the deceased person to return. Confuse fact and fantasy, sometimes attributing death to magic. Grieve in intermittent bursts, appearing to forget about the death at times but becoming upset again later.
- Children aged 6-9 years: Grasp that death is permanent and universal but may still imagine it as avoidable. Develop an interest in practical aspects such as what happens to the deceased person’s body. May feel a sense of responsibility for the death based on their behavior or thoughts.
- Children aged 9-12 years: Possess a similar understanding of death as adults. Recognize that death is universal, unavoidable, and permanent. Understand that death can be sudden and fear their own mortality. Begin contemplating the meaning of life and what happens after death.
- Adolescents: Have an adult-level understanding of death. May engage in risk-taking behaviors as a way to explore life and test boundaries.

Practical Ways to Support a Grieving Child:

Storytelling: Utilize storytelling as a helpful tool for children to process loss, grief, and transition.
Support and Counseling: Provide extensive support and counseling to guide a child through the bereavement period and help them transition back to normal life without complications of grief.
Communication and Expression: Encourage open communication within the family, allowing children to express their emotions through dressing, writing, storytelling, and games.
Preparation and Truthfulness: Prepare children by explaining the truth about the loss. An unprepared child may feel overwhelmed by sudden loss and experience shock and confusion.
Coping Skills Development: Help children develop coping mechanisms to navigate their grief. Offer age-appropriate guidance and support during counseling sessions.
Age-Appropriate Communication: Speak and listen to children using language and concepts suitable for their age and level of understanding.
Consistency and Stability: Maintain consistency in the child’s daily routine and environment, recognizing that grieving children may face multiple losses, such as changes in schooling or separation from their home.
Individualized Approach: Allow each child to grieve at their own pace, respecting their unique needs and providing individualized care.
Active Listening and Empathy: Assure the child that you are listening and genuinely care about their feelings at any given moment.
Normalizing Death: Teach children that death is a natural part of life by relating it to examples from nature, such as flowers, leaves, and animals, which can help them accept the reality of death.
Patience and Understanding: Recognize that children react differently to grief, requiring patience and understanding from caregivers and professionals.
Involvement and Choices: Offer grieving children choices, such as visiting the hospital, viewing the body, or attending the funeral, empowering them to participate based on their comfort level.
Continuity and School Support: Encourage a sense of continuity in the child’s schooling, as it can help them feel that life is returning to normal.

Things to Say to Children:

Explain that death is universal and inevitable, using examples from nature like flowers and leaves.
Acknowledge that death can be unpredictable.
Assure children that it’s okay to wish the person had not died.
Validate their feelings of anger and sadness.
Encourage reliance on religion and beliefs to accept and understand the concept of death.
Do not shy away from using the words “dead” or “death.”
Reassure children that they had nothing to do with the death.
Be honest about not having all the answers.
Highlight aspects of their life that will remain unchanged, such as the same room, school, toys, and friends.
Emphasize that life continues after pain and that there will be happy times again.

Things Not to Say to Children:

Avoid saying that the deceased is “sleeping” or has been “lost,” as it can confuse and frighten children.
Refrain from suggesting that the deceased “wanted” to go to heaven, as it implies a choice that may cause the child to feel abandoned.
Avoid trying to stop the grieving process by using phrases like “big boys don’t cry.” Allow children to express their grief naturally.