Some believe complicated grieving to be a response out-side the norm, occurring when a person is void of emo-tion, grieves for prolonged periods, or has expressions of grief that seem disproportionate to the event. People may suppress emotional responses to the loss or become obses-sively preoccupied with the deceased person or lost object. Others actually may suffer from clinical depression when they cannot make progress in the grief process (Zhang, El-Jawahri, & Prigerson, 2006). Figure 12.1 depicts an overview of complicated grieving.
Previously existing psychiatric disorders also may com-plicate the grief process, so nurses must be particularly alert to clients with psychiatric disorders who also are grieving. Grief can precipitate major depression in a per-son with a history of the disorder. These clients also can experience grief and a sense of loss when they encounter changes in treatment settings, routine, environment, or even staff.
Although nurses must recognize that complications may arise in the grief process, the process remains unique and dynamic for each person. Immense variety exists in terms of the cultural determinants in communicating the experience and the individual differences in emotional reactions, depth of pain, and time needed to acknowledge and grasp the personal meaning or assimilate the loss.
For some, the effects of grief are particularly devastating because their personalities, emotional states, or situations make them susceptible to complications during the pro-cess. People who are vulnerable to complicated grieving include those with the following characteristics:
Low truth in others
A previous psychiatric disorder
Previous suicide threats or attempts Absent or unhelpful family members
An ambivalent, dependent, or insecure attachment to the deceased person.
· In an ambivalent attachment, at least one partner is un-clear about how the couple loves or does not love each other. For example, when a woman is uncertain about and feels pressure from others to have an abortion, she is experiencing ambivalence about her unborn child.
· In a dependent attachment, one partner relies on the other to provide for his or her needs without necessar-ily meeting the partner’s needs.
· An insecure attachment usually forms during childhood, especially if a child has learned fear and helplessness (i.e., through intimidation, abuse, or control by parents).
A person’s perception is another factor contributing to vulnerability: Perception, or how a person thinks or feels about a situation, is not always reality. After the death of a loved one, a person may believe that he or she really can-not continue and is at a great disadvantage. He or she may become increasingly sad and depressed, not eat or sleep, and perhaps entertain suicidal thoughts.
Zhang, El-Jawahri, and Prigerson (2006) and Zisook and Zisook (2005) identified experiences that increase the riskfor complicated grieving for the vulnerable parties previ-ously mentioned. These experiences are related to trauma or individual perceptions of vulnerability and include the following:
· Death of a spouse or child
· Death of a parent (particularly in early childhood or adolescence)
· Sudden, unexpected, and untimely death
· Multiple deaths
· Death by suicide or murder
Based on the experiences previously identified, those most intimately affected by the terrorist attacks on September 11, 2001 could be considered at increased risk for complicated grieving.
The person with complicated grieving also can experience physiologic and emotional reactions. Physical reactions can include an impaired immune system, increased adre-nocortical activity, increased levels of serum prolactin and growth hormone, psychosomatic disorders, and increased mortality from heart disease. Characteristic emotional responses include depression, anxiety or panic disorders, delayed or inhibited grief, and chronic grief (Zisook & Zisook, 2005).
Because the grieving process is unique to each person, the nurse must assess the degree of impairment within the context of the client’s life and experiences—for example, by examining current coping responses compared with previ-ous experiences and assessing whether or not the client is engaging in maladaptive behaviors such as drug and alcohol abuse as a means to deal with the painful experience.