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Chapter: Psychiatric Mental Health Nursing : Grief and Loss

Dimensions of Grieving

People have many and varied responses to loss.



People have many and varied responses to loss. They express their bereavement in their thoughts, words, feelings, andactions as well as through their physiologic responses. Therefore, nurses must use a holistic model of grieving that encompasses cognitive, emotional, spiritual, behavioral, and physiologic dimensions (Lobb et al., 2006).


Cognitive Responses to Grief


In some respects, the pain that accompanies grieving results from a disturbance in the person’s beliefs. The loss disrupts, if not shatters, basic assumptions about life’s meaning and purpose. Grieving often causes a person to change beliefs about self and the world, such as perceptions of the world’s benevolence, the meaning of life as related to justice, and a sense of destiny or life path. Other changes in thinking and attitude include reviewing and ranking values, becoming wiser, shedding illusions about immortality, viewing the world more realistically, and reevaluating religious or spiri-tual beliefs (Zisook & Zisook, 2005).


Questioning and Trying to Make Sense of the Loss


The grieving person needs to make sense of the loss. He or she undergoes self-examination and questions accepted ways of thinking. The loss challenges old assumptions about life. For example, when a loved one dies prema-turely, the grieving person often questions the belief that “life is fair” or that “one has control over life or destiny.” He or she searches for answers to why the trauma occurred. The goal of the search is to give meaning and purpose to the loss. The nurse might hear the following questions:


·    “Why did this have to happen? He took such good care of himself!”


·    “Why did such a young person have to die?”


·    “He was such a good person! Why did this happen to him?”


Questioning may help the person accept the reality of why someone died. For example, perhaps the death is related to the person’s health practices—maybe he did not take good care of himself and have regular checkups. Questioning may result in realizing that loss and death are realities that everyone must face one day. Others may dis-cover explanations and meaning and even gain comfort from a religious or spiritual perspective, such as believing that the dead person is with God and at peace (Neimeyer et al., 2006).


Attempting to Keep the Lost One Present


Belief in an afterlife and the idea that the lost one has become a personal guide are cognitive responses that serve to keep the lost one present. Carrying on an internal dia-logue with the loved one while doing an activity is an example: “John, I wonder what you would do in this situ-ation. I wish you were here to show me. Let’s see, I think you would probably. . . .” This method of keeping the lost one present helps soften the effects of the loss while assim-ilating its reality.

Emotional Responses to Grief


Anger, sadness, and anxiety are the predominant emo-tional responses to loss. The grieving person may direct anger and resentment toward the dead person and his or her health practices, family members, or health care pro-viders or institutions. Common reactions the nurse might hear are as follows:


·    “He should have stopped smoking years ago.”


·    “If I had taken her to the doctor earlier, this might not have happened.”


·    “It took you too long to diagnose his illness.”


Guilt over things not done or said in the lost relation-ship is another painful emotion. Feelings of hatred and revenge are common when death has resulted from extreme circumstances, such as suicide, murder, or war (Zisook & Zisook, 2005). In addition to despair and anger, some peo-ple may also experience feelings of loss of control in their lives, uncharacteristic feelings of dependency on others, and even anxiety about their own death.


Emotional responses are evident throughout the griev-ing process. A common first response to the news of a loss is to be stunned, as though not perceiving reality. Emo-tions vacillate in frequency and intensity. The person may function automatically in a state of calm and then sud-denly become overwhelmed with panic. The outcry of emotion may involve crying and screaming or suppressed feelings with a stoic face to the world.


Eventually reality begins to set in. He or she often reverts to the behaviors of childhood by acting similar to a child who loses his or her mother in a store or park. The grieving person may express irritability, bitterness, and hostility toward clergy, medical providers, relatives, comforters, and even the dead person. The hopeless yet intense desire to restore the bond with the lost person compels the bereaved to search for and recover him or her. The grieving person interprets sounds, sights, and smells associated with the lost one as signs of the deceased’s presence, which may intermit-tently provide comfort and ignite hope for a reunion. For example, the ring of the telephone at a time in the day when the deceased regularly called will trigger the excitement of hearing his or her voice. Or the scent of the deceased’s per-fume will spur her husband to scan the room for her smiling face. As hopes for the lost one’s return diminish, sadness and loneliness become constant. Such emotional tumult may last several months and seems necessary for the person to begin to acknowledge the true permanence of the loss.


As the bereaved person begins to understand the loss’s permanence, he or she recognizes that patterns of think-ing, feeling, and acting attached to life with the deceased must change. As the person relinquishes all hope of recov-ering the lost one, he or she inevitably experiences moments of depression, apathy, or despair. The acute sharp pain initially experienced with the loss becomes less intense and less frequent.

Eventually, the bereaved person begins to reestablish a sense of personal identity, direction, and purpose for liv-ing. He or she gains independence and confidence. New ways of managing life emerge, new relationships form. The person’s life is reorganized, and seems “normal” again, although different than before the loss. The person still misses the deceased, but thinking of him or her no longer evokes painful feelings.


Spiritual Responses to Grief


Closely associated with the cognitive and emotional dimensions of grief are the deeply embedded personal val-ues that give meaning and purpose to life. These values and the belief systems that sustain them are central com-ponents of spirituality and the spiritual response to grief. During loss, it is within the spiritual dimension of human experience that a person may be most comforted, chal-lenged, or devastated. The grieving person may become disillusioned and angry with God or other religious figures or members of the clergy. The anguish of abandonment, loss of hope, or loss of meaning can cause deep spiritual suffering.

Ministering to the spiritual needs of those grieving is an essential aspect of nursing care. The client’s emotional and spiritual responses become intertwined as he or she grap-ples with pain. With an astute awareness of such suffering, nurses can promote a sense of well-being. Providing opportunities for clients to share their suffering assists in the psychological and spiritual transformation that can evolve through grieving. Finding explanations and mean-ing through religious or spiritual beliefs, the client may begin to identify positive aspects of grieving. The grieving person also can experience loss as significant to his or her own growth and development.


Behavioral Responses to Grief


Behavioral responses to grief are often the easiest to observe. The grieving person may function “automati-cally” or routinely without much thought, indicating that the person is numb—the reality of the loss has not set in. Tearfully sobbing, crying uncontrollably, showing great restlessness, and searching are evidence of the outcry of emotions. The person actually may call out for the deceased or visually scan the room for him or her. Irritability andhostility toward others reveal anger and frustration in the process. Seeking out as well as avoiding places or activities once shared with the deceased, and keeping or wanting to discard valuables and belongings of the deceased, illustrate fluctuating emotions and perceptions of hope for a reconnection.


During disorganization or working through grief, the cognitive act of redefining self-identity is essential but dif-ficult. Although superficial at first, efforts made in social or work activities are behavioral means to support the per-son’s cognitive and emotional shifts. Drug or alcohol abuse indicates a maladaptive behavioral response to the emo-tional and spiritual despair. Suicide and homicide attempts may be extreme responses if the bereaved person cannot move through the grieving process.


In the phase of reorganization, or recovery, the bereaved person participates in activities and reflection that are per-sonally meaningful and satisfying. Redefining the meaning of life, finding new activities and relationships restore the person’s feeling that life is good again.


Physiologic Responses to Grief


Physiologic symptoms and problems associated with grief responses are often a source of anxiety and concern for the grieving person as well as for friends or caregivers. Those grieving may complain of insomnia, headaches, impaired appetite, weight loss, lack of energy, palpitations, indiges-tion, and changes in the immune and endocrine systems. Sleep disturbances are among the most frequent and per-sistent bereavement-associated symptoms (Zisook & Zisook, 2005).

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