3B PSYCHIATRICT NURSING

IX. GRIEF AND LOSS

Sang-an, D. & Tulang, A. | February 22, 2023

TOPIC OUTLINE:
I. Types of Losses
a. Physiologic loss  When these human needs are taken
b. Safety loss
away or not met for some reason, a
c. Loss of security and a sense of
belonging
person experiences loss.
d. Loss of self-esteem TYPES OF LOSSES DEFINITION
e. Loss related to self-actualization Physiologic loss Examples include
II. The Grieving Process amputation of a
a. Theories of Grieving limb, a mastectomy
b. Tasks of Grieving or hysterectomy, or
III. Dimension of Grieving loss of mobility.
IV. Application of the Nursing Process Safety loss Loss of a safe
environment is
KEY TERMS evident in domestic
violence, child
abuse, or public
GRIEF - The subjective emotions and affect violence. A person’s
that are a normal response to the experience home should be a
of loss. safe haven with trust
that family members
GRIEVING - Also known as bereavement,
will provide
refers to the process by which a person
protection, not harm
experiences the grief. or violence. Some
ANTICIPATORY GRIEVING - Is when people public institutions,
facing an imminent loss begin to grapple with such as schools and
the possibility of the loss or death in the near churches, are often
associated with
future.
safety as well. That
MOURNING - Is the outward expression of feeling of safety is
grief. Rituals of mourning include having a shattered when
wake, sitting shiva, holding religious violence occurs on
ceremonies, and arranging funerals. campus or in a holy
place.
TYPES OF LOSSES Loss of security and The loss of a loved
a sense of one affects the need
 One framework to examine different belonging to love and the
types of losses is Abraham Maslow’s feeling of being
hierarchy of human needs. loved. Loss
According to Maslow (1954), a accompanies
hierarchy of needs motivates human changes in
actions. relationships, such
as birth, marriage,
divorce, illness, and
death; as the
meaning of a
relationship
changes, a person
may lose roles
 within a family or and self-actualization is challenging
group. and demands flexibility and focus.
Loss of self-esteem Any change in how
a person is valued at
work or in
relationships or by
him or herself can
threaten self- THE GRIEVING PROCESS
esteem. It may be
an actual change or  Nurses interact with clients responding
the person’s
to myriad losses along the continuum
perception of a
of health and illness.
change in value.
Death of a loved  The therapeutic relationship and
one, a broken therapeutic communication skills such
relationship, loss of as active listening are paramount
a job, and retirement when assisting grieving clients.
are examples of
change that THEORIES OF GRIEVING
represent loss and
can result in a threat
to self-esteem.  Among well-known theories of grieving
Loss related to self- An external or are those posed by Elisabeth Kübler-
actualization internal crisis that Ross, John Bowlby, George Engel,
blocks or inhibits and Mardi Horowitz.
striving toward
fulfillment may
KÜBLER-ROSS’S STAGES OF GRIEVING
threaten personal
goals and individual
potential. A person  Elisabeth Kübler-Ross (1969)
who wanted to go to established a basis for understanding
college, write books, how loss affects human life. As she
and teach at a
attended to clients with terminal
university reaches a
illnesses, a process of dying became
point in life when it
becomes evident apparent to her. Through her
that those plans will observations and work with dying
never materialize or clients and their families, Kübler-Ross
a person loses hope developed a model of five stages to
that he or she will explain what people experience as
find a mate and they grieve and mourn:
have children.
These are losses
that the person will
grieve.

 The fulfillment of human needs

requires dynamic movement
throughout the various levels in
Maslow’s hierarchy. The simultaneous STAGES OF GRIEVING DEFINITION
maintenance of needs in the areas of Denial It is shock and
physiologic integrity, safety, security disbelief regarding
and sense of belonging, self-esteem, the loss.
Anger It may be expressed
 toward God, 4. Reorganizing and reintegrating the sense
relatives, friends, or of self to pull life back together
health care
providers.
Bargaining It occurs when the
person asks God or
fate for more time to ENGEL’S STAGES OF GRIEVING
delay the inevitable
loss.
Depression It results when  George Engel (1964) described five
awareness of the stages of grieving as follows:
loss becomes acute.
Acceptance It occurs when the
person shows
evidence of coming
to terms with death.

 This model became a prototype for

care providers as they looked for ways
to understand and assist their clients in STAGES OF GRIEVING DEFINITION
the grieving process. Shock and disbelief The initial reaction to
a loss is a stunned,
numb feeling
BOWLBY’S PHASES OF GRIEVING accompanied by
refusal to
 John Bowlby, a British psychoanalyst, acknowledge the
reality of the loss in
proposed a theory that humans
an attempt to protect
instinctively attain and retain
the self against
affectional bonds with significant overwhelming
others through attachment behaviors. stress.
These attachment behaviors are Developing As the individual
crucial to the development of a sense awareness begins to
of security and survival. acknowledge the
loss, there may be
crying, feelings of
helplessness,
frustration, despair,
and anger that can
be directed at self or
others, including
God or the
deceased person.
Restitution Participation in the
rituals associated
Bowlby described the grieving process as
with death, such as
having four phases: a funeral, wake,
1. Experiencing numbness and denying the family gathering, or
loss religious ceremonies
2. Emotionally yearning for the lost loved one that help the
individual accept the
and protesting the permanence of the loss
reality of the loss
3. Experiencing cognitive disorganization and
and begin the
emotional despair with difficulty functioning in recovery process.
the everyday world
Resolution of the The individual is and tend to be short-
loss preoccupied with the lived
loss, the lost person Denial and intrusion People move back
or object is and forth during this
idealized, and the stage between
mourner may even denial and intrusion.
imitate the lost During denial, the
person. Eventually, person becomes so
the preoccupation distracted or
decreases, usually involved in activities
in a year or perhaps that he or she
more. sometimes isn’t
Recovery The previous thinking about the
preoccupation and loss. At other times,
obsession ends, and the loss and all it
the individual is able represents intrudes
to go on with life in a into every moment
way that and activity, and
encompasses the feelings are quite
loss. intense again.
Working through As time passes, the
HOROWITZ’S STAGES OF LOSS AND ADAPTATION
person spends less
time bouncing back
 Mardi Horowitz (2001) divides normal and forth between
denial and intrusion,
grief into four stages of loss and
and the emotions
adaptation:
are not as intense
and overwhelming.
The person still
thinks about the
loss, but also begins
to find new ways of
managing life after
loss.
Completion Life begins to feel
“normal” again,
though life is
STAGES OF LOSS AND DEFINITION different after the
ADAPTATION loss. Memories are
Outcry First realization of less painful and do
the loss. Outcry may not regularly
be outward, interfere with day-to-
expressed by day life. Episodes of
screaming, yelling, intense feelings may
crying, or collapse. occur, especially
Outcry feeling can around anniversary
also be dates but are
suppressed as the transient in nature.
person appears
stoic, trying to TASKS OF GRIEVING
maintain emotional
control. Either way,
 Grieving tasks, or mourning, that the
outcry feelings take
a great deal of bereaved person faces involve active
energy to sustain rather than passive participation. It is
 sometimes called “grief work” because
it is difficult and requires tremendous
effort and energy to accomplish

TASKS OF GRIEVING DEFINITION

SIX Rs Accepting the reality It is common for
 Rando (1984) describes tasks inherent of the loss people initially to
to grieving that she calls the “six Rs:” deny that the loss
has occurred; it is too
painful to be
acknowledged fully.
Over time, the person
wavers between
belief and denial in
grappling with this
task. Traditional
rituals, such as
SIX Rs DEFINITION funerals and wakes,
Recognize Experiencing the are helpful to some
loss, understanding individuals.
that it is real, and Working through the A loss causes pain,
that it has happened pain of grief both physical and
React Emotional response emotional, that must
to loss, feeling the be acknowledged
feelings and dealt with.
Attempting to avoid
Recollect and Memories are
or suppress the pain
reexperience reviewed and relived
may delay or prolong
Relinquish Accepting that the
the grieving process.
world has changed
Adjusting to an It may take months
(as a result of the
environment that for the person to
loss) and that there
has changed realize what life will
is no turning back
because of the loss be like after the loss.
Readjust Beginning to return
When a loved one
to daily life; loss
dies, roles change,
feels less acute and
relationships are
overwhelming
absent or different,
Reinvest Accepting changes
lifestyle may change,
that have occurred;
and the person’s
reentering the world,
sense of identity and
forming new
self-esteem may be
relationships and
greatly affected.
commitments
Emotionally The bereaved person
relocating that which identifies a special
SIX Rs has been lost and place for what was
moving on with life lost and the
 Worden (2008) views the tasks of memories. The lost
grieving as: person or
relationship is not
forgotten or
diminished in
importance but rather
is relocated in the
mourner’s life as the
person goes on to
form new
relationships, friends,
life rituals, and
moves ahead with
daily life.