Objectives

 Describe the characteristics of

anticipatory, complicated and
disenfranchise grieving process.
 Differentiate grief, mourn and bereave.
 Describe the influence of culture and
society on how individuals experience
loss and grief.
 Identify appropriate and inappropriate
helping behaviors or approaches of
healthcare providers when caring for the
bereaved.
 Identify the common individuals and
gender differences in the grieving process.
 Identify loss- and grief-oriented rituals
useful in clinical practice.
 Describe the relationship between
personal attitudes and experiences and
one's effectiveness in intervening with
individuals and families experiencing
death, dying, loss, and grief.
DEATH & GRIEF
 What Is Grief?

“Grief is the emotion people feel when

they experience a loss. There are
many different types of loss, and not
all of them are related to death. For
example, a person can also grieve
over the breakup of an intimate
relationship or after a parent moves
away from home.”
“Grief is a natural reaction to the loss
of someone important to you. Grief
is also the name for the healing
process that a person goes through
after someone close has died. The
grieving process takes time, and the
healing usually happens gradually.”
*“Although everyone experiences grief
when they lose someone, grieving
affects people in different ways.”

*Depends on relationship with person.

*Circumstances under which they

died.
Cont.

*Knowing someone is going to die

can give us time to prepare.
*If they were suffering, it can mean
a sense of relief.
*If the person that died was young,
we may feel it was unfair.
 “Losing someone suddenly can be
extremely traumatic, though, no
matter how old that person is. Maybe
someone you know died unexpectedly
- as a result of violence or a car
accident, for example. It can take a
long time to overcome a sudden loss
because you may feel caught off guard
by the event and the intense feelings
that are associated with it.”
*Grief can make us feel guilty.

*Some people might blame

themselves or think they could
have done something to stop the
death.
“Others might think if only they had
been better people, than their loved
ones might not have died. These
things aren't true, of course - but
sometimes feelings and ideas like this
are just a way of trying to make sense
of something that's difficult to
understand.”
 Coping With Grief
“The grieving process is very
personal and individual - each
person goes through his or her
grief differently. Some people
reach out for support from
others and find comfort in good
memories.”
Coping cont.
*Throw selves into activities to
take mind off loss.
*Become depressed and
withdraw from activities,
peers, family.
*Everyone handles grief in
different ways.
“For some people, it may help to
talk about the loss with others.
Some do this naturally and
easily with friends and family,
others talk to a professional
therapist.”
Do children experience grief?

“Yes, if children are old

enough to love, they are
old enough to grieve.
Many times in our society
children are the forgotten
grievers.
 Example
“Joey's friends expected he'd be really upset at
his mom's funeral, so they were surprised
that he was smiling and talking with people
as if nothing had happened. When they asked
him about it, Joey said that seeing his friends
at the funeral cheered him up because it
reminded him that some things would still be
the same. Joey was able to cry and talk about
how he felt when he was alone with his dad
after the funeral.”
 DSM IV
Bereavement
along w/diagnosis of Major Depressive Disorder

 “This category can be used when the focus of

clinical attention is a reaction to the death of a loved
one.”
 Can be linked with a “Major Depressive Episode
(e.g., feelings of sadness and associated symptoms
such as insomnia, poor appetite, and weight loss).”
 Symptoms must still be present 2 months after loss.
 Can’t be considered “normal” grief reactions.
Type of Grieving
1. Anticipatory Grief
Definition:
The total set of
cognitive, affective,
cultural, and social
reactions is expected
death felt by the
patient and family.
 The following aspect
of anticipatory grief
have been identified
ANTICIPATORY among survivors:
GRIEVING - when • Depression
people facing an
imminent loss begin to
grapple with the very • Heightened concern
real possibility of the for the dying person
loss or death in the
near future • Attempts to adjust to
the consequences of
death
2. DISENFRANCHISED GRIEF- grief over
a loss that is not or cannot be
acknowledged openly, mourned publicly or
supported socially
Disenfranchised grief
- is a term describing
grief that is not
acknowledged by
society.
- Is grief others don’t
recognize.
- Grief may be the
death of a secret
partner or a pet or a
miscarriage
3. Complicated Grief
These patterns are described in comparison to normal
grief and highlight variations from the normal pattern.
They include descriptive labels such as the following:
-Inhibited or absent grief: A pattern in which persons
show little evidence of the expected separation distress,
seeking, yearning, and other characteristics of normal
grief.
-Delayed grief: A pattern in which symptoms of distress,
seeking, yearning, etc., occurs at much later time than is
typical.
-Chronic grief: A pattern emphasizing prolonged duration
of grief symptoms.
-Distorted grief: A pattern characterized by extremely
intense or atypical symptoms
What are the Five Stages
of Grief and Do They
Always Occur in the Same
Order?
The five stages:

Denial
Anger
Bargaining
Depression
Acceptance
Elisabeth Kübler-Ross
Stages (cont.)
 The stages are tools to help us frame
and identify what we may be feeling.
 Different for everyone.
 Doesn’t always happen in exact order,
may revert before moving forward.
Typical Physical Symptoms of Grief

 difficulty going to sleep, or waking in the

middle of the night
 weight loss or gain; over- or under-eating
 low energy or fatigue
 headaches, chest pain, or racing heart
 upset stomach or digestive problems
 hair loss
 Grief or Depression?
Grief
 Experienced in waves
 Diminishes in intensity
over time
 Healthy self-image
 Hopelessness
 Response to support
 Overt expression of
anger
 Preoccupation with
deceased
Depression
 Moods and feelings are
static
 Consistent sense of
depletion
 Sense of worthlessness and
disturbed self-image
 Pervasive hopelessness
 Unresponsive to support
 Anger not as pronounced
 Preoccupation with self
There are many ways people who are grieving
can help themselves:
– Attending support groups
– Therapy with a psychologist or other licensed
mental health professional
– Journaling
– Eating Well
– Exercising
– Getting enough rest
– Antidepressants such as Zoloft, Paxil, Wellbutrin,
Lexapro, Celexa, Prozac and can be very effective
to those who become clinically depressed
 (continued)
– Reading and learning about death-
related grief responses
– Seeking comforting rituals
– Avoiding major changes in residence,
jobs, or marital status
– Allowing emotions
– Seeking solace in the faith community
 Factors that may hinder
the healing process

 Avoiding or minimizing emotions

 Using alcohol or drugs to self-medicate

 Using work to avoid feelings

 Gender Differences
Women Men
 express their feelings  more likely to take on a
early after loss managerial role
 reach out for social  intellectualize their
support emotions
 are seen to express  indicate that they feel more
more sorrow, anger, fear, and loss of
depression, and guilt control
 more willing to talk
 use denial more
about the loss of a child
 more private about grief
 Developmental Grief
Responses
Ages 2-4
 Concept of Death
– Death seen as reversible
 Grief Response
– Intensive response but brief
– Very present oriented
– Most aware of changes in patterns of care
– Asking questions repeatedly
 Developmental Grief
Responses
Ages 4-7
 Concept of Death
– Death still seen as reversible
– Feeling of responsibility because of wishes and
thoughts
 Grief Response
– More verbalization
– Great concern with process. How? Why?
– May act as though nothing has happened
– General distress and confusion
 Developmental Grief
Responses
Ages 7-11
 Concept of Death
– Still wanting to see death as reversible but
beginning to see it as final
– Death seen as punishment
 Grief Response
– Specific questions
– Desire for complete detail
– What is the right way to respond?
– Starting to have ability to mourn and understand
mourning                      
 Developmental Grief
Responses
Ages 11-18
 Concept of Death
– Ability to abstract
– Beginning to conceptualize death
 Grief Response
– Extreme sadness
– Denial
– Regression
– More often willing to talk to people outside of family and
peer support
– Risk-taking
It's only when we truly know and
understand that we have a limited
time on earth -- and that we have no
way of knowing when our time is up,
we will then begin to live each day to
the fullest, as if it was the only one we
had.
~Dr. Elisabeth Kübler-Ross
 Needs of the 2 – 5 year old
 Kind and understanding tone of voice
and demeanor
 Encouragement to talk about how s/he
feels in whatever way s/he can express it
 Permission to “play about” death and the
events surrounding the experience
 Open and direct manner that says “I’m
with you and you are with me. There are
no secrets.”
 Needs of the 2 – 5 year old
(continued)
 Sharing of how you feel or felt when a
similar thing happened
 Reassurance that remaining family
members will take care of the child
 Needs of the 5 – 9 year old
 Clear answers in simple terms to the
questions that they ask, no matter how
improbable their fears seem
 An accepting listener to the memories s/he
has of the deceased
 Explanations to refute the magical beliefs
that feed their fears
 Acceptance of play, artwork, songs, etc.
about the events surrounding the death
 Needs of the 9 – 12 year old
 To be taken seriously, no matter how
shallow his/her concerns seem
 To be included in family discussions about
the changes brought about by the death
 To have his/her ways of grieving accepted
 While this age-group may understand death
intellectually, they may have great difficulty
understanding it emotionally.
 Needs of the Teenager
 To be included in planning & decision
making
 To be informed of what to expect in terms
of events, ceremonies, rituals, etc.
 To know what to expect from various
relatives
 To know what is expected of them
 To witness adults grieving so they can
learn adult ways to grieve
 Needs of the Teenager
(continued)
 To be encouraged to talk about what
they think and feel and have their
thoughts and feelings respected
 What to Do
 Act natural
 Show genuine care and concern
 Make it clear that you are there to listen
 Talk openly and directly about the
person who died
 Keep in mind that evenings, weekends,
anniversaries, and holidays can be extra
challenging times
 What to Do
 Find a way to help children symbolize
and represent the death
 Pay attention to the way a child plays;
this is one of the main ways that
children communicate
 Say that you are sorry about the loss
 Sit next to a child that wants closeness
 What NOT to Do
 Try to shelter children from the reality of
death; it can be a learning experience
 Give false or confusing messages
(“Grandma is sleeping now.”)
 Tell a child to stop crying because others
might get upset
 Try to cheer the person up or distract from
the emotional intensity (“At least he’s no
longer in pain.” “She’s in a better place
now.”)
 What NOT to Do
 Offer advice or quick solutions (“I know
how you feel.” “Time heals all
wounds.”)
 Pry into personal matters
 Ask questions about the circumstances
of the death
 Signs that Bereavement in Young
People Needs Outside Intervention
 If a young person pretends that absolutely
nothing has happened
 If school work takes a dramatic decline or
the student develops a school phobia
 If a young person threatens suicide
 If a young person panics frequently
 If a young person becomes involved with
alcohol or drugs
 If a young person begins committing serious
socially delinquent acts
 Interventions
 Explore client’s perception and meaning of the
loss
 Allow adaptive denial
 Assist client to reach out for and accept
support
 Encourage client to examine patterns of
coping in past and present situation of loss
 Encourage client to care for himself
 Offer client food without pressure to eat
 Use effective communication