Bereavement (Treatments)

Grieving is extremely tiring, both physically and emotionally. The grief one is feeling is not just for the person who died, but also for the unfulfilled wishes and plans with the person. Death often reminds people of past losses or separations. Mourning may be described as having the following three phases:

• The urge to bring back the person who died
• Disorganization and sadness
• Reorganization

Depression shares common features with grief, but can completely take over the way you think and feel.

Symptoms of depression include:

• A sad or "empty" mood that will not go away or lighten
• Persistent feelings of hopelessness or worthlessness
• A negative preoccupation with self

Depression in older people has been linked to death from suicide, heart attack, and other causes. Much can be done to ameliorate severe symptoms through formal treatment or through support-group participation. If you feel that you or someone you know is having difficulty in coping with their loss, seek professional help. A family physician can often help, or grief counseling or therapy may be appropriate.

Grief counseling helps mourners with normal grief reactions work through the tasks of grieving. Grief counseling can be provided by professionally trained people or in self-help groups where bereaved people help each other. All of these services may be available in individual or group settings.

The goals of grief counseling include:

• Describing normal grieving and encouraging the bereaved to accept the loss by talking about it
• Helping the bereaved to identify and express feelings related to the loss (for example, anger, guilt, anxiety, helplessness, and sadness)
• Helping the bereaved to separate emotionally from the deceased, as well as to make decisions and live alone
• Helping the bereaved to understand his or her methods of coping
• Describing normal grieving and the differences in grieving among individuals
• Providing continuous support
• Providing support at important times, such as birthdays and anniversaries
• Identifying coping problems the bereaved may have, and making recommendations for professional grief therapy, if necessary

Grief therapy is used with people who have more serious grief reactions. The goal of grief therapy is to identify and solve problems the mourner may have in separating from the person who died. When separation difficulties occur, they may appear as physical or behavioral problems, delayed or extreme mourning, conflicted or extended grief, or unexpected mourning.

In grief therapy, the mourner talks about the deceased and tries to recognize whether he or she is experiencing an expected amount of emotion about the death. Grief therapy may allow the mourner to see that anger, guilt, or other negative or uncomfortable feelings can exist at the same time as more positive feelings about the person who died.

Humans tend to make strong bonds of affection or attachment with others. When these bonds are broken, as in death, a strong emotional reaction occurs. After a loss, a person must accomplish certain tasks to complete the process of grief. These basic tasks of mourning include accepting that the loss happened, living with and feeling the physical and emotional pain of grief, adjusting to life without the loved one, and emotionally separating from the loved one and going on without him. It is important that these tasks are completed before mourning can end.

In grief therapy six tasks can be used to help a mourner work through her grief:

1. Develop the ability to experience, express, and adjust to painful grief-related changes
2. Find effective ways to cope
3. Establish a continuing relationship with the person who died
4. Stay healthy and keep functioning
5. Reestablish relationships, and understand that others may have difficulty empathizing with the grief he is experiencing
6. Develop a healthy image of herself and the world

Complications in grief may come about due to unresolved grief from earlier losses. The grief for these earlier losses must be managed to handle the current grief. Grief therapy includes dealing with blockages to the mourning process, identifying any unfinished business with the deceased and identifying other losses that result from the death. The bereaved must see that the loss is final and to picture life after the mourning period.

Grief therapy may be available as individual or group therapy. A contract is set up with the individual that establishes the time limit of the therapy, the fees, the goals, and the focus of the therapy.

Complicated Grief

Complicated grief reactions require more complex therapies than uncomplicated grief reactions. Adjustment disorders (especially depressed and anxious mood or disturbed emotions and behavior), major depression, substance abuse, and even post-traumatic stress disorder are some of the common problems of complicated bereavement. Complicated grief is identified by the extended duration of the symptoms, the disruption to daily life caused by the symptoms or by the intensity of the symptoms (for example, intense suicidal thoughts or acts).

Complicated or unresolved grief may appear as a complete absence of grief and mourning, an ongoing inability to experience normal grief reactions, delayed grief, conflicted grief, or chronic grief. Factors that contribute to the chance that one may experience complicated grief include the suddenness of the death, the gender of the person in mourning, and the relationship to the deceased (for example, an intense, extremely close or very contradictory relationship).

Grief reactions that turn into major depression require treatment. Someone who avoids any reminders of the person who died, who constantly thinks or dreams about the person who died, or who gets scared and panics easily at any reminders of the deceased may be suffering from post-traumatic stress disorder. Substance abuse may occur, frequently in an attempt to avoid painful feelings about the loss and consequent symptoms (such as sleeplessness), and this should also be treated.

Children and Grief

In the past, children were thought to be miniature adults and were expected to behave as adults. It is now understood that there are differences in the ways in which children and adults mourn.

Unlike adults, bereaved children do not experience continual and intense emotional and behavioral grief reactions. Children may seem to show grief only occasionally and briefly, but in reality a child's grief usually lasts longer than that of an adult. This may be explained by the fact that a child's ability to experience intense emotions is limited. Mourning in children may need to be addressed again and again as the child gets older. Since bereavement is a process that continues over time, children will think about the loss repeatedly, especially during important times in their life, such as going to camp, graduating from school, getting married, or giving birth to their own children.

A child's grief may be influenced by her age, personality, developmental stage, earlier experiences with death, and her relationship with the deceased. The surroundings, cause of death, family members' ability to communicate with one another and to continue as a family after the death can also affect grief. Factors that may influence grief include the child's ongoing need for care, the child's opportunity to share his feelings and memories, the parent's ability to cope with stress, and the child's steady relationships with other adults.

Children do not react to loss in the same ways as adults. Grieving children may not show their feelings as openly as adults. Grieving children may not withdraw and dwell on the person who died, but instead may throw themselves into activities (for example, they may be sad one minute and playful the next). Often families think the child doesn't really understand or has gotten over the death. Neither is true; children's minds protect them from what is too powerful for them to handle. Children's grieving periods are shortened because they cannot think through their thoughts and feelings like adults. Also, children have trouble putting their feelings about grief into words. Instead, his behavior speaks for the child. Strong feelings of anger and fears of abandonment or death may show up in the behavior of grieving children. Children often play death games as a way of working out their feelings and anxieties. These games are familiar to the children and provide safe opportunities to express their feelings.

Children's Grief and Developmental Stages

Children at different stages of development have different understandings of death and the events near death.

Infants

Infants do not recognize death, but feelings of loss and separation are part of developing an awareness of death. Children who have been separated from their mother may be sluggish, quiet, unresponsive to smiling or cooing, undergo physical changes (for example, weight loss), be less active, and sleep less.

Age 2-3 years

Children at this age often confuse death with sleep and may experience anxiety as early as age 3. They may stop talking and appear to feel overall distress.

Age 3-6 years

At this age children see death as a kind of sleep; the person is alive, but only in a limited way. The child cannot fully separate death from life. Children may think that the person is still living, even though she might have been buried, and ask questions about the deceased (for example, how does the deceased eat, go to the toilet, breathe, or play?). Young children know that death occurs physically, but think it is temporary, reversible, and not final. The child's concept of death may involve magical thinking. For example, the child may think that his or her thoughts can cause another person to become sick or die. Grieving children under 5 may have trouble eating, sleeping, and controlling bladder and bowel functions.

Age 6-9 years

Children at this age are commonly curious about death, and may ask questions about what happens to one's body when it dies. Death is thought of as a person or spirit separate from the person who was alive, such as a skeleton, ghost, angel of death, or bogeyman. They may see death as final and frightening but as something that happens mostly to old people (and not to themselves). Grieving children can become afraid of school, have learning problems, develop antisocial or aggressive behaviors, become overly concerned about their own health (for example, developing symptoms of imaginary illness), or withdraw from others. Or, children this age can become too attached and clinging. Boys usually become more aggressive and destructive (for example, acting out in school), instead of openly showing their sadness. When a parent dies, children may feel abandoned by both their deceased parent and their surviving parent because the surviving parent is grieving and is unable to emotionally support the child.

Ages 9 and older

By the time a child is 9 years old, death is known to be unavoidable and is not seen as a punishment. By the time a child is 12 years old, death is seen as final and something that happens to everyone.

Treatment—Child Specific

A child's grieving process may be made easier by being open and honest with the child about death. Not talking about death indicates that the subject is taboo and does not help a child to cope with loss. Use clear, direct language. Explanations should be simple and straightforward. Euphemisms such as "She passed away" or "We lost him" are best avoided, as they can confuse and alarm children. Each child should be told the truth, using as much detail as he or she is able to understand. Listen to any questions the child may have and try to answer them as fully as possible. Children often need to be reassured about their own security (they often worry that they, or a surviving parent, will also die).

If you are planning a memorial ceremony, try to include the child in the arrangements and in the ceremony itself. These events help children (and adults) remember loved ones. Children should not be forced to be involved in funerals or memorials, but they should be encouraged to take part in those portions of the events with which they feel most comfortable. If the child wants to attend the funeral, wake or memorial service, she should be given a full explanation of what to expect in advance. Try to encourage them to express their feelings. The surviving parent may be too incapacitated by his own grief to give the child full attention. Therefore, support from a familiar adult or family member can be extremely helpful.