Grief study guide.docx

Grief Grief is an expected process that clients experience after they have suffered a loss. The American Psychological Association defines grief as “the anguish experienced after significant loss, usually the death of a beloved person.” This sensation is experienced when someone or something that a...

Grief Grief is an expected process that clients experience after they have suffered a loss. The American Psychological Association defines grief as “the anguish experienced after significant loss, usually the death of a beloved person.” This sensation is experienced when someone or something that a client has a deep connection with is lost. Grief can occur after receiving bad news about one’s health or from many life situations. A client may experience grief due to the loss of a loved one such as a spouse, a parent, a sibling, a child, or a close friend. Other examples of losses that may trigger grief include divorce, retirement, loss of a job, loss of friendship, loss of financial stability, a miscarriage, or moving to a new city. Grief can include both emotional and physical manifestations, and it is usually accompanied by physiological stress. Clients may exhibit anxiety, difficulties in concentrating, thinking about the past excessively, and agitation. Just as there are different causes of grief, so there are different types of grief that clients may experience in response to a loss in their life. Grief is the body’s way of healing after one has suffered a loss. Normal grief, also known as uncomplicated grief, is caused by the loss of a loved one, through death or the ending of a relationship. In addition, grief can be triggered by other experiences that are painful or traumatic to the client. Although the period for which an individual grieves a loss will differ for every person, most people will experience grief after a loss for several months to a year. Nevertheless, it is essential to remember that normal grief is different for everyone. Individuals’ display of grief is as diverse as the individuals themselves. Grief is experienced differently by everyone, as an individual’s sense of loss is unique to that person, and people’s feelings regarding loss reflect their own unique make-up. Feelings experienced during grief often include sadness, guilt, yearning, anger, and regret. There is no timeline for how long an individual will experience grief, nor is there an ordinary degree or severity to which an individual will experience grief. Grief typically lessens over time as feelings decrease in intensity, and the person experiencing grief simultaneously moves forward in their acceptance of the loss. Not all individuals will process their grief in this way, however; some will instead follow a different path leading to chronic and debilitating grief. Grief is primarily thought of as being caused by the death of a loved one, but it has many other causes—for example, loss of identity, loss of safety, loss of autonomy, and loss of dreams or expectations. Loss of identity can be experienced when a client faces the loss of a role or relationship, such as after divorce, when one is no longer considered a spouse; or when a child goes off to college, leaving the parent as an empty nester; or after having undergone a double mastectomy, when a client might feel a loss of femininity. Loss of safety is experienced when clients perceive that they have lost physical, emotional, and mental happiness. Loss of security can be experienced when clients find themselves evicted or have erratic housing arrangements, among children of divorced parents, or when a survivor of physical abuse fears for their safety daily. Loss of autonomy is experienced because of older adults’ inability to take care of themselves and belief that they can no longer contribute to society, or when individuals have a worsening condition that affects their physical or cognitive capability. Loss of dreams and expectations is experienced when an individual’s hopes and dreams remain unfulfilled. Examples include clients whose career path fails to mirror their expectations; students struggling to find where they belong in the real world; and a couple who are coming to terms with infertility. Thus, there are many causes of grief unrelated to death, and nurses need to be aware of clients experiencing all sources of grief so they can assist them in working through their grief with support and guidance. Anticipatory grief is defined as grief that is experienced before the loss of someone or something. This kind of grief arises when a loss is expected: A loved one is still living, but a substantial diagnosis has been made, the client’s health is worsening, or death is imminent. Anticipatory grief commonly occurs when a client has been identified as having a terminal illness or has been suffering from a chronic disease over an extended period. This type of grief can be experienced by clients who have a connection with the dying person or are the dying person themselves. As with normal grief, there is no exact amount of time over which a person may experience anticipatory grief. Even though a person has experienced anticipatory grief previously, the prior experience will not affect the present grief experience or the degree of grief an individual experiences after a loss. Clients who suffer anticipatory grief can display both mental and physical manifestations. According to Metzger, common findings of anticipatory grief include sadness, anger, loneliness, guilt, anxiety, fear, fatigue, and poor concentration. It is normal to have this type of grief when someone or something that a client loves is expected to be lost, and clients can experience anticipatory grief when they face a looming crisis or end of life. Prolonged grief disorder (PGD), previously known as complicated grief, is grief that lasts longer than 6 months and can be so significant that it affects the client’s ability to function. Clients who are experiencing prolonged grief are unable to accept the death of the loved one. Their behavior is marked by a persistent need to find the deceased person, and they are preoccupied with thoughts of the deceased person. Other manifestations of prolonged grief disorder include feelings of guilt (self-blame), anger, and difficulty participating in new and different activities. It is not unusual for clients experiencing prolonged grief to detach themselves from their friends or family, making it harder for them to recover as they become isolated and lonely. Nursing interventions for PGD include showing concern, allowing clients to voice their feelings, and providing emotional support and guidance. If a nurse becomes concerned that a client has the potential for self-harm, the nurse has an ethical responsibility to notify the provider immediately to get mental health services for the client. Health care providers can diagnose complicated grief as a medical disorder and can provide the client with the most appropriate treatment available, including support and therapy. Disenfranchised grief is grief related to a relationship that does not coincide with what is considered by society to be a recognized or justified loss. The loss is considered by society to be one of shame or socially uncomfortable and, therefore, not worthy of grief. Because the loss is not regarded as worthy of grief, social support is not provided to the grieving individual. Clients who are experiencing disenfranchised grief are left to grieve alone and in silence, as compared to clients experiencing normal grief, for whom rituals are routinely utilized to lessen the burden after a loss. Disenfranchised grief can occur as a result of a loss being unrecognized as significant (e.g., loss of a pet or miscarriage), an unrecognized relationship (e.g., an extramarital affair), an unrecognized griever (e.g., a young child), or the loss itself being disenfranchised (e.g., suicide). In all of these cases, a relationship has been lost as well as the griever’s ability to grieve in public and receive the social support that assists in the grieving process. Clients experiencing disenfranchised grief can suffer from depression, unstable emotions, social isolation, physical symptoms, insomnia, and low self-esteem. Although grief is a normal response to loss, every person has their own unique way of moving through the grieving process. Grief theories and models have been developed as a means of providing an explanation and guidance in anticipating how a person may cope and adjust when experiencing grief and loss. In addition to these grief theories and models, researchers have identified some other common responses to grief that clients may experience. One of the best-known grief theories is Kubler-Ross’s Five Stages of Grief. Her theory was quickly adopted by therapists and other health care professions to understand the grief process. The Kubler-Ross model identifies five stages in the grieving process: denial, anger, bargaining, depression, and acceptance. Originally it was believed that those who were grieving had to go through all five stages in a precise, sequential order. Later, Kubler-Ross revised the theory, stating that the five stages were not sequential, and an individual may not necessarily experience all of them. In other words, an individual may go through three stages, or five stages, or may bounce back and forth between stages. Denial, in which the client refuses to believe reality, is the first stage in the Kubler-Ross theory and is an attempt to lessen the pain of the loss. In this stage, it is not uncommon for the client to have a feeling of numbness and shock. The mind is trying to adjust to a loss of someone or something and wonders how life will continue in this altered state. The client is trying to understand what has happened and deal with the feelings of losing someone or something. Denial is a time in which the client reflects on and relives the time spent with the person, and questions how life can move forward without the person. It is the body’s way of slowing things down and giving time to adjust to the loss, so that the client will not become emotionally overwhelmed. Anger is the second stage, in which the client is trying to adjust to the loss and is feeling severe emotional distress. The client thinks, “Why me?” and “It’s not fair.” If clients have a strong religious faith, they may question their belief in the deity. It is normal to feel angry after the loss of someone or something. Anger provides a means of releasing emotional discomfort. Blaming of others for the loss can also occur, with anger being targeted at loved ones such as family and close friends. Anger is a necessary and healthy stage of grief. It will eventually dissolve, and the more anger that is felt, the faster a person will heal. After a loss, many people feel abandoned and left alone. The feeling of anger connects the client to reality, and it is something that will connect the client to people once again. Bargaining is the third stage, as the client tries a different approach in an attempt to relieve or minimize the pain felt from the loss. Usually, clients try bargaining with a higher power by making a promise to do something in exchange for a different, better outcome—for example, “I promise I will be a better person if you let this person live.” This response is an attempt to avoid grief through the act of negotiating. In this stage, guilt is also commonly experienced as part of the bargaining stage. The client worries, “If only I had driven them to work that day, they would still be here today”. Depression is the fourth stage—the stage where reality sets in, and the loss of the loved one or thing is deeply felt. The realization that the loved one is gone or the situation is over becomes real. The client feels numbness and a sense of immense loss, mourns the loss, and wonders if it is worth continuing in life alone. Some clients might withdraw, not wanting to be around others as they try to deal with the loss. It is natural and appropriate to have feelings of depression during the grieving process. Acceptance is the last stage in the Kubler-Ross theory of grief: It is the point at which the person still feels the pain of the loss but realizes that all will eventually be well. The person acknowledges the new reality, such as a spouse or child who is never coming back or a job that they will never return to. Some days will be better than others, with a higher number of good days versus bad days. In this stage, the person begins to connect with friends again, and may perhaps make new friendships. The person recognizes that nothing will take the place of the loss, but that life goes on. The Dual Process Model suggests that the process of grieving oscillates (shifts back and forth) between two types of responses: loss-oriented and restoration grief. During the loss-oriented process, grief is conveyed through intense thoughts and feelings. The person feels sad, longs for the person who has died, feels sad about how the person died, and believes it is unfair that the person will not be part of the griever’s future. The restoration grief process involves coping with other losses that come with the death of a loved one (secondary losses) and rebuilding one’s life without the loved one. The loss of a loved one brings about not only feelings of grief, but also changes that are a result of the loss. The restoration process is a time of thinking about the future, filled with new tasks and obligations. A fundamental aspect of the Dual Process Model is the process of going back and forth between the loss-oriented responses and restoration-oriented responses. Clients who are bereaved shift between these responses repeatedly. For example, when a client becomes tired of focusing on feeling sad and longing for the person who has died, the client will switch to focus on their new roles and responsibilities. It is typical for the client who is grieving to move back and forth between the processes. Concentrating on one process too much can be detrimental, especially if the client uses this approach to avoid dealing with the emotions of losing a loved one. Dr. J. William Worden’s theory suggests that a grieving client commonly engages in four tasks as part of the grieving process. The key idea is that grieving clients can involve themselves in the grieving process, permitting themselves to acknowledge the loss and adjust to life after the loss. The four tasks of grieving are (1) accept the reality of the loss, (2) experience the pain of grief, (3) adjust to an environment without the deceased, and (4) find an enduring connection while embarking on a new life. The first task of this model is overcoming denial of the loss and accepting the loss that has occurred. This task consists of accepting the loss as reality versus believing that it never happened. Denying the loss does not make it go away. Grief is a natural way of mourning that the body and mind must be permitted to go through. The first step in grieving is acceptance, and accepting the loss allows the mourner to move forward in the grieving process. The second task is to be aware of the emotion and to experience the pain of grief. In today’s culture, many people are fearful of feeling strong emotions. They may do everything in their power to avoid feeling, yet preventing the feeling of strong emotions only makes the pain worse. Coping with emotions can be handled through writing, creating songs, or whatever works best for the client. The important thing is that feelings are dealt with and not suppressed. The task in this phase is to adjust and get used to living without the loved one being around. Life is no longer the same, and the client may feel as if moving on in their life is a betrayal of the loved one or that becoming closer to a friend is betraying the friend whom they have lost. Clients in this phase have to reestablish themselves and rearrange their lives without the presence of the loved one. The final task is to stay connected to the deceased loved one while simultaneously moving forward in one’s life. Even though the loved one is no longer in the client’s life, the client will always have lasting memories of times spent together. Instead of clients focusing on what they have lost, they should focus on what they had. Death is considered a normal occurrence in life, yet it is also one of the most difficult challenges that a person may experience. Bereavement is a term used to describe a period in which a person experiences grief and mourning after a loss. Mourning is described as the expression of grief in public. Mourning can be affected by religious beliefs, ethnic background, or cultural customs. Practices associated with mourning often provide structure to the grieving process. The response to the death of a loved one varies depending on the circumstances surrounding the death. Common findings include crying spells, difficulty sleeping, changes in food intake, and decreased productivity in the work setting. The client may at first find it difficult to believe that death has occurred, with this disbelief then being followed by anger that the person has died. Feelings may be extraordinarily intense and accompanied by mood swings. The reaction of the client experiencing a loss reflects the circumstances surrounding the death and the relationship with the deceased. If the client experiencing grief fails to process that grief within a month to a year, the person could be experiencing complicated grief. Most clients see a decline in grief manifestations after 6 months. After suffering the loss of a spouse or partner, the surviving partner may have to make numerous choices related to funeral arrangements and financial issues at one of the most difficult times possible. The client may also be faced with having to share the news of the death with children and assist them in processing the grief. The loss of a child is devastating to a parent and can be an overpowering experience. Parents must process additional issues along with the usual findings of grief after the death of a child. Parents may feel an injustice has occurred—that a parent should not lose a child. They may have days on which they feel pain, alternating with days on which they feel numb, in a cycle that can linger for months. A parent’s world often revolves around taking care of a child, even when the child is no longer living with the parent. Losing a child takes away the parent’s ability to fulfill the parenting role—a role that they anticipated carrying out for many more years to come. When a parent loses a child, they lose a piece of themselves, regardless of the child’s age. The loss of a parent, caregiver, or guardian can be profoundly affecting for their children, regardless of the age of the parent and child. The grief response after a parent has died reflects factors such as the circumstances in which the parent died (violent deaths can lead to grief disorders), the child’s relationship with the parent prior to the parent’s death, if the child believes it was time for the parent to die, and the gender of the child and the parent. Not having an opportunity to say goodbye to a parent has an impact on a child’s coping ability and may lead to feelings of anger and depression. The death of a parent can be especially painful for children who have had a troubled relationship with the deceased parent. Managing grief from a loss due to suicide can be overwhelming for those left behind. It can be harder to process because of the feelings of shame, guilt, and rejection felt from the loss. In many cultures, suicide of a loved one is still associated with a sense of shame and disgrace. This may worsen the bereaved person’s feelings of loneliness. The bereaved person may be without some of the support previously provided in the past. It is common for the client who has lost a pet to experience intense feelings of sorrow. Pets provide companionship, acceptance, and emotional support. They are often thought of as members of the family. Some people may find it challenging to comprehend the strong emotions a person has over the death of a pet and, therefore, may be less understanding. Experiencing that grief and loss may include feeling shock and confusion, followed by extended periods of sadness and depression. The intensity of the unhappiness felt will lessen over time, however, and clients will typically return to their usual self, providing the client has healthy behaviors and social support. There is no standard period for a person to grieve and recover from the loss of a pet, although mourning for months to a year or more is not uncommon. There are many different types of feelings and behaviors a client may experience after someone close to them has passed away. Grief is frequently reoccurring, as the intensity of grief comes and goes in cycles. A person may be feeling less grief, but then encounter the grief once again. Reactions to grief can involve complicated feelings, thoughts, physical sensations, and behaviors. Grief reactions are defined as a person’s response to loss. The range of feelings for a client who has experienced a loss may include shock, anger, anxiety, numbness, denial, guilt, sadness, relief (if death is expected), and depression. A grieving client may begin to cry as they listen to a song that causes them to think of the person who has died. The range of psychological experiences may include disbelief, fixation, trouble concentrating, and hallucinations. Physical sensations related to grief include a tightness or heaviness in the chest or throat that is non-cardiac related, gastrointestinal findings such as nausea or upset stomach, dizziness, headache, muscle weakness, and tiredness. The behaviors of a person experiencing grief may include difficulty falling asleep or staying asleep, lost interest in consuming food or socializing, and becoming short-tempered or hostile. Every client’s experience with grief is unique to them, and feelings of grief will come and go. Sometimes feelings of grief are intensified around significant dates and anniversaries such as the deceased person’s birthday or death date, or around the holidays. The length of time for which a person grieves, the characteristics that the person displays during grief, and the intensity of grief can be affected by various factors. The circumstances in which a person died can influence a person’s grief. For instance, was the death sudden, or had the person been suffering from a terminal illness? The deceased person’s age can influence the reaction to the death, including whether the deceased person was a young child versus an older adult. Customs, religious, or spiritual beliefs of the grieving person can also play a role in how the client displays grief for a loss. Prior experience with loss can have an impact on the client who is grieving, just as any previous experiences affect future experiences. For the person who has unresolved issues with the person who has died, the grieving process may be more difficult.