Colin Murray Parkes
St Christopher's Hospice, Sydenham, London SE26 6DZ
Taken from: http://www.bmj.com/cgi/content/full/316/7134/856
Series editor: Colin Murray Parkes
Doctors are well acquainted with loss and grief. Of 200 consultations with general practitioners, a third were thought to be psychological in origin; of these, 55a quarter of consultations overallwere identified as resulting from types of loss.1 In order of frequency the types of loss included separations from loved others, incapacitation, bereavement, migration, relocation, job losses, birth of a baby, retirement, and professional loss.
After a major loss, such as the death of a spouse or child, up to a third of the people most directly affected will suffer detrimental effects on their physical or mental health, or both.2 Such bereavements increase the risk of death from heart disease and suicide as well as causing or contributing to a variety of psychosomatic and psychiatric disorders. About a quarter of widows and widowers will experience clinical depression and anxiety during the first year of bereavement; the risk drops to about 17% by the end of the first year and continues to decline thereafter.2 Clegg found that 31% of 71 patients admitted to a psychiatric unit for the elderly had recently been bereaved.3
Despite this there is also evidence that losses can foster maturity and personal growth. Losses are not necessarily harmful.
Yet the consequences of loss are so far reaching that the topic should occupy a large place in the training of health care providersbut this is not the case. One explanation for this omission is the assumption that loss is irreversible and untreatable: there is nothing we can do about it, and the best way of dealing with it is to ignore it. This attitude may help us to live with the fact that, despite modern science, 100% of our patients still die and that before they die many will suffer lasting losses in their lives. Sadly, it means that, just when they need us most, our patients and their grieving relatives find that we back away.
| Summary points |
|Recent approaches to loss|
A 1944 study of bereaved survivors of a night club fire focused attention on the psychology of bereavement, and led to the development of services for the bereaved and to other types of crisis intervention services.4 It established grief as a distinct syndrome with recognisable symptoms and course, amenable to positive or negative influences. This, in turn, fuelled interest in the new fields of preventive psychiatry and community mental health. Elizabeth Kubler Ross's studies extended this understanding to dying people,5 and helped to provide a conceptual framework for the humanitarian work of Dame Cicely Saunders and the other pioneers of the hospice movement.
More recently the improvements in palliative care have led to improvements in home care for the dying. Home care nurses have bridged the gap and general practitioners have had a central role, not only in caring for dying patients and their families but also in supporting people through many other losses. This is the main theme of this series, which draws together authorities with special knowledge of the losses which afflict our patients and their families and looks at the practical implications for doctors.
|The components of grief|
Three main components affect the process of grieving. They include the urge to look back, cry, and search for what is lost, and the conflicting urge to look forward, explore the world that now emerges, and discover what can be carried forward from the past. Overlying these are the social and cultural pressures that influence how the urges are expressed or inhibited. The strength of these urges varies greatly and changes over time, giving rise to constantly changing reactions.
Most adults do not wander the streets crying aloud for a dead person. Bereaved people often try to avoid reminders of the loss and to suppress the expression of grief. What emerges is a compromise, a partial expression of feelings that are experienced as arising compellingly and illogically from within.
Much empirical evidence supports the claims of the psychoanalytic school that excessive repression of grief is harmful and can give rise to delayed and distorted griefbut there is also evidence that obsessive grieving, to the exclusion of all else, can lead to chronic grief and depression. The ideal is to achieve a balance between avoidance and confrontation which enables the person gradually to come to terms with the loss. Until people have gone through the painful process of searching they cannot "let go" of their attachment to the lost person and move on to review and revise their basic assumptions about the world. This process, which has been termed psychosocial transition, is similar to the relearning that takes place when a person becomes disabled or loses a body part.
| The course of grief |
|The normal course of grief|
Human beings can anticipate their own death and the deaths of others. Unlike the grief that follows loss, anticipatory grief increases the intensity of the tie to the person whose life is threatened and evokes a strong tendency to stay close to them.
Although the moment of death is usually a time of great distress, this is usually quickly repressed and, in Western society, the impact is soon followed by a period of numbness which lasts for hours or days. This is sometimes referred to as the first phase of grieving.6 It is soon followed by the second phase, intense feelings of pining for the lost person accompanied by intense anxiety. These "pangs of grief" are transient episodes of separation distress between which the bereaved person continues to engage in the normal functions of eating, sleeping, and carrying out essential responsibilities in an apathetic and anxious way.
All appetites are diminished, weight is lost, concentration and short term memory are diminished, and the bereaved person often becomes irritable and depressed. This eventually gives place to the third phase of grieving, disorganisation and despair. Many find themselves going over the events which led up to the loss again and again as if, even now, they could find out what went wrong and put it right. The memory of the dead person is never far away and about a half of widows report hypnagogic hallucinations in which, at times of drowsiness or relaxation, they see or hear the dead person near at hand. These hallucinations are distinguished from the hallucinations of psychosis by the circumstances in which they arise and by their transiencethey disappear as soon as the bereaved arouse themselves. A sense of the dead person near at hand is also common and may persist.
As time passes the intensity and frequency of the pangs of grief tend to diminish, although they often return with renewed intensity at anniversaries and other occasions which bring the dead person strongly to mind. Consequently the phases of grief should not be regarded as a rigid sequence that is passed through only once. The bereaved person must pass back and forth between pining and despair many times before coming to the final phase of reorganisation.
After a major loss such as the death of a loved spouse or partner, the appetite for food is often the first appetite to return. By the third or fourth month of bereavement the weight that was lost initially has usually returned, and by the sixth month many people have put on too much weight. It may be many more months before people begin to care about their appearance, and for sexual and social appetites to return. Most people will recognise that they are recovering at some time in the course of the second year.
|Assessing the risk|
Much research, in recent years, has enabled us to identify people at special risk after bereavement either because the circumstances of the bereavement are unusually traumatic or because they are themselves already vulnerable (box). These risk factors can give rise to complicated forms of grief that can culminate in mental illness. A clear understanding of these factors will often enable us to prevent psychiatric disorder in bereaved patients.
| Factors increasing risk after bereavement |
Traumatic circumstances Death of a spouse or child Death of a parent (particularly in early childhood or adolescence)
Sudden, unexpected, and untimely deaths (particularly if associated with horrific circumstances)
Multiple deaths (particularly disasters)
Deaths by suicide
Deaths by murder or manslaughter
Vulnerable people General: Low self esteem
Low trust in others
Previous psychiatric disorder
Previous suicidal threats or attempts
Absent or unhelpful family
Ambivalent attachment to deceased person
Dependent or inter-dependent attachment to deceased person
Insecure attachment to parents in childhood (particularly learned fear and learned helplessness)
Bereavement has physiological as well as emotional effects (lower box). It also affects physical health: after bereavement, the immune response system is temporarily impaired 7 8 and there are endocrine changes such as increased adrenocortical activity and increases in serum prolactin and growth hormone,2 as in other situations that evoke depression and distress.
| Complications of bereavement |
A variety of psychiatric disorders can also be caused by bereavement, the commonest being clinical depression, anxiety states, panic syndromes, and post-traumatic stress disorder. These often coexist and overlap with each other, as they do with the more specific morbid grief reactions. These last disorders are of special interest for the light that they shed on why some people come through bereavement unscathed or strengthened by the experience while others "break down."
It is a paradox that people who cope with bereavement by repressing the expression of grief are more likely to break down later than are people who burst into tears and get on with the work of grieving. The former are more liable to sleep disorders, depression, and hypochondriacal symptoms resembling the symptoms of the illness that caused the bereavement ("identification symptoms"). Not all psychogenic symptoms, however, are a consequence of repressed or avoided grief. Some reflect the loss of security which often follows a major loss and causes people to misinterpret as sinister the normal symptoms of anxiety and tension.
At the other end of the spectrum of morbid grief are people who express intense distress before and after bereavement. Subsequently they cannot stop grieving and go on to suffer from chronic grief. This may reflect a dependent relationship with the dead person, or it may follow the loss of someone who was ambivalently loved. In the former case the bereaved person cannot believe that he or she can survive without the support of the person on whom they had depended. In the latter, their grief is complicated by mixed feelings of anger and guilt that make it difficult for them to stop punishing themselves ("Why should I be happy now that my partner is dead?").
Some degree of ambivalence is present in all relationships. To some degree its effects can be assuaged by conscientious care during the last illness, and many people will recall "We were never closer." If members the family have been encouraged and supported so that they have been able to care, and the death has been peaceful, anger and guilt are much less likely to complicate the course of grieving.
These two patterns of grieving often seem to occur in "avoiders" (people with a tendency to avoidance) and "sensitisers" (those with a tendency to obsessive preoccupation), respectively.9
|Preventing and treating complicated grief|
Doctors are in a unique position to help people through the turning points in their lives which arise at times of loss. In order to fulfil this role we need information and skills. One of our problems as caregivers is our ignorance of our patients' view of the world. Not only do we seldom know what they know or think they know about the situation they face, we do not even know how that situation is going to change their lives. It follows that we need to find out these things and, where possible, add to their knowledge or correct any misperceptions, taking care to use language that they can understand. (This is easier said than done when words like "cancer" and "death" mean different things to doctors than they do to most patients.) Above all, we should spend time helping them to talk through and to make sense of the implications of the information we have given. If need be, we should see them several times to facilitate this process of growth and change. General practitioners, because they are likely to know the person, are often well placed to provide this "trickle" of care. For most bereaved people the natural and most effective form of help will come from their own families, and only about a third will need extra help from outside the family.
Members of health care teams can often prepare people for the losses that are to come. People need time to achieve a balance between avoidance and confrontation with painful realities, and we need to take this into account when we impart information that is likely to prove traumatic. One way is to divide the information that needs to be confronted into "bite sized chunks." Doctors do this when we break bad news a little at a time, telling a patient as much as we think he or she is able to take in. Patients seldom ask questions unless they are ready for the answers, and they will usually ask precisely what they want to know and no more. It follows that we should invite questions and listen carefully to what is asked rather than assuming that we know what the patient is ready to know. By monitoring the input of information, a person can control the speed with which they process that information.
| Breaking bad news |
Supporting bereaved people
A visit from the general practitioner to the family home on the day after a death has occurred enables us to give emotional support and to answer any questions about the death and its causes that may be troubling the family. Newly bereaved people often feel and behave, for a while, like frightened and helpless children and will respond best to the kind of support that is normally given by a parent. A touch or a hug will often do more to facilitate grieving than any words.
In the acute stages it is usually best to give support by personal contact, preferably in the client's home. Later the help of a group in which bereaved people can learn from each other, as well as a counsellor, may be helpful. Organisations such as Cruse Bereavement Care and the member organisations of the National Association of Bereavement Services may be able to provide either of these types of help. The Compassionate Friends (for bereaved parents), Lesbian and Gay Bereavement, Support after Murder and Manslaughter (SAMM), and the Widow-to-Widow programmes that exist in the United States and other parts of the world provide mutual help by bereaved people for others with the same types of bereavement.