Grief and Bereavement

Grief and Bereavement

Allan Kellehear, PhD., FAcSS. University of Bradford.

Grief is the natural emotional and social consequences of attachment and loss, whether this is loss of a limb, one’s country, one’s employment or marriage, or other crucial relationships important to identity and personal aspiration. Although there are many sources of personal loss, the term ‘bereavement’ refers specifically to the loss of an important relationship through death. The grief associated with loss after bereavement is widely acknowledged to be associated with a number of serious co-morbidities and mortalities. These consequences can be medical (e.g. arrhythmias, gastro-intestinal disorders, or insomnia,), psychological (e.g. anxiety, depression, or sexual acting out) and social (e.g. lost work or school days, social isolation and loneliness, increased use of health services) (Abel et al 2018). More serious consequences can follow, for examples the sudden death of a surviving spouse/partner, or even suicide (Raphael 1983).

The psychological literature about grief is intimidatingly large, and largely problem-focused. There have been serious professional and academic concerns over the ‘pathologizing’ of human sorrow – unnecessarily making sadness into a psychological ‘condition’ and blurring the boundaries between ‘complicated’ or ‘abnormal’ grief and normal grief (Walter 1999,  Howarth 2007). Some of this criticism is based largely on the ever shrinking time period that is considered ‘usual’ for adaptation (Horwitz & Wakefield 2007). This body of professional opinion and research too often portrays grief as largely a negative, destructive force (Kellehear 2002). Grief is often portrayed as a personal ‘train wreck’ or crisis in life. But although some people do encounter serious problems and challenges during the course of their grief, the most important public health insight is to acknowledge that the overwhelming majority of people more or less come to terms with their loss over time. The experience of a significant loss lasts forever. And the potency of that loss changes over time as does our personal ways of dealing with these changes over the years. Many of these changes elicit constructive and positive (albeit under-recognized) responses to both character and to society – from greater compassion, meaning-making or personal insight to contributions to reform agendas and legacies in medicine, science, or the arts.

For those whose grief takes them from the initial periods of unrelenting distress toward further physical, psychological or social decline, the debates about which therapeutic interventions are most effective, and when, is an ongoing debate. Initial presentations of grief can vary widely – from highly demonstrative and persistent weeping and wailing to somber stoicism to apparent indifference. These differences are encouraged or moderated by different social conventions but they do vary even within the same ethnic or religious communities. As such then, these early expressions cannot in and of themselves, be used to predict long term outcomes for bereavement. In this context, most clinicians dealing with the impact of dying or death will adapt their approach to the patient or family only in their initial phases of grief.

Much of the current literature suggests that encouraging people into counseling in their initial period of bereavement is neither a particularly helpful nor an effective solution to this early experience of personal loss (Stroebe, Schut, Stroebe 2005, Neimeyer 2010). In the first days and weeks of grief after bereavement, friends and family should be encouraged to come together and support each other for the longer term, in the ways they know best, employing the intimate knowledge they have of each others needs. Clinicians can also play an important role in offering comfort and support within their workplace environments – for patients, family, – and just as importantly – for other colleagues. This should involve prioritizing listening over talking and awareness raising about support services. However, the epidemiological reality is that most people do cope with loss in the longer term with little to no professional assistance. Most people find their own social networks to be satisfactory, or even superior, to professional interventions from the health services (Aoun et al 2018).

These above comments notwithstanding, it is important to recognize that sometimes there are patients with little or no family. There are also many instances of surviving family members with little or no extended social supports beyond themselves. This is particularly the case for some migrant families, older patients, international visitors, or for the homeless and imprisoned. For these and other similar examples, a counselor or a spiritual advisor (such as a hospital chaplain) can be a very useful referral or additional colleague in support. It may also be useful to ensure that people in these particular circumstances are made aware of the support services that the hospital, hospice, or care home can provide them after death.  It is common for patients and families not to be aware of the support services that are available to them in matters to do with dying, death, and bereavement. This type of information is a sound first order response to experiences of grief in patients and their families.

It is important to re-emphasize here, that grief is not the sole province of surviving family and friends, and that dying people and many of our own professionals grieve too. Many patients (and colleagues) will try to ‘be strong’ for family (or for other colleagues) and may more conveniently find comfort and support from a ‘stranger’ such as a chaplain. Supervision arrangements for colleagues should always explicitly create a space for the experience of loss and grief during the course of professional practice. On the other hand, many individuals, families and colleagues, can feel embarrassed or vulnerable if the extent of their grief is made known to others. In the UK there are many ways that patients and their families can seek confidential, even anonymous, support. (see for example Cruse Bereavement Care https://www.cruse.org.uk/bereavement-services/get-help ). The NHS also have useful information sites for both advice and action (see https://www.nhs.uk/conditions/stress-anxiety-depression/coping-with-bereavement/#stages-of-bereavement-or-grief ).

Finally, the public health challenge for the experience of grief and loss is to provide adequate – and mainstream – social supports for all citizens so that the many do not follow the few into poor health outcomes. This means understanding that support for the human experiences of grief and loss is everyone’s civic responsibility. Workplaces and schools, faith groups and local governments, cultural sites and festivities, among others, have a civic responsibility to provide supports for ‘grieving in place’. In other words, wherever grief may be found, so too must supports be found. Public information and education, health promotion rather than mere distress management, and community development of supports rather than solely professional interventions, all these are crucial for any civic plan to deal with grief and loss across the lifespan and in everyday life.

Abel, J., Kellehear, A., Karapliagou (2018) Palliative care – the new essentials. Annals of Palliative Medicine 7 (2), S3-S14.

Aoun, S., Breen, LJ., White, I., Rumbold, B., Kellehear, A (2018) What sources of bereavement support do the bereaved perceived to be helpful and why? Empirical evidence for the compassionate community approach. Palliative Medicine see DOI: 10.1177/0269216318774995

Raphael, B (1983) The anatomy of bereavement. New York, Basic Books.

Walter, T (1999) On bereavement: The culture of grief. Milton Keynes, Open University Press.

Howarth, G (2007) Death & Dying: A sociological introduction. Cambridge, Polity Press.

Horwitz, AV and Wakefield, JC (2007) The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. New York, Oxford University Press.

Kellehear, A (2002) Grief and Loss: Past, present, and future. Medical Journal of Australia 177 (4), 176-177

Stroebe, W.,  Schut, H.,  Stroebe, MS (2005) Grief work, disclosure and counseling: Do they help the bereaved? Clinical Psychology Review 25, 395- 414.

Neimeyer, R (2010) Grief counseling and therapy: the case for humility. Bereavement Care 29 (1), 4-7.