Bereavement in adult life

British Medical Journal, March 14, 1998 by 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, 55--a quarter of consultations overall--were 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 providers--but 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.

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 grief--but 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 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.