Bereavement in adult life

British Medical Journal, March 14, 1998 by Colin Murray Parkes

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.