Bereavement and End of Life Issues > Chapter 2 - Relevant Literature

Chapter 2: Relevant Literature

II. Relevant Literature

Literature on bereavement is extensive but similar.As a result, some of the explanatory processes overlap. This can be seen as a strength rather than a weakness in understanding the process of grieving.It is important to keep in mind at the onset that people cope with death in individual ways and may not fit into a particular process or stage (Hudson, 1981).

Kubler-Ross wrote about the five stages a dying patient goes through on learning about his or her impending death (Kubler-Ross, 1969). Included in her book is a chapter on the grief reaction of the family which is also divided into similar stages.The first of these stages is that of denial and isolation.In this stage, the surviving family member has a difficult time believing that the deceased is actually gone.The person may talk out loud to the individual, set a place at the table for them, or keep the person's room just as it was prior to the death.Isolation is a result of not wanting to face others who represent a threat to their denial.

After denial and guilt are worked through, the survivor may begin to express anger.This anger might be directed toward the deceased, a doctor (who in the survivor's perception should have saved the person), or towards oneself as a result of guilt for missed opportunities. Kubler-Ross notes that if the survivor is able to express his or her anger, then they will feel grief for the loss. This lends onto acceptance as the person realizes the loss of the person and comes to understand more fully what that means to them individually.

Edelstein (1984) differentiates between the stages in the mourning process of an anticipated death and maternal bereavement for the unexpected death of a child. The normal mourning process contains two stages, acute and chronic, with different phases in each stage and associated affect with each. In the acute stage of the process are the phases of shock, searching, grief reactions, and separation reactions.

In shock, the individual experiences numbness, disbelief, shrieking and motor retardation.This phase varies in intensity depending on the preparation for the loss, and it is usually very short. The searching phase includes attempts of the individual to recover the lost individual and is marked in affect by weeping. Part of the process in this stage is the constant testing of reality showing again and again that the deceased individual no longer exists in the external world. Grief reactions occur when there is the realization that nothing can be done to recover the loss. The associated affect in this stage includes despair, sadness, depression, fatigue, and helplessness. The final phase of the acute stage is that of separation reaction which produces anger and anxiety in affect. The anger is as a result of being left by the deceased person and anxiety is the response to the loss and threat of one's security.

The period of separation reaction moves the individual into the chronic stage of mourning.This stage has just one phase which is reintegration and its acceptance of loss. At this time the individual begins the process of removing energy from the relationship with the deceased individual and shifts it to others. It also displays the ability to integrate the experience of the death's reality.

In maternal bereavement similar phases are processed with slight variations.The major difference is Edelstein's division of the process into three different stages. The first of these is disorganization which is described as a "disruption in the equilibrium as a result of trauma." The second stage is holding on/letting go whose major dynamics are the "struggle to relinquish the child as living; retaining memories and identification." The last stage is reorganization which is the modification of the equilibrium to an integration of past and ongoing activities, and loss into life (p. 15).

Elsewhere in her book Edelstein summarizes the psychological defenses used in bereavement.Probably the most notable of these is denial which is used to reduce the emotional response. It is manifested, as stated earlier, in ordinary ways such as setting a place at the table the deceased or buying his or her favorite foods. Another defense is avoidance. This may be manifested by purposely not buying any of the deceased person€™s favorite foods, even though the survivor may like the food.

Identification is manifested in the survivor taking on some personality traits of the one lost, ensuring that the attachment continues. Altruism is manifested in the survivor when direct gratification is given up to help others. Finally, projection is used to attribute feelings not acceptable in oneself on to another. An example of this is the blaming of others for the death to try and rid one's feelings of guilt.

As with Edelstein, Raphael (1980) writes that shock is the initial reaction to the death of a loved one.She describes this as a time when the reality of the loss is avoided so that the egocan absorb the reality more slowly. Intellectual awareness of the loss is present while the emotional awareness is exhibited by an increasing wave of anguish. This emotional experience is the pain of being separated from the loved one. This may be turned into anger toward the deceased person for leaving, and then is projected onto another since this feeling is irrational. In addition, at this time all energy is focused into the relationship of the deceased at the expense of other relationships.

As time goes on and the person understands through trial and error that the deceased person is no longer there, acceptance begins to unfold with a full realization of the loss. With this realization the ego, knowing the needs of survival, gives up the lost relationship and this emotional energy is given again to the outside world.

In addition, a great sense of disorganization and despair occur.Disorganization occurs as a result of other losses such as a loss of roll, identity, status and security. Interactions and activities which were previously enjoyed now have no meaning. There are many memories of the deceased, often with idealistic views. The ability to view the negative aspects in addition to .the positive will be important for undoing the bonds.

After the initial crisis of the loss, the mourning will continue on as different things come up that reintroduce the loss.These include birthdays, dates of previous plans, and anniversaries of the death.

Corazzini (1980) writes about what he calls the "three phases of development for the bereft self."The first phase is loss.The person is stunned by a loss that will cause permanent changes in him and his relationship with others. Grief behaviors occur and regular interactional patterns cease. The second phase is that of consolidation. At this point, the bereft individual becomes depressed at the realization of the loss as permanent. Also, during this phase, the individual must begin to let go of the attachment to the lost one and produce the emotional energy to produce other significant relationships to replace this one. As this process or transfer of energy is accomplished the person enters the last stage; that of reintegration. During this phase the individual develops a different attachment to the deceased and draws on happy memories. When this is accomplished the mourner leaves this stage and the mourning process.

Three basic tasks of grief that Rando (1984) writes about are the emancipation from the bondage of the deceased, readjustment to the environment in which the deceased is missing, and the formation of new relationships. In the first task the griever must go through a decathexis, removing the emotional self he had previously invested into the relationship. The second task of adjustment to the world without the deceased may include adopting new roles and skills to compensate for that which was previously performed by the loved one. Examples could include a woman supporting the family financially if she had not previously done so, or a man taking care of more household details his wife used to do. The third task is to take the emotional energy that is withdrawn from the previous relationship into new relationships, as has been stated in the other models.

Finally, Aguilera (1990) writes that it is not the death itself that is the critical question, but how the person perceives and relates to the knowledge that death is certain. This agrees with the statement at the beginning of this section that reaction to death is an individual reaction based on many factors. These factors will be addressed in the next section.
Question No.2. Kubler-Ross' stages of grief do not include which of the following:

a. Denial
b. Anger
c. Acceptance
d. Relief

Question No.3. Raphael wrote that ______ is the initial reaction to the death of a loved one.

a. Despair
b. Anger
c. Shock
d. Acceptance

Question No.4. The primary treatment strategy in the Kubler-Ross approach is to be available and empathetic.

a. True
b. False

Question No.5. Edelstein differentiates between the stages in the mourning process of a(n) ______________ for the unexpected death of a child.

a. Anticipated death and maternal bereavement
b. Uneventful death and depressed bereavement
c. Sudden death and long-term bereavement
Bereavement and End of Life Issues > Chapter 2 - Relevant Literature
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