9/17/2019

Exploring Grief and Loss

A look at grief, loss, and coping styles

What is Loss? There are different types of loss

• Physical loss is the loss of something tangible, it is no longer present

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There are different types of loss

• Relational loss is talking about the loss of a relationship with someone that you had an attachment to

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There are different types of loss

• Symbolic loss is intangible, it can be the loss of someone’s dreams or hopes

What is Grief?

http://www.dictionary.com/browse/grief

Grief is something most will recognize or may experience at some point in their lifetime

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The Myths Behind Elisabeth Kubler-Ross’ “Five Stages of Loss” 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

The Five Stages…… • Have evolved and are sometimes misunderstood • Never meant to tuck messy emotions into neat packages • Are responses to loss many people have but there is not a typical response to loss • Are part of a framework to assist us in learning to live without the one we lost • Are not stops on a linear timeline in grief • Not everyone goes through all of them or in a prescribed order • Kubler Ross & Kessler (2005) pg. 7.

Mourning • The outward expression of the loss • To feel or express grief or sorrow • A individual’s response to loss will be different

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Different Coping Styles

Intuitive Styles of Coping Instrumental Styles of Coping

Historically • Bereavement studies were predominately conducted on women • In 2010 – Doka and Martin were trying to explore gender and grief – They found that a grieving style is impacted by one’s gender, but not determined by their gender

Intuitive Styles of Coping

• Want to process their emotions • May experience waves of emotions • How they feel inside matches their expression of their grief • Feel more of their emotions, rather than thinking • Want to express their feelings • Feelings are intensely felt • Physical exhaustion and/or anxiety may occur • May have times of confusion, difficulty concentrating, disoriented, and/or disorganized • Tend to be more women in this style of coping

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Intuitive Styles of Coping

What may be impactful for this type of coping?

• Support groups

• Discussion

• Someone to sit and listen to them

• May come across as overwhelmed to others so take the time to sit and listen

Instrumental Styles of Coping

• Experience grief more physical or cognitive ways • They express their grief in more physical or behavioral ways • Focused on actively responding to their grief • More thinking rather than feeling • Periods of cognitive dysfunction may occur • Generally unwilling to discuss feelings • Tends to be more men in this style of coping

Instrumental Styles of Coping

What may be impactful for this type of coping?

• Acknowledge and validate their pain

• Be aware they may use action to process their grief

• Remind yourself that this person may come across as being cold or removed because they are not talking about feelings, but they still are processing grief

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There are different coping styles for grief, but you must consider each relationship as well

– Parents – Grandparents – Siblings – Gender Differences

Dads and Grief

Let’s hear a letter from a grieving dad to other dads out there grieving the loss of a child

• https://www.today.com/parents/grieving- father-tells-other-dads-it-s-ok-cry-t112550

“It has been shown that the greatest risk to a relationship is presented by unequal or non- congruent grieving processes between partners”

Kersting & Wagner (2012) p 190

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Watch the communication between this couple https://www.youtube.com/watch?v=Nbf8zfm5ATQ

Siblings

How a child grieves is associated with their developmental level and any previous experiences with death

Children need to be included in this process. If they are not they may feel confused and may not work through their grief

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Siblings Parents may struggle with how to, or how much, to involve the sibling(s) of the child that has passed away. The parents will need to decide what they feel is appropriate for their child. These are just suggestions based on developmental age.

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Age Birth - 2

• No understanding of death • Mindful of the loved one missing • Possible behaviors may be: – Crying – Rocking – Sleeplessness – Thrashing

What May Help

• Reassurance • Hugging or cuddling • Maintain routines as much as possible • Meet the child’s physical needs • Include the child in the process of mourning • Be patient

Age 3-5

• May not understand death is permanent • May see this as temporary or reversible • Possible behaviors may be: – Repetitive questions – Intense dreams – Crying – Fighting – Acts as if the death didn’t happen

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What May Help

• Allow safe ways to express their feelings • When answering questions be truthful and keep the answers simple • Let he/she cry • Use reflective listening allowing the child to talk openly • Include the child in the family’s rituals and mourning

Age 6-12

• Understand that death is final • May think that his/her thoughts or actions caused the death • Thinks about life’s milestones without the deceased • Possible behaviors may be: – Acts like the death didn’t happen – Withdrawal – Nightmare/sleep disturbances – Aggressive or acting out

What May Help Age 6-9

• Answer questions truthfully • Allow for the child to express their feelings through physical and verbal outlets • Let the child choose how to be involved in the mourning process • Find peer support • Give physical contact • Make time to be with that child

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What May Help Age 9-12

• Allow regressive behavior • Expect and accept mood swings • Be available to listen and to talk • Offer physical contact • Encourage expression of feelings through numerous outlets • Let the child choose about involvement in death and mourning

Age 12 years and up • Denial • May sense own impending death • May utilize spiritual concepts to cope • His/her words or actions may have caused the death • Possible behaviors may be: – Mood Swings – Hides Feelings – Impulsive/High risk behaviors – Changes in peer groups – Changes in eating patterns

What May Help Age 12 and Beyond

• Expect and accept mood swings • Support relationships with understanding adults • Answer questions truthfully • Find peer support • Encourage journaling • Allow them to choose about the level of involvement in death and mourning – Making a scrapbook • Encourage exercise

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All Ages, at parent’s discretion

• Give the child opportunities to talk about how they are feeling

• Celebrate the memory of their sibling through walks or yearly celebrations

• A scrapbook (with pictures if available) for them to look back through

All Ages, at parent’s discretion

• Involve the child in planning the memorial service

• Create handprints in different colors

Microsoft Clip Art • Let them express their feelings through poetry, art, drawing, or creating their own mementos

What About Grandparents?

Grandparents are grieving for the loss of the grandchild and for their own child who is experiencing this loss.

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Grandparents

• This unique relationship can offer both comfort for the grieving parent or could be a source of tension.

• The grandparent is seeing their child suffer and that is incredibly difficult. The grandparent may not be forthcoming with their emotions for fear of further hurting their child. The parent that lost the child may want to protect their parent(s) from further pain and not fully disclose their grief.

Grandparents

• Articles addressing grandparents and the loss of a grandchild found that they felt isolated, didn’t know where to turn for support, and had a hard time finding someone to listen to them – If you notice this with a family you are caring for you can help. Contact pastoral care and see if they will come by to talk with the grandparent.

Does it matter when the loss occurred; 12 weeks, 25 weeks, or full term to determine the amount of grief a parent will experience? Is that measureable?

Researchers on this topic have not been able to find an association between the length of gestation and the intensity of grief, anxiety, or depression. A woman losing a child at 11 weeks gestation may be just as distraught as a woman that looses a child at 20 weeks gestation

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An early loss

Families that experience an early loss may not feel supported as they mourn the loss of their child. This may be due to a lack of understanding from society that their attachment to this baby began in pregnancy, not after delivery. Also, significant dates, such as what the due date would have been, may be difficult for these families.

Watch this ED physician interact with two parents that just went through a miscarriage…Yes this is from a television show but it is a 2017 episode!

https://www.amazon.com/The- Wedding/dp/B075417P14/ref=sr_1_1?ie=UTF8 &qid=1523383259&sr=8- 1&keywords=this+is+us+season+2+episode+8

Not all grief is due to the loss of a life, but may be due to the loss of what the parents dreamed their child’s life would be. Remember symbolic loss is intangible, it can be the loss of someone’s dreams or hopes.

CDC.gov

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Welcome to Holland

https://www.tours-tickets.com/media/1339861/2018_cat_hollandtours.jpg

https://www.freedomtreks.co.uk/sites/default/files/styles/category_galleries/public/amsterdam- colourful-houses-holland.jpg?itok=l2N7mt4D

Grief involving surviving infant(s)

Grief involving surviving infant(s) Health care providers should avoid dialogue such as: • Focusing on the fact that one (or more) of their babies is alive • The death of one of their multiples was meant to be so this baby could live • Explaining or stating if their baby had lived he/she would have had a multitude of complications………

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“Grief is described as a natural reaction to separation, bereavement or loss of a loved one. It manifests physically, psychologically, socially and behaviorally.”

McGuinness, Coughlan, & Power (2014).

Grief Response: Physical Reactions

• Headaches • Muscular Aches • Nausea • Tiredness and Exhaustion • Menstrual Irregularities • Loss of appetite • Pain • Insomnia • Tenseness • Sensitivity to Noise Microsoft Clip Art

Grief Response: Affective Reactions

• Sadness Affect is the experience of feeling or emotion • Anger • Guilt • Jealousy • Anxiety and Fear • Shame • Feelings of Powerlessness or Hopelessness • Relief • Feelings of Emancipation

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Grief Response: Cognitive Reactions

• Obsessive Thinking • Inability to Concentrate • Fantasizing • Apathy • Dreams • Disorientation and Confusion • Reviewing the Circumstances of the Loss • A Sense of the Deceased’s Presence • Attempts to Cognitively Understand the Loss

Grief Response: Spiritual Reactions

• Searching for Meaning in the Loss • Changes in Spiritual Behavior, Feelings, or Beliefs.

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Grief Response: Behavioral Experiences The behavioral experience is influenced by the person’s emotions • Crying • Illness-related Behaviors • Outward Expression of Emotion • Observable Changes in Religious/Spiritual Behaviors and Expressions • Searching Behaviors • Avoiding or Seeking Reminders of the Loss • Obsessive Activity • Activities That Give a Sense of continued Connection to the Loss • Social Withdrawal • Absentmindedness • Accidents • Changes from Preloss Behaviors • Increases in the Use of Alcohol, Smoking, and Other Chemical Use Microsoft Clip Art

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Please Remember…

• We can show our support to these families, and each other, in numerous ways • Understanding that people grieve in different ways is critical • Allowing yourself the right to feel is important, and having an avenue to express these feelings is vital

So How Can We Help…..

https://a.wattpad.com/cover/41388148-352-k299634.jpg

Refuge and Grief Megan Divine

https://www.refugeingrief.com/

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There is No Magic Pill or Formula

• Give verbal responses to show you're listening • Use body language to show that you're listening

• Stay present and Validate & Acknowledge their feelings – “this must be very hard for you…. • Strive to talk less and listen more

References • Buglass E (2010) Grief and bereavement theories. Nursing Standard. 24, 41, 44-47. Date of acceptance: January 4 2010. • Carlson, R. (2012). Helping families create keepsakes when a baby dies. International Journal of Childbirth Education (27) 2 p 86-91 • Davidson, M., London, M., & Ladewig, P. (2016). Old’s maternal-newborn nursing & women’s health across the lifespan (10th ed.). Boston: Pearson. • Devine, M. Refuge and Grief https://www.refugeingrief.com/ • Doka, K, & Martin, T. (2010). Grieving beyond gender: Understanding the ways men and women mourn. New York, NY: Routledge • https://www.pdx.edu/students-with-children/sites/www.pdx.edu.students-with- children/files/Welcome%20to%20Holland.pdf • Gilrane-McGarry, U., & O’Grady, T. (2011). Forgotten grievers: An exploration of the grief experiences of bereaved grandparents. International Journal of Palliative Nursing, 17 (4). P 170-176 • Glenn, A. (2015). Using online health communication to manage chronic sorrow: Mothers of children with rare diseases speak. Journal of Pediatric Nursing 30 doi:org/10.1016/j.pedn.2014.09.013 • Kersting, A., & Wagner, B. (2012) Complicated grief after perinatal loss. Dialogues in Clinical Neuroscience, 14 (2) p 187-194 • Kubler Ross, E. & Kessler, D. (2005). On Grief and Grieving. New York, NY: Scribner

References • Leis-Newman, E. (2012). Miscarriage and loss losing a pregnancy can affect a woman — and her family — for years research finds. American Psychological Association . 43 (6) Print version: page 56 • Sousou, J., & Smart, C. (2015). Care of the childbearing family with intrauterine fetal demise. Nursing for Women’s Health 19 (3). doi: 10.1111/1751-486X.12205 • McGuinness, D., Coughlan, B., & Power, S., (2014). Empty arms: Supporting bereaved mothers during the immediate postnatal period. British Journal of Midwifery, 4 (22), 246-252. • McGrath, J. (2011). Neonatal nurses: What about their grief and loss? The Journal of Perinatal & Neonatal Nursing DOI: 10.1097/JPN.0b013e318208cbf6 • O’Leary, J., Warland, J., & Parker, L. (2011). Bereaved Parents’ perception of the Grandparents’ reactions to perinatal loss and the pregnancy that follows. Journal of Family Nursing (17) 3 p 330-356. DOI: 10.1177/1074840711414908 • Roose, R., & Blanford, C. (2011). Perinatal grief and support spans the generations: Parents’ and grandparents’ evaluations of an intergenerational perinatal bereavement program. The Journal Perinatal & Neonatal Nursing (25), 1 p. 77-85. DOI: 10.1097/JPN.0b013e318208cb74 • Vitale, S. & Falco, C. (2014). Children born prematurely: Risk of parental chronic sorrow. Journal of Pediatric Nursing 29 (3) doi: 10.1016/j.pedn.2013.10.012

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References • Welte, Teri M., (2013). Gender Differences in Bereavement among Couples after Loss of a Child: A Professionals Perspective. Master of Social Work Clinical Research Papers. Paper 271. http://sophia.stkate.edu/msw_papers/271 • Wheeler-Roy, S. & Amyot, B. (2004). Grief counseling resource guide: A field manual. https://www.omh.ny.gov/omhweb/grief/ • Yalom, V. & Doka, K. (2010). Kenneth Doka on Grief Counseling and Psychotherapy (Interview transcript). Retrieved from Psychotherapy Web Site: https://www.psychotherapy.net/interview/grief-counseling-doka • Youngblut, J., & Brooten, D. (2013). Parents’ report of child’s response to sibling’s death in a neonatal or pediatric intensive care unit. American Journal of Critical Care. 22(6). doi:10.4037/ajcc2013790. • Youngblut, J., Brooten, D., Blais, K., Kilgore, C., & Yoo, C. (2015). Health and functioning in grandparents after a young grandchild’s death. Journal of Community Health. 40:956–966 doi: 10.1007/s10900-015-0018-0 • http://www.sciencemuseum.org.uk/broughttolife/people/johnbowlby.aspx • https://www.youtube.com/watch?v=iLx7xVf1CN4

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