N307 Study Notes Flashcards
Explain Bowlby’s Phases of Mourning
acronym: NYDDR
Stage 1: Numbness: The person has yet to adjust and so feels shock, distress, fear, perhaps anger at the loss. The protest may take forms of denial such as “No: this cannot have not happened to me. I can’t believe it. It is all a bad dream.” In the clinic a patient may react saying “Those cannot be my test results!”
This phase may last hours, or it may last much longer. Weeping is common; this may form both a protest at the loss and an attempt to recover what has been lost: weeping draws attention to one’s loss and pleads for assistance. The bereaved person may need to talk about the death, even though relatives may prefer to avoid talking about it.
Be aware that a person is this initial stage of grief may feel anger and hostility, sometimes directed towards you, the physician: “You didn’t save him; you could have done more.” Sometimes it is directed at themselves: “I should have been there; I could have helped.” At other times it may be directed towards the dead person: “Why did you leave me? I need you.”
The anger that can accompany this first stage is difficult to deal with in a rushed clinic. It is a secondary emotion, resulting from pain or fear. An empathic comment (“That must be tough”) may help diffuse the pain and so reduce the anger somewhat.
Be aware, also, that well-intentioned actions such as removing a body soon after death may impede a family’s ability to adjust to the loss by looking one last time at their relative. One function of funerals is to provide a formal recognition that a death has occurred. They communicate this fact to everyone, saving the family the difficulty of informing people themselves. Viewing a body in a casket may help move the process of mourning forward. The doctor’s may play an important role in providing the family with factual information on what happened and why, to help them face the reality of the death.
Stage 2: In Bowlby’s model the stage of initial shock leads to a phase of yearning and searching for the lost person. The grieving person becomes preoccupied with the lost person; the world seems empty and meaningless without them. The bereaved may think about the lost person for hours, reliving memories even though this is painful. The predominant emotion is of painful sadness. This appears to be a process of transferring feelings of attachment for the person onto memories of the person; as each memory is relived, the person gradually assembles the internal realization that the relationship has ended. There may be returns to denial during this process.
In other models this stage is merged with the stage of disorganization:
Stage 3: Disorganization and despair. Through this process of mental reliving the lost person, the bereaved person comes to accept the permanent loss and experiences restlessness and aimlessness; perhaps becoming withdrawn, introverted and irritable. Like anger, depression pushes other people away. Relationships lose warmth and spontaneity; the person may feel guilty and angry about their feelings. The world seems bleak and empty, but this differs from clinical depression in that the person’s self-esteem is still intact.
Somatic symptoms may include digestive disturbances, loss of appetite, choking sensations, lack of energy and physical exhaustion. Most people at this stage try to avoid being reminded of the lost person. Some become restless and need to pace about
Stage 4. Reorganization. Here the grief begins to recede and the person begins to establish new patterns and goals in their life, a process that may take months or even years. Painful memories begin to fade and hurt is replaced by cherished memories, pleasure and affection. New activities and relationships are begun, although survivor guilt may be evoked if a new love object enters the person’s life.
When the process evolves successfully, the person may mature and grow from the experience of bereavement. A widow may become more independent, feel better able to take care of herself, and may undertake projects she never could while her husband was alive.
What are the Kubler-Ross’ Stages of Dying? Explain each.
acronym: DABDA
Denial — “I feel fine.”; “This can’t be happening, not to me.”
Denial is usually only a temporary defense for the individual. This feeling is generally replaced with heightened awareness of possessions and individuals that will be left behind after death. Denial can be conscious or unconscious refusal to accept facts, information, or the reality of the situation. Denial is a defense mechanism and some people can become locked in this stage.
Anger — “Why me? It’s not fair!”; “How can this happen to me?”; ‘“Who is to blame?” Once in the second stage, the individual recognizes that denial cannot continue. Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Anger can manifest itself in different ways. People can be angry with themselves, or with others, and especially those who are close to them. It is important to remain detached and nonjudgmental when dealing with a person experiencing anger from grief.
Bargaining — “I’ll do anything for a few more years.”; “I will give my life savings if…”
The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the individual is saying, “I understand I will die, but if I could just do something to buy more time…” People facing less serious trauma can bargain or seek to negotiate a compromise. For example “Can we still be friends?..” when facing a break-up. Bargaining rarely provides a sustainable solution, especially if it’s a matter of life or death.
Depression — “I’m so sad, why bother with anything?”; “I’m going to die soon so what’s the point?”; “I miss my loved one, why go on?” During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect from things of love and affection. It is not recommended to attempt to cheer up an individual who is in this stage. It is an important time for grieving that must be processed. Depression could be referred to as the dress rehearsal for the ‘aftermath’. It is a kind of acceptance with emotional attachment. It’s natural to feel sadness, regret, fear, and uncertainty when going through this stage. Feeling those emotions shows that the person has begun to accept the situation.
Acceptance — “It’s going to be okay.”; “I can’t fight it, I may as well prepare for it.” In this last stage, individuals begin to come to terms with their mortality, or that of a loved one, or other tragic event. This stage varies according to the person’s situation. People dying can enter this stage a long time before the people they leave behind, who must pass through their own individual stages of dealing with the grief.
