Phase 4the Grieving Process

Death is an inevitable part of the human experience yet we all have some level of emotional discomfort with death. It is only natural that we experience fears and concerns when we come in contact with the dead or dying and their loved ones. Even though we cannot do anything medically for those already dead, we can do a great deal to influence the way a family will begin coping with its loss. However, we must understand the grieving process so we can be optimally effective in our interactions.12

There are some basic family needs that, if met, will have a positive effect on our relationship. The first is to listen.

Family Needs

Listening is the first step to assess, understand and empathize. Asking an open-ended question allows family members to talk freely about their feelings with someone who is willing to listen. Listening offers direct comfort and support and is helpful in planning an individualized approach.12

Nonverbal

Nonverbal communication may be one of the most reliable indicators of an individual's emotional state. Some of these indicators may include a lowered head, hunched shoulders and weeping. Holding, rocking, or gently patting are common nonverbal ways to express sympathy. In some instances, offering a quiet and continuing presence that indicates a willingness to stay until the shock of the loss is absorbed is helpful. Often after the initial shock is resolved, family members and significant others can support and comfort each other.

No two families or individuals are alike and there are no templates to grief. Understanding a family means needing to gather as much information as possible to know them as a unit and as individuals. This can take time but is invaluable in establishing trust and rapport. Often the smallest acts of kindness can win the trust and confidence of a family.12

Families often have not been prepared about what to expect, which may result in unnecessary anxiety and stress, and the family may become overwhelmed. It is crucial to explain even the smallest of things and to address emotional needs.

Physical and Emotional Needs

When family members are notified of the death, they need a quiet and private place to express their grief and collect their thoughts. Sometimes, a family's intensity of emotion may be unexpected. It is crucial to avoid making judgments, as this is sure to come through in nonverbal communication. Disapproval of their expression of grief is in no way helpful or constructive. Spending time with families, offering to get them water or a soft drink, offering to make phone calls and expressing emotion can make a big difference in how they begin coping with their loss.12

Stages of Grieving

An important part of assisting families in coping is recognizing the stages of grief. While people do go through stages, they are often not well defined. Some writers list as few as three and others, as many as ten. People tend to vacillate between stages and can be in different stages in one day or at the same time. Overall, it is important to remember that grief is expressed in a variety of ways: anger, depression, irritability, confusion, guilt, anxiety, relief, numbness, preoccupation, ambivalence and fear. What we learn most often from people in grief is that it is a state of transition. What is felt today may not be felt tomorrow.

Grief is the natural response to any loss. There is a process humans go through in dealing with grief. The natural process lasts approximately two years, with peaks and valleys during this time. The intense peaks are anniversaries, birthdays, holidays and most Sundays. There is also usually a peak just before the two-year anniversary of the loss. Above all, individuals must be allowed to grieve in a manner suited to them.

Denial/shock/numbness/isolation

This is a documented period of vague unreality in which the body goes into an unconscious function of preventing emotional overload. The person is sad but there is an unreal quality about it. There is a sense that as soon as the movie is over, all will be over. The tears, the wailing, and the stoicism demonstrated by different cultures all indicate both the shock of the loss and the realization that the survivor will also one day die. A common symptom during this period is sleep disturbance. There may be constant sleep or no sleep at all. Feelings of weariness and numbness are pervasive. Time is needed to process what has occurred, which may be demonstrated by staring at the ceiling, remembering and feeling. There may be a feeling of "falling apart" or "going crazy". There may be dreams, flashbacks to the scene of the death, the funeral and concerns about the future as well as the reality of the loved one not being in the house or in the bed. This can last for approximately three weeks but varies according to the suddenness of the loss. Sudden death creates more shock than a lingering illness.29,16,17

Bargaining/searching

This is a time of intense yearning for the dead person that can last for four to six weeks. There will be a disbelief that the death has occurred and there may be an act as if the person were still alive. Symptoms include wanting to tell the person something, calling the person on the phone, writing a note and then looking forward to speaking with the person when driving home from work. There may be a search for the person that has died; driving around town looking for them, frequenting the old places for shopping, entertainment, study, religion or relaxation. It is not uncommon to hear reports from the loved one of being able to hear, see or smell the scent of the deceased. At this time, the survivor will return to the hospital or speak with nurses involved to thank them and then also to visit where the person died.

Bargaining may also take place, asking God if the family member can do something in particular, to take away the loss.29,16,17

Reality/mitigation/experiencing the pain

This period comes around the third or fourth month when reality becomes apparent. This is a time of depression and deep despair. The survivors may wake up in the middle of the night facing the reality they will never see their loved one again. They may experience chest pain, inability to breathe, they may call friends in the middle of the night, and cry uncontrollably. There may also be tightness in the throat, sighing, emptiness in the stomach, weakness, headaches and their appetite may diminish or disappear. This is a time of great emotional swings with restlessness, tension, fears, panic, fear of dying or of others dying. Dreaming has been reported of seeing the loved one in a casket, seeing the body dead, but talking, and the feeling of the loved one entering a room. Composing a letter of feelings and words left unsaid can be helpful, as well as going to talk to the deceased at the grave. Friends are important and need to listen, support and hold the survivors.29,16,17

Depression/reaction/anger

This is generally around the fifth to sixth month following the time filled with emotional turmoil. This is where survivors hit "rock bottom" and get angry. They may exhibit irritability, bitterness, hostility, and aggression. They may feel hurt, frustration, fear or rejection. There is always anger in grief and it must be focused somewhere. The feeling of guilt causes the "what ifs" to begin. There is a strong feeling of what could have been done differently. Feelings of anger surface and can be aimed at caregivers, family, friends, God and the survivors themselves. The survivors may remember all the quarrels in the past with the deceased and then think about the future of being alone, and then become angry at the deceased. Symptoms that may be exhibited during this time include: sleeping all the time to avoid pain, becoming very busy to avoid thinking, becoming hyper-religious to seek out every emotional and religious experience possible, drinking to mask the hurt, and being promiscuous to fill the need of being loved so deeply.

Knowing that these feelings may occur can help, but talking with others who have experienced similar things can be helpful at this time. Again, listening and understanding are of utmost importance.29,16,17

Recovery/acceptance

Towards the end of the first year to up to two years, the survivors begin to recover and reconstruct their lives. This may be marked by being able to deal with something that has been avoided until this time. The survivors may begin to participate in social events, religious and community activities, work and more of a routine. They may begin to form new relationships and begin to form new identities for themselves.

This is a very vulnerable time and individuals may seek out entirely different types of persons or jump too quickly into relationships. There is also a feeling during this time of survivors wanting everyone to remember their loved one, and to know the significance of that person's life.

The truth is that people handle grief like they handle other major difficulties in their lives. There is no designated time frame when grief must be resolved and most importantly, people need to do what works best for them in their own time frame.13

People in grief need someone to listen while they tell their story. Grief recovery requires telling and retelling the experience. In a sense people talk their grief away. The ability to simply listen is the greatest help possible in every stage of grief.29,16,17

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