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Grief – Natural versus Complicated

Depression – Mental or Physical Disease?
January 20, 2014

Grief – Natural versus Complicated

Grief is a stressful experience, and therefore, can be reviewed through the transactional theory of stress by Lazarus and Folkman. This theory describes coping as problem-focused and emotion-focused. In grief, individuals may use both coping strategies interchangeably depending on the process stage. For example, it may be helpful to react emotionally by crying or venting out anger and despair while mourning, and then to access the situation and make a plan for restoring one’s life during the adjustment phase.

Grief is a normal and natural reaction to the loss experienced by human beings and explained through many theoretical frameworks. For example, the attachment theory first defined by John Bowlby defines grief as a psychological and evolutionary mechanism securing bonds between individuals. According to the attachment theory, the attachment bond could express itself in three ways – proximity to the attachment figure providing the child with safety from the threat; the accessibility of the attachment figure providing a secure base from which the child might more confidently confront challenge; and separation from the attachment figure triggering separation anxiety, a state of anxious distress in the child in which the child’s energy and attention were directed to regaining proximity to the attachment figure. There is evidence suggesting that the attachment bond is maintained even after the death of the attachment figure, through the photographs, letters, personal items reminding of the deceased. In the attachment bond, one perceives self either as needful or as protective depending on the nature of the relationship, i.e. child is needful of the parent, but the parent is protective of the child, in relationship of spouses – the roles depend on personal characteristics and nature of the relationship.
We usually describe the stages of grieving suggested by Bowlby and Parker in 1970 as numbness, pining, disorganization, and reorganization. The duration and intensity of each stage may vary greatly, but the variation in the process may be considered pathological. Family systems prospective focuses on how family members construct the meaning of death, and suggests that the shared meaning of death in the family will greatly influence how the family and each individual member will grieve. The family death meaning is shaped through generations and encompasses family structure, processes, traditions, and dynamics. Families, who perceive the death of a family member as a relief from pain and suffering, have a different meaning of death than the family, who perceive the loved ones death as something that should have been prevented. Family systems theory provides three concepts to explain the family meaning-making process – roles, rules, and boundaries. Roles define the expectation attached to a position of the member in the family. It can be a mother or a father, but also the peacemaker, the scapegoat, and the family star. When one of the positions becomes vacant through the death of a family member, the family must appoint the new member to fill the void. Rules define the family responses, which govern family interactions and grief responses. Boundaries define delineation of the family elements within and outside of the family environment, and may include separating the family from its environment, separating generations within the family, and separating subgroups within the family. The meaning of death may be different across the separated groups or surviving members of a particular group. The dynamics of the sociocultural developments are very obvious in grief studies. Grief has earlier been addressed to as an emotion, however, is currently being regarded more and more as a disease. As this continues, grief will accrue more and more definitions of the disease and will lose the meaning of an emotion.  It is thus important to adapt the family therapy to a timeline of grief processes, by examining each family member affected and the family processes and dynamics.
Some losses may be easier to come to terms with than others. For example, the death of very old family members, which are expected and imminent. Other losses, like losses of children or young adults to accidents, illnesses, or wars are far more difficult to process. As parents, we wish our children to survive us, and there are multiple reasons to explain that. Our children carry our legacy, family and cultural history, our genetic blueprint. Their life provides a confirmation of our immortality, as we live on in our children and through our children into grandchildren and beyond. However, these thoughts may turn to be “dysfunctional” from the point of view of the cognitive-behavioral therapy in cases of complicated grief. When a child is lost, parents need to confront the painful aspect of the loss, to integrate and transform their grief. Dysfunctional thoughts and beliefs need to be restructured. Restructuring dysfunctional thoughts includes confronting the false beliefs, expectations, and finding a deeper meaning in loss. This could be an ability to focus on creating a legacy for the surviving parent and their deceased child through other channels, being able to embrace own mortality and the beauty of life “here and today”, and finally being there for other loved ones (such as other surviving children), who are suffering most in cases when a family loses a child by losing both a sibling and a parent, who is no longer able to care for them.
When the process or a part of the grief process fails, and the grief interferes with relationships, work, impacts the health severely – there is a reason to consider that complicated grief may be the reason. Complicated grief combines the features of depression and post-traumatic stress disorder and requires intervention to resolve. The DSM-V will be including complicated grief as a condition in its new edition. Complicated grief is a prolonged grief disorder with elements of a stress response syndrome. To meet criteria for complicated grief, the bereaved presents with symptoms of separation distress, such as searching for the deceased and preoccupation with the loss, and traumatic distress in the form of disbelief, emotional detachment, and bitterness. These symptoms must have caused significant impairments in functioning for a minimum of two months to qualify for the diagnosis of complicated grief. Predictors of complicated grief prior to the death include previous loss, exposure to trauma, a previous psychiatric history, attachment style, and the relationship to the deceased. Factors associated with the death include violent death, the quality of the caregiving or dying experience, close kinship relationship to the deceased, marital closeness and dependency, and lack of preparation for the death. Perceived social support play a key role after death, along with cognitive appraisals and high distress at the time of death. Avoidance of reminders of the loss contributes to functional impairment after controlling for other symptoms of complicated grief.
Earlier research provides solid evidence of biological links between grief and increased risk of morbidity and mortality. Bereaved individuals are at higher risk of depression, anxiety, and other psychiatric conditions, highly susceptible to infections and a variety of other physical illness, due to the considerable weakening of the immune system. Bereaved individuals have higher consultation rates with doctors, use more medication, are more often hospitalized. The risk of mortality is associated with medical conditions in bereavement, as well as with suicide.

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