This article has been developed from the original work of Revd Robert Lloyd Richards who wrote the material for the MSc in Pain Management when he was a Senior Anglican Chaplain at the University Hospital of Wales NHS Trust and from a dissertation completed by Jamie Given, a previous MSc Student.
The experience of loss and bereavement is something that is firmly part of human experience and as such, even though the experience is certainly distressing, and often painful, we are also to a significant degree equipped to deal with it. Morrison  provides narratives from two patients, the first example was a patient who had taken an overdose of medication after her husband had left her for another woman after eight years of marriage. The patient told of how her husband’s affair with the other woman had been going on for six months before she knew about it. In expressing her pain and suffering, some of the things she said were ‘nothing makes sense anymore and I can’t believe in anything anymore’. ‘I just feel empty and shattered, nothing means anything anymore’. The patient further commented that not only had her future been taken away, but her past had been destroyed.
In the second example, a patient is faced with having her leg amputated which means that she is no longer able to go back to living at home on her own. The decision was made to find a nursing home for her and the patient was devastated. It had taken some time for the carers discovered that the patient’s devastation was not caused by the prospect of losing her home, having her leg amputated or going to a nursing home, it was because she would not be able to take her pet cat to the nursing home with her, which meant that she would lose the cat given to her by her late husband just before he died. The cat had been her only companion for the last few years and now she was faced with the prospect being deprived of all she had left that gave meaning and purpose to her life.
The pain of loss and bereavement is often made more manageable by appropriate support and especially by appropriately knowledgeable and skilled carers; those that take the time to explore the important issues from the individual’s perspective. We will be looking at the management of bereavement and, as part of that, we will be looking at some of the ‘loss models’ that can help in understanding the underlying processes, and the contexts in which the pain of grief is experienced.
A word of caution. Talking and thinking about bereavement can bring to the surface private thoughts and feelings as well as the pain of them. If you have had a recent, or even not so recent, significant bereavement and think that reading this may be difficult, make sure that you have someone that you can contact for support. Bereavement and the pain of loss, and indeed its management, is a complex subject and because it is so emotive, many of you reading will have experienced such pain.
The experience of grief often has something to do with loss of control. The terms grief and loss have already been used and, of course, the experience of loss need not be by death. It is certainly true that ‘bereavement-type experiences’ occur when those kinds of losses take place. These range from the loss of a limb, to loss of a relationship, to loss of a job and so on. The loss of a person is probably the archetypical loss and so we will only concentrate on bereavement of persons, but clearly much of what we say about the pain and its management will be true for other kinds of loss.
The first kind of pain associated with loss, therefore, is the anguish or anxiety of loss of control and a sense of personal devaluation. We will take this further when we look at some of the loss models and the experience of transition in a moment.
Many of the details of bereavement pain management we will examine when we look at the loss models. Why is the management of bereavement pain important and are bereavement experiences ever totally resolved? The answer, probably, is that rarely are bereavements ever totally resolved, although within a certain time they can be well managed. Even many years after a major bereavement an unexpected trigger like finding an old photograph, or even an old hat that belonged to the deceased, can cause painful feelings to resurface, albeit for a short period.
It is equally true that while bereavement can be postponed, it can never be avoided and the experience of most bereavement counsellors is that the longer the grieving process is postponed, the more painful and, certainly, the more difficult it eventually is.
In major loss, the death of a significant other person brings about a significant change in ourselves. Frequently change is painful or, at the very least, unsettling and no more than in changes that follow someone’s death. What do we mean when we say that bereavement is an experience of transition?
Transition is an experience, which we all have and we experience it many times in our lives. Mostly it is relatively unproblematic and most of the time, we deal with it and move on. Let us begin then with a definition of transition. Put simply, the process of transition is when we separate from something, go through an intermediate stage of half belonging, half not belonging, and then re-integrate in a slightly different way, perhaps in the same context or in a new context. The most obvious example of transition that we have all experienced in some form or another is that of growing up. In our youth we begin to separate from our parents, we grow up, we move away either emotionally or even physically and in the point of transition, we negotiate new relationships with people. We begin to explore our independence, we are full at one moment of self-confidence, and in another self-doubt. Are we still a child? Are we now an adult? No one quite knows. Involved in this is the rejection of parental authority and often other kinds of authority. Finally out of the painfulness of all that, we re-integrate as adults both with our parents, with other adults and society and so on.
If our own experience of the transition of our teenage years was unproblematic then we can probably be very grateful for it, although there is a very strong school of thought which suggests that unless we have had some form of experience of pain in transition in our teenage years, further transitions in our adult years are actually more difficult, though you may like to disagree with that.
While the experience of growing up in our teenage years is a classic example of transition there are, of course, many others. Before we go on to consider them let us look at the features of each stage in transition. First in the separation stage there is pain. We move out of the comfortable set of parameters, in which we understand our role, or we understand our responsibilities, and we find it challenging. Separating from our stable situation is best done in normal time, and not out of time. When we integrate at the end of the transition process there is a re-establishment of stability and it is cemented by an understanding that there is no going back. You cannot go back to the state you were in before you passed through transition. It would be interesting if you could think of any examples of where people change and do try to go back. Experience of transition is, of course, extremely stressful. It is a time of change and anxiety. It is a time when decisions have to be made and sometimes decisions cannot be made. It is a time for letting go, it is a time of feeling very fearful and it is also a time of discontentment.
Most importantly, transition is typified by a sense of loss of control, and that is unsettling. In many transition experiences, society provides us with lots of rituals to help us to get through, from separating into re-integration. Rituals associated with bereavement include the funeral and such things as letting go by visiting the dead person in the undertaker’s parlour. Rituals are also associated with re-integration. Some experiences of bereavement, however, society does not readily recognise and, therefore, the process of transition is much more difficult, such as the experience of miscarriage. Although increasingly recognised as a genuine bereavement experience, society is still very intolerant of those who are explicit in their grief and, therefore, it is often done privately and is often left unresolved. This is a point particularly where spiritual crisis can cause a great deal of trouble.
Another kind of transition is that of moving from the stability of a childless marriage relationship, for example, to the instability of potential parenthood. Are you having a baby? Are you yet a parent? Can you talk about being a mum or dad? In such a transition, there may be feelings such as anxiety, stress, change, even discontentment and certainly loss of control. In due time the baby arrives, there is a re-integration with the family and with society at large; suddenly parenthood is a reality and all of rituals are again associated with this. Society expects people to behave in a certain sort of way, expects them to stay in and not leave their children at home alone. Those kinds of things actually radically change the meanings we attach to being a person, because being a person now means also being father or mother, even grandfather or grandmother. That kind of transition is often done very well, although not without its stresses and strains and it would be inappropriate to say that the majority of people who go through that experience, experience spiritual pain, through there may be serious questions and debates during the process of pregnancy and the change from childlessness to parenthood.
Nothing illustrates better the earlier point that transition results in a state where there is no going back, than the experience of the death of the child. Not only would it be insensitive to refer to the couple as childless but it would also not recognise the meanings that are attached to the acquisition of parenthood. If people go through that experience of transition from childlessness to parenthood and the child dies, that does not make them non-parents. They are simply parents whose child has died. Spiritual pain, certainly confusion of meanings, can arise if such parents then pretend that they are childless. That example takes us back again to the spiritual pain associated with bereavement, loss and grief. Bereavement is not the only example of transition that we can think of nor is it the only kind of transition that prompts spiritual pain.
When we experience illness we move from the state of being healthy, or at least sufficiently healthy to be fully functioning, to another state which is a little confused and uncertain, and over which we may have little control. It is certainly unclear as to whether at the end of it we will return to healthiness or whether we will remain in a state of ‘unwellness’.
The experience of illness, can itself be an experience of transition. The features of transition have already been mentioned and these are experienced by people who move from wellness to ‘unwellness’. Sickness brings about an unsatisfactory quality of life, and we loose control over a number of things that we used to exercise decision making about. If we come into hospital, or we have to rely on people in the community to help us, then we find that a significant amount of control is lost over our lives.
In hospital, of course, we give up significantly more than at home. We are told when we can sleep, whether we can dress or not, we have to obey orders and, most importantly for some people because they find it most difficult, we have very quickly to learn to trust strangers. Do you think that health care institutions recognise illness as involving the experience of transition?
It is the task of the health carer, of course, to re-integrate the unwell back into wellness but remember that one of the features of transition is that there is no going back. When a patient is discharged from hospital after experiencing a heart attack they do not go back to being a person who has never had a heart attack, there are certain things that are now changed. They may well be in a state in which they are happy with their quality of life, but they have not actually returned to the state they were in before. They have moved on into a new kind of wellness. Spiritual pain then has its roots, not so much in a disease or complaint, but in the processes that get under way when people are caught up in their illnesses. It is important to make that distinction, because caring for the illness does not necessarily mean that you are caring for the crisis through which the patient may be passing.
Spiritual pain may result from the processes, which get underway when illness is experienced. Spiritual pain can also result from the confusion of meanings, which result from changes taking place ‘out of time’. The most obvious example of transition out of time is when leaving home takes place much later than is ‘normal’. The very fact of doing certain things out of time or experiencing things out of time brings its own tension and its own crisis and can prompt spiritual pain. This is easily illustrated by reference to a generally agreed maxim that parents should not outlive their children. When a child dies before a parent dies, it is always considered to be out of time. When a very young child dies then there are other feelings of anger and unfairness, and it is all because these things are out of time.
All points of change, and certainly all points of loss, are points of transition. Most of us manage most of them quite well. If we reflect on our own experience we can probably think of points of transition which we have managed well; some which leave some things unresolved and which we have never really finally dealt with; and some no doubt, only a few hopefully, that we have managed badly. We also might be able to think of points of transition in our own experience which have been out of time and how more difficult those were to deal with. We are now going to turn our attention to the ‘loss models’ to investigate further bereavement as a transition experience. Do keep in mind as you read, the added pain of loss that is out of time. As you read, reflect on any examples from your own experience.
The thought that there may be a theoretical basis to grief may seem strange when the pain of bereavement is so personal and particular to each individual. It is not intended that by focusing on the theory we should imply that we can explain away the pain, rather the opposite. By looking at different ways theorists have talked about pain we can better understand the phenomenon of grief and this must result in more sensitive management. The loss models will be briefly outlined and some similarities between them identified and we will then return to the models to see how they can help in bereavement management. The first loss model to look at is offered to us by Lindemann . His is a three-stage model that can be expressed as in Figure 1.
Fig.1. Lindemann’s loss model
Writing as long ago as the early 1940s, Lindemann highlighted what now seems quite obvious, that death occurs as a ‘normal’ event and grief is, therefore, a process that is ‘normal’ to the human condition. The most obvious thing about Lindemann’s model is that it exactly mirrors the classic three phases of transition (Figure 2).
Fig.2. Three phases of transition
The time of transition is a time of confusion and uncertainty marked to a large degree by a sense of loss of control. Lindemann describes the stage of acute mourning in terms that reflect that confusion (Figure 3).
Fig. 3. Lindemann’s stages of acute mourning
It is interesting that Lindemann puts pain, physical pain, at the top of his list. All the others are sources of distress and we must all have seen and perhaps experienced them. Our own experience tells us that these things are often presented as ‘stages’. This does not mean that there is always a clear chronology to them or that everyone does them to the same degree, let alone the same order. The danger of thinking strictly of stages of grief is that it implies that once done it is finished but, as we well know, feelings experienced in one stage can resurface much later but without the implication that this represents a regression in the grieving process. The next two theorists will be examined together. Worden  and Bowlby  both remain within the framework of the transition process but have four stages (Figure 4).
Fig.4. Worden’s and Bowlby’s loss models
Both Worden and Bowlby take the basic transition structure further than Lindemann by reminding us of two ways of understanding the process. Worden puts the focus on the phases, while Bowlby illustrates the feelings. To get the whole picture we could add the five features of (Lindemann’s) acute mourning and it would look like Figure 5.
Fig 5. The features of Lindemann’s, Worden’s and Bowlby’s loss models
Before looking at the bereavement pain management in detail, a fourth theorist gives us a further development. Even though Schneider  has eight stages they still fit into the transition framework (Figure 6).
Fig 6. Schneider’s loss model
The distinctive feature of Schneider’s model is that he sees it as illustrating the fact that the bereavement experience itself can be a point of growth and development for the bereaved and that significant personal healing takes place as people move out of the transition phase (stage 5) into the re-integration phase (stages 6 to 8). Schneider’s model is slightly more complicated than the first three, so before we look at the whole theoretical picture in terms of loss management, it will be useful to look further at this fourth model. What Schneider means by stage 1, knowing that the death has taken place, is different from being aware of the loss (stage 4).
It is the difference between the head and the heart’s knowledge and understanding. The total awareness of the death (stage 4) is eventually gained by moving from holding on (stage 2) and letting go (stage 3). In other words, the bereaved may know intellectually that death has occurred but the intellectual fact is difficult to grasp until the letting go is also under way. We are all aware of the importance of rituals, which assist in this. The funeral itself may be the point at which the heart accepts what the head already knows.
At stage 5, getting a perspective on the loss is seen as the point at which healing begins. This is the point, says Schneider, when the confusion begins to be resolved. Schneider in his last three stages goes further than simply seeing them as an expression of re-integration after transition. Grief is a process that changes the bereaved (remember in transition there is no going back) and Schneider puts a positive gloss on this by saying that ultimately bereavement can be a positive experience and an experience of growth. With hindsight, some of us may see our bereavement experiences as times when we were changed and as such they may have been points of growth. What do you think?
Individuals grieve because of a loss; this may be death of a loved one, loss of a job, a disabling illness or a divorce. It is important to understand how the individual will react to this loss and how we, as health care professionals, can support and help manage this process. The loss management process will be examined using the phases of transition already discussed. Take a few minutes to think about how you might behave in managing a bereaved person at the initial point of grief. It may help to reflect on what help you might have received or you would have wished to receive under such circumstances. The grid below will allow you to address your thoughts.
As the first stage of transition, it is important for the bereaved to be reassured that processes accesses are underway over which they can retain some control. It is important, as health carers, that we do not unnecessarily deny that control by over managing the situation while not effectively managing the person.
Within what Lindemann calls acute mourning all the conflicting and confusing processes are underway. As far as physical pain is concerned, not only should this receive attention and not be treated as psychosomatic, but we must be aware that people presenting with physical symptoms might do so because of recent bereavement. How often do you take a bereavement history? Even to call it a ‘preoccupation’ with the image of the deceased is perhaps to be judgemental. There is a need, very often, to re-affirm the fact that death has occurred and before the funeral, this often involves frequent visits to the undertakers and sudden display of photographs. It is important to affirm this as ‘normal’ bereavement behaviour. Again, guilt and anger are normal emotions for the bereaved and in helping people focus their feelings it is possible to alleviate the disabling effect of these emotions. For those caught up in the care of the bereaved there is always the temptation to view the emotions of those in grief as irrational. The grieving themselves may say ‘I think I am going mad’. There is, however, a rationality that makes sense to the bereaved and it is only from our frame of reference that it may seem irrational.
Linked with this is the feeling that there is a loss of patterns of behaviour. Experience shows that in bereavement the normal ‘filter’ that can prioritise the importance of thoughts, tasks and so on becomes damaged. As well as feeling strange at not being able to prioritise thoughts, it can result in great distress and coping by refusing to make any decisions. This kind of distress can be managed by gently putting a little structure on things and actually suggesting that some things do need to be decided soon, but other things can be left.
The two phases of feelings in Bowlby, yearning and searching and disorganisation and despair are in many ways another way of putting Lindemann’s acute mourning. Within what Bowlby calls ‘yearning and searching’, it is important to remain non-judgemental, not to restrict the way people are thinking, even bizarre thoughts. It is worth also reflecting on whether there is an element of being out of time in this stage. As disorganisation and even despair become the painful features of grief, the carer should explicitly acknowledge what has died in the bereaved and how far the despair reflects mourning for something lost in them. A woman mourning her first child may well also be mourning her motherhood.
While Bowlby concentrates on feelings, Worden focuses on phases. In this middle stage, he says the bereaved must experience the pain and adjust to the loss. As we have said before, bereavement might be postponed but it can never be avoided. Grief is a solitary experience and in the end, we can only help by acknowledging the feelings, but not trying to explain them, by moving on at the pace of the bereaved with no preconceptions as to how quickly or slowly that should be. The distress and even physical pain need not be a secret pain. If it is acknowledged by carers, the power of feeling isolated disappears. In adjusting to the pain of grief, memory is a powerful tool and the use of constructive memory can lead people to find new meanings to going on living.
In Schneider’s first stage (the fourth model) he talks of ‘knowing’ that the death has taken place and the second stage ‘awareness’ of the loss that represents a deeper understanding. Remember the importance of telling the story to do what Worden calls ‘accepting the reality of the loss’.
In the second stage of the fourth model, meaning and healing go hand in hand. Holding on and letting go, is exactly the process that people go through in the early part of their grieving. In fact, finally letting go may take a very long time indeed, what we are concerned with here is how we manage the yearning and searching that hanging on and letting go entails.
In the second stage, there is often a painful reassessment of the meaning that the deceased person had for the bereaved. Very painful feelings arise, for example, when an only daughter realises that her aged parent had retained emotional and even physical control over her as a carer and now she has ‘nothing to look forward to’. Letting go can be complicated by a sense of relief, which in turn makes the bereaved feel guilty.
Getting a perspective on the loss when real awareness of the death has been achieved, is for Schneider, a point at which healing can begin. If we assume that bereavement can bring its own healing or, at least, a therapeutic change, then we have to be sensitive to the contexts when therapeutic change is not obvious or when it is too soon to expect it, otherwise we are in danger of being patronizing. There is, however, the ability to self-heal, though even healing experiences are not themselves inevitably pain free.
It is obviously in the second phase of transition that loss management has to take place. It is sometimes achieved quite quickly, but for others it can take many years. Worden reminds us that counselling might not be enough and that when grief is totally dysfunctional, specific expert therapy may be needed. For those of us who operate at a helping, counselling level, it is important to recognise when further therapy is appropriate. Clearly, the issue of being out of time is relevant to loss management, and the way in which previous transition experiences have been managed is never irrelevant.
We may speak of the resolution of grief, or the re-integration as the last phase of transition, as an event. It is, of course, a process that Bowlby calls reorganization and Worden re-investment of energy. It is certainly difficult to pin it down to an actual moment. With hindsight, the bereaved can look back and recognise ‘that this month has been better than last month’ or that ‘once the first Christmas/year was over, I began to cope better’.
The re-integration stage is usually not as fraught as the main second phase though there can be problems. How can I relate to my own bereavement history? It is self-evident that issues of living and dying challenge our own understanding of what life is all about, about its (un) fairness, and about the deepest levels of human nature and our being. These are also profoundly religious questions, although we might prefer to call them spiritual issues.
In helping to understand the above models, you may want to reflect on the study by Walton  who wanted to discover what spirituality meant for patients with acute myocardial infarct (AMI), and on how spirituality influences their recovery. Five phases were used to describe the basic social processes experienced with AMI. The five phases were:
1. Facing mortality.
2. Letting go of fear and turmoil.
3. Identifying and making lifestyle changes.
4. Seeking Gods purpose.
5. Finding meaning and purpose in every-day life.
Incidently, although the transition through the five phases were unique for each participant, the study found that there were differences between men and women on how they discover meaning and purpose in their suffering. In the first phase, facing mortality, both male and female participants experienced a strong sense of impending death and mortality, in which they also experienced the pain of fear and anxiety. They also found that being diagnosed with and experiencing AMI may cause individuals to experience spiritual pain that can manifest as fear and anxiety as they are confronted with their own mortality. This may result in loss of meaning and purpose in their lives.
- Morrison, R., 1994. Patients’ sense of completion. BMJ, BMJ 308, 1722.
- Lindermann, E., 1944. Symptomatology and management of acute grief. American Journal of Psychiatry, American Journal of Psychiatry 101, 141.
- Worden, J., 1982. Grief Counselling and Grief Therapy. Springer, New York.
- Bowlby, J., 1986. Attachment and LossL Loss, Sadness and Depression. Basic Books, New York.
- Schneider, J., 1984. Stress Loss and Grief. United Press, Baltimore.
- Parkes, C., Weiss, R., 1983. Recovery from Bereavement.. Basic Books, New York.
- Walton, J., 2002. Discovering meaning and purpose during recovery from an acute myocardial infarction. Dimens Crit Care Nurs, Dimens Crit
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