27978Coping with Grief -----The loss of someone close to us - KEEP THIS
- Jan 31, 2006COPING WITH GRIEF
Based on the ABC Radio Series
Mal McKissock is a Palliative Care and Bereavement Education Consultant. He began his career in the health field as a nurse in 1965. Ten years later, while working in a community health centre, he began to work specifically with dying and bereaved people. His experience in this area was extended by a period as Deputy Director of Nursing at a 100 bed public hospital which specialised in the care of the terminally ill.
Mal is now well known and respected for his expertise in the care of dying people and in bereavement counselling. His unique ability to teach this special area of health care has been appreciated by a wide variety of professionals and volunteers throughout Australia. He was one of the founders of The National Association for Loss and Grief (NALAG) of which he was national president.
Mal has received study scholarships to Israel, Canada and the USA and currently is in private practise providing a counselling service for dying and bereaved people.
WHAT IS NORMAL GRIEF?
ANNIVERSARIES AND SPECIAL DATES
HOW MUCH CAN I STAND?
COPING WITH THE IMMEDIATE NEEDS
OF THE BEREAVED
BEREAVEMENT AND ITS EFFECT ON HEALTH
CHILDREN AND GRIEF
GENDER DIFFERENCES IN GRIEF
SEXUALITY AND GRIEF
HOW TO HELP
HOW TO HELP YOURSELF
Most of us will experience grief at some stage of our lives and although grief is most closely associated with coping with the loss of someone close to us - a spouse, a family member, a close friend - through death, we also experience grief in response to other losses in life - a job, a close relationship, our health.
In the preliminary research for the (Australian) ABC's six-part radio series Step by Step -Coping with grief (one of the first of the Continuing Education series to be produced by ABC Educational it became clear to the production team that few people have any preparation for handling grief or are equipped to support family and friends at times of grief and personal loss.
Researcher and interviewer Julia Lester spoke with a number of people who told of how they felt as they worked, often blindly, through the grieving process. So often the contributors told of feelings which were frightening and painful, odd and even bizarre. With valuable input from bereavement educators and others whose professional work brings them into close contact with people trying to cope with grief and loss, the series showed that many of these feelings and responses to grief are very normal, and part of the process which must be worked through to resolve grief.
Bereavement Counsellor and Educator Mal McKissock was one of the professional people who made a significant contribution to the series. I am pleased that he has written this book which provides a concise and valuable means of furthering our understanding of the experience and process of coping with grief and loss.
The experience of grief, in response to loss, is known to all human beings, regardless of age, sex, creed and culture. The extremes of this grief appear when one loses a close and meaningful relationship. Death, divorce, separation, abortion, the loss of limb or lifestyle, even forced retirement will precipitate the most painful human emotion.
Though the responses to these losses are similar. It is generally agreed that death is the most significant, maybe because of its finality, maybe because death confronts one's own mortality or finiteness. But even if you have experienced loss not by death but by other means it will be possible to identify it with many of the reactions and responses described in this book.
Whatever the cause of the loss, there is little value in making comparison about the feeling one has. There is no consolation in hearing that there is always someone worse off than you are. Pain is a relative experience. When I am hurting, it is very difficult for me to imagine someone else's hurt. For example, if I had a migraine, I would find no relief in hearing that someone else had a worse one. How could theirs be worse than mine? When I have a migraine it hurts like hell, when you have one I hardly feel a thing, therefore mine is obviously worse than yours.
In our society people get upset if you demonstrate your reaction to pain openly. For example, if you cry openly in reaction to an event, even bereavement, after a short period of tolerance those around you will begin to placate your feelings - they will say things like, "Buck up, think of the kids, every cloud has a silver lining, it's God's will." You're young enough you can have another baby" or You can get married again." All of these platitudes and clichés, though not malicious, are designed to prevent you from expressing your feelings. There is a very genuine belief that getting upset is bad for you.
If you do get upset, you will often be described as breaking down, falling apart, cracking up, or not coping. All of these terms are derogatory, patronising and show a great deal of misunderstanding. On the other hand, if you demonstrate restraint, if you don't appear too upset when someone you love has died, you'll often be described as brave, strong, courageous, holding yourself together, and coping very well. Our language is basically designed to prevent you from expressing your feelings.
The feelings you experience when you are bereaved are healthy, normal and apart of the healing process. Failure to express them will often lead to more intense reactions, including physical illness and in some cases, death. There is a great deal of research showing that when bereaved people do not receive support and permission to grieve openly, their sickness and death rate is increased significantly.
This book gives an outline of the grieving process, the kind of reactions which occur when one is bereaved. It also offers suggestions on how to enhance the grieving process and decrease potential suffering. It should be read by those who are in touch with the bereaved people, as well as the bereaved themselves.
Some of the ideas may seem strange at first, especially to those who have not experienced bereavement. They are based on many years of experience with bereaved people, and if they are adhered to they will allow the bereaved and those who care for them to share a more compassionate, understanding relationship. This will in turn, lead to the healthy resolution of grief and eventually enable the bereaved to heal.
There are several basic principles to remember.
-It is normal and healthy to express the intense and painful emotions relating to loss.
-Grieving is important for healing the wound of separation.
_ A bereaved person may experience a wide range of feelings - shock, sadness, anger, guilt depression and despair, as well as relief, hope and acceptance.
-The painful feelings will diminish with time. If they remain intense and prolonged then professional help may be required.
- A total absence of grief - when a person carries on as if nothing has happened - is not a healthy sign and also may indicate the need for professional help.
- -A bereaved person who has not successfully grieved is more prone to illness, both physical and psychological.
WHAT IS NORMAL GRIEF?
HOW DO PEOPLE USUALLY REACT
Something that people say to the bereaved is, "it's just a matter of time". I have never found this platitude to be of use to anyone. It is just another way of saying "I don't know what to do or say that will make you feel better." Helpers need to understand that to feel better is not appropriate when someone you love has died. Let us look for a moment at the significant time factors associated with bereavement.
THE FIRST DAY
Particularly when the death is sudden there is a sense of shock and a general feeling of numbness. This reaction is both emotional to protect you from the knowledge, and physical, to stimulate the necessary bodily chemicals which will help you survive the intense situation.
Often associated with the numbness is denial. "No it can't be true". "It must be a mistake". This is a defensive reaction to cushion the blow, an attempt to push away reality, to protect yourself from such trauma. During this initial period which may last from several minutes to several hours, or even days in some cases, there is often not much expression of other feelings. At this point it is important that you are in the company of someone who is able to understand your responses and allow you to do whatever you need. This initial period eventually gives way to overwhelming feelings. As you become more aware of the reality of the situation, the greater the intensity of your feelings becomes and during this time you will need to have with you someone who is not frightened by your responses, someone who will allow you to express your feelings in whatever way you are able. You may need to cry, scream, kick, yell or withdraw. As well it will help you if someone is able to assist with practical things like telephone calls, transport, or organising minor details, someone who will be your advocate in the period which follows. While this is often the time of intense pain and anguish, the best way to ensure a healthy outcome is to give way to emotion. Do not attempt to inhibit your grief by so-called self control. Do not follow platitudes like "buck up and think of the kids". The kids indeed, will also heal more successfully if they are encouraged to express their own feelings. You can be a model of healthy grief in the same way that you have been a model for other aspects of their lives.
It is not generally advisable to take drugs during this time. The use of tranquillisers, sedatives and sleeping tablets, often suppresses normal reactions and leads to a greater difficulty in the future. If you feel it is necessary to take some medication, it should be with caution. One of the problems with medication can be the clouding of reality. Though you may feel less pain temporarily, as the drug starts to wear off, your awareness of the pain increases again. So in the first numbness, intense sadness, anger, guilt, disbelief and confusion, also physical reactions like loss of appetite, nausea, restlessness, agitation, sleeplessness. All of these are normal, though devastating, and I will discuss them further in the following chapter.
THE THIRD DAY
This seems to be another significant time for the bereaved person. Reality is beginning to sink in and that often coincides with the funeral. You have survived three whole days. The numbness is starting to wear off but the pain may seem to be increasing and you wonder "how will I ever get through the funeral?" Days and nights are a blur, one mixing into the other. You still can't believe what has happened. "This is a nightmare, maybe I'll wake up soon and it will all be over." It should have been me who died."
THE SEVENTH DAY
Loneliness, isolation and despair are the feelings that often appear at the end of the first week. For many, sunset on the day one week after bereavement marks a time when they feel at their worst.
These feelings are also in response to the sense of being alone created by the departure of friends and relatives. At the time of the funeral people come from far and wide to pay their respects, to share their love and offer consolation. Now just seven days later, they have all but disappeared. Friends and relatives have returned to their homes in the city or country, neighbours have returned to work. (In this country (Australia) we can only get up to three days compassionate leave when a close relative dies.) people don't drop in so much as before and you are left alone. Coupled with the increasing awareness of reality, being alone encourages despair. You may begin to question your won sanity. "Am I going mad?' "How can I ever survive?" This feeling seems to continue over the next few weeks. One moment you may feel reasonable and then, all of a sudden, with little or no warning, a black cloud descends upon you, and once again you are in the depths of despair, alone, desperate and crying out for relief.
FOUR TO SIX WEEKS LATER
This is the time when I find people saying "Its getting worse, it's not getting any better, I'm going downhill". Or a relative will ring me, an adult daughter, for example, seeking help. "I'm really worried about Mum. Dad died about five weeks ago and at the time she was really brave, she coped really well, much better than she would, but now she's going downhill, not eating very much, not sleeping and she's crying a lot more than she did when it happened. "I just don't know what to do." First I listen to the daughter and acknowledge how distressing it must be to see what is happening to her Mum. I then ask her about her Dad's death and generally let her talk about it - get it off her chest. Then later I attempt to reassure her that what is happening to Mum is all right and to be expected. It is not that the pain and despair are getting worse, it is just that the defence mechanisms are wearing off and the feelings which have always been there are coming to the surface. They need to come to the surface, it is a good sign in the healing process, even though it is distressing. What Mum needs now is someone who will let her express this her feeling, not someone who will force feed her then knock her out with sedatives. She needs to talk about her feelings over and over again.
ANNIVERSARIES AND SPECIAL DATE
During the first year as special dates approach there will often be a sense of intense pain, both in anticipation and on the day. Birthdays, anniversaries, Christmas, all of which were happy celebratory times, now are the absolute antithesis of the joy they once were. It seems that every day is just the same as every other one without that person.
In the first year people describe grief as "coming in waves". There is a familiarity with the degree of intensity, constant at first, but lessening so that there are brief periods, maybe only minutes, when there is some relief and when the feelings abate for a while. This relief period appears to lengthen although the intensity of the pain when it returns is just as great. So, over the first weeks and months the periods stretch into hours or even days when there is some respite. But when the reaction returns it is again intense and may occur at any time without warning. You may be cleaning your teeth and not thinking about anything in particular when all of a sudden you are overwhelmed by despair. You ask yourself "How can I just go on doing things like cleaning my teeth when he/she is dead?" your head says, "What are you doing? You don't need that now, he's not here any more, he doesn't need the cereal", meanwhile something in your heart says, "Don't listen, put the cereal in your trolley". Here you stand, confused, distressed, trying to grapple with love and death. You know on some level that if you put the cereal in the trolley, there is some sense of his being alive, but if you leave the cereal on the shelf you are acknowledging that he's dead. In frustration and self protection, you leave the trolley and hasten from the supermarket to the safety of your home, full of resignation and despair, convinced you'll never recover.
These events are familiar to many. Do not despair. They are part of the healing and you will recover. You may never "get over" the death, but you will learn to live with the absence of the person you love. The pain will decrease and although the feelings may be similar they will not be so intense.
ONE YEAR LATER
From around eleven months after the death, the anniversary reaction may begin - indicated by the reappearance of the feelings, thoughts and reactions experienced immediately following the death. There is a section on common reactions following this, but I would like to mention here one recurring phenomenon, that of bodily distress. At the time of death most people have a physical response - headaches, backache, chest pain (particularly if the deceased died from heart attack), nausea, vomiting, diarrhoea, period problems in women. Because grief affects virtually every bodily system you can experience distress in any part of your body. This, then, often recurs in the time around the anniversary date. The distress is either similar to previous reactions (it is very common in spouse or near relative to produce the symptoms of the condition from which the victim died and this will be discussed later) or because of the physical vulnerability of the bereaved. You may develop minor or even major infections. You may experience a cold that you can't shake off or a cold sore that will not heal. Some women develop things like Monilia.
It is useful to prepare yourself for the anniversary and to attempt to maintain your physical health - maybe even with vitamin supplements. As well, it is helpful to plan to spend the time in a productive way, perhaps with someone who cares about you or somewhere you are able to be yourself. Don't rely too heavily on the memories of others, unintentionally they may let you down. Remind them, ask for help and accept it when it is offered - not as a method of avoiding pain, but as a way of confronting it, sharing it and then letting it go.
Build in contingency plans, e.g. If you think you would prefer to be alone on the day of the anniversary try to keep someone on notice " so you can call them for company should you change your mind. If you want to be with people plan to be with people who will understand if you change your mind and want to withdraw for a little while.
In conjunction with the emotional responses to grief there are a host of physical responses. One of these is designed to decrease the pain to a manageable degree. When someone we love dies, our body produces a number of narcotic-like chemicals similar to heroin and morphine. They are very powerful pain killing chemicals and are produced to create the numbing experienced in the beginning. For those who cry these chemicals are released through our tears. That's why it is important to be able to cry if you want to. Then, gradually, as the weeks go by, the production of these chemicals decreases and around four to six weeks after the death they are significantly low. The resultant increase in distress is both an increased awareness of reality and the body's attempt (through increased crying, for example) to produce more chemicals and so assist further in survival. And it works. How many times do you sit down, have a good cry and feel better afterwards?
With this in mind it is easier to understand the role and importance of crying, and how beneficial it is for a support person not only to allow but, on occasions, encourage crying to help ease the pain.
Don't associate crying and getting upset with going downhill. In fact they show you are going uphill and it's a very difficult haul - but you can make it. Be kind to your self - let go
NOT EATING, NOT SLEEPING
As for not eating and not sleeping, these also are a part of healthy grieving.
The body chemicals mentioned above have a relaxation effect on the muscles in your body. These muscles include those used for digestion. Because they are slowed down your body says to itself don't eat because you can't digest it and your bowel also is unable to respond to get rid of waste. Your body does not need the same quantity of food you would consume in other circumstances and it creates the loss of appetite to enable your energy to be redirected. However, it is important that the food you eat is nutritious. Fresh fruit and vegetables in small quantities but of good quality are particularly good.
There are many reasons for not sleeping, one of the main reasons being the amount of adrenaline trapped in your body. Adrenaline is the stress chemical produced when we are in danger. It is called the chemical of fight or flight because it is produced when we perceive ourselves to be under threat. It gives us the energy to "fight" to protect ourselves from danger or for "flight", to get away as quickly and as far as possible from the threat. Bereavement has been regarded as the most potent form of stress the body has to withstand, so we have produced enormous amounts of adrenaline to help us. Our muscles are loaded with it, they become tense, tight, and our heart (myocardium, or heart muscle) becomes tense and beats more strongly (palpitations), ready for action. Then nothing happens but we stayed primed just in case. In previous generations and in other cultures we would have used a significant amount of this adrenaline in the grieving process. We would have sat down around the body of the deceased and wept and wailed for three days and nights, at the end of which we would not have had a wail left in our bodies. We wouldn't have to worry about tranquillisers or sleeping tablets, we would just collapse from this exhaustion. Nowadays we don't weep and wail so we are stuck with all the adrenaline (tension) in our bodies and don't know what to do with it. Instead of using drugs, it would be much better to go on long walks, maybe on the beach, maybe in the park, preferably with a friend with whom you can talk. Do some gardening or even some housework, in spite of the fact that these are the things your friends will do for you as their way of saying, "I care". That is very nice, but don't forget how important it is to use up your adrenalin.
I have also found it helpful to refer people to a chiropractor or physiotherapist or masseur for some massage therapy. It is unfortunate that in this country massage ahs been used as a euphemism for other things, because it is one of the oldest forms of healing therapy. It helps to unblock trapped energy, loosen (relax) tight muscles and realign the spine after a traumatic (emotional) blow.
HOW MUCH MORE CAN I STAND?
The feelings and responses are infinite, but here I will list the most common and those which go under many names.
"NO, IT'S NOT TRUE"
This familiar reaction (it's described as a healthy ego defence mechanism as previously stated, is your body's way of protecting you against the onslaught of this most threatening information. It may persist for minutes, hours or days, and, in extreme cases, weeks, months or even years.
The extreme cases are ore likely to be those where there is an absence of reality, that is, where there is no body as, for example in a drowning where the body is not recovered, or where someone is missing in action, believed dead. The bereaved person is just saying "No, I don't want to accept it - I can't not yet"
Give them space. They will acknowledge reality when they are able to.
As already mentioned any bodily system or organ in the body can be affected to a large or small degree, ranging from mild gastro-intestinal disturbance e.g. dyspepsia, heartburn, constipation, through to sever incapacitating symptoms e.g. migraine, or acute chest pains, the latter specially common where the deceased died from a heart attack. In one case both daughter and grand-daughter experienced intense chest pain and thought they were about to die after the death of the father and grandfather from heart attack. It is not uncommon for the chest pain to necessitate medical consultation and even hospital admission for investigation. I saw another example of chest pains being a response to sudden death when a woman was referred to me some six on after the sudden death of her teenage son in a motor vehicle accident. She was referred to me because the doctors couldn't find any physical cause for her recurrent pain the onset which coincided with the son's death. In our conversation, Mrs. X told me her son had been driving his recently acquired second-hand car when it apparently went out of control on a bend. It went over the embankment and finally crashed into a tree. When I asked her to tell me how her son actually died, she re-told the story, but also added graphic description of how he was impaled on the steering wheel. As she mentioned the manner in which her son died she struck herself on the chest immediately producing the now familiar chest pain ...... whereupon she began to weep and weep ..... making her won connection between the chest pain and her son's death.
Another example of this common and frightening experience concerns a death from cancer. A mother of two (girl aged ten, boy aged eight) died after a protracted illness lasting a number of years. The final symptom of her worsening condition was a complete obstruction of her bowel. She was re-admitted to hospital for investigation of constipation and it was there discovered that the obstruction was the result of her cancer. No curative treatment could be offered at the time and she died a short while later. Ten days after the death, her ten-year-old woke in the night with intense abdominal pain. She was taken to hospital where it was discovered she had acute severe constipation with the same symptoms her mother experienced before her death. This was treated and there were no long term difficulties.
ANGER vs. AGGRESSION
This often intense and frightening reaction is familiar to many of those who experience grief and can result from the nature of the death, or some behaviour of the deceased prior to the death, or neglect or mismanagement, real or imagined. The feeling is potent, often most marked in the period surrounding the notification of death, or when the numbness starts to subside." How could this happen?" the bereaved person asks, sometimes blaming others for the death or action. Unfortunately the anger is sometimes directed at those who are closest, that is, family and friends.
But anger is just another way of expressing pain, and wherever possible it needs to be expressed. It does not matter, however, how it is expressed. For example, you may yell and scream in rage about something someone did and even though that person may not be present, still the feelings will decrease. The energy invested in the feeling dissipates. The feeling left behind may still be called anger, but it is less intense than it was before. You had the chance to express it. Another way is to find a physical activity which enables you to use that energy, sport for example, or even letting fly with broken crockery you have saved for such an occasion. Clear a wall in the garage, spread out a sheet to save time cleaning up, draw a picture which symbolises the anger, and throw the broken crockery.
If you don't get to express your anger it will often build upon the inside and explode or, worse, cause physical problems like those already mentioned. I have found it useful to discourage close family members such as a spouse from being the one to inform he partner of death, particularly a sudden death. I recall a number of times when a husband ahs informed his wife that their child has been killed in an accident. Often the result has been that the wife attempts to push away the reality of death, so also she pushes away the husband because he symbolises the death. There are cases, too, where the partner may also be seen as the "cause' of the death. Before he/she told the partner that their child was dead, the child was alive. Giving the news of the death symbolically killed the child so the spouse is rejected for subconscious reasons that neither can understand. Remember that anger, like other responses, is a survival mechanism. The individual is saying "This is what I need to do to survive."
Ask yourself "If I took away their anger, what would they have left?" If the answer is nothing, do not attempt to stop them from expressing their anger. That would not be helpful. This is not to say that any type of behaviour must be wanton and damage then of course social restraints must be applied - but don't confuse raised voices and 'acting out" behaviour with aggression.
Guilty -"If Only ..."
'Please God give me one more chance ... I won't blow it this time."
If every person who wanted to wind back the clock, to right the wrong, was able to do so, we would still be stuck back at the beginning of time.
Guilt is a means of expressing unexpressed behaviour. It gives people the opportunity of verbalising the feelings they have of not having done something that they will never get the chance to do. Being prevented from expressing their guilt only adds to the burden. Not only do they not get to do it, they can't even say how bad they feel about not doing it. Whether that means that they didn't get the chance to say "I love you" the morning before he/she left for work, or the child left for school. Or to say they're sorry for not watching the child around the pool, or sorry for driving the car in a dangerous manner, whatever it might be, they need a chance to express it. The person experiencing the guilt needs to be able to recount, apologise, repent, confess, and say "I'm sorry" (from the heart).
There is no value in saying "Now come on, you shouldn't blame yourself". Whether they should or shouldn't isn't relevant. They are blaming themselves and that's all that matters. Bereaved people don't sit around thinking, "How am I going to upset these people? I know I'll feel guilty." They just respond the way their bodies need to. When you are feeling guilty, talk about it, write it down, express it in some way.
Guilt is often a way of experiencing the love that has nowhere to go. If you stop yourself from expressing guilt prematurely, then you stop yourself from expressing love. It will eventually decrease in its intensity if it is allowed to be expressed.
ANGER AND GUILT
Threat to relationships
Where these two feelings are present in a given situation (which they often are), there is enormous volatility. For example, if a child dies and the father feels angry (How could it happen?) and the mother feels guilt (It's all my fault), we have a serious problem because the relationship is at risk, There is a limit to what people in that situation can do for each other. They need outside support, not taking sides but allowing them to talk about it (often separately) so that they don'' burden their relationship with emotions too powerful to handle.
The outside support need not be a bereavement counsellor, but it does need to be someone who can listen without judging.
When a person says "I feel so responsible for my child/husband/wife dying" it doesn't mean they are responsible, it means they feel responsible. Listen to the feeling and let them express it. They need someone able to walk the fine line between blame and placation, between saying "yes, it is your fault!" and "Don't say that"
Though I do use this term, I prefer to describe the feeling as intense sadness. The reason is that depression is a clinical term, used to indicate a psychiatric condition for which there is a recommended treatment, often of a pharmaceutical nature, whereas intense sadness does not necessarily require treatment of a pharmaceutical nature.
The behaviour which often goes with this feeling includes loss of appetite, inability to sleep, recurrent bouts of sadness, lack of energy, lack of interest/motivation, little reason for living. All of these reactions characterise acute grief.
Yet, if you accept the label "depression" many who are uneducated in the care of bereaved people will diagnose loss of appetite as anorexia and lack of sleep as insomnia. These confirm the diagnosis of depression, for which you may be prescribed antidepressants. The use of drugs, as I have mentioned before, in the main is to be discouraged. There are however, occasions when drugs may be indicated but only after all else has failed - including counselling by a counsellor skilled in working with bereaved people.
This occurs when, as pointed out, the numbness wears off and you are confronted with the reality of death, the finiteness of death, the fact that death is forever. You respond by losing all hope of ever seeing that person again - not the desire to see them, you still retain that, just hope. Then, in a state of extreme vulnerability, you interpret the situation to mean that they are never coming back, and that is how you will feel as you do forever. That interpretation is wrong. You will surely feel as you do for some time to come, but not forever. You will recover through support, acceptance, understanding and many other caring things people can offer, but the recovery will be slow.
Some of the ways people have expressed their grief are as a void, a feeling of disfiguration. "I feel like a part of me has gone." "The light of my life has been extinguished". There is now something missing. That is why I feel so overwhelmed." In response to this feeling some people believe that if only they can replace the person, all will be well. So the parents of a stillborn child are advised to have another baby. Parents of a young child are told they are young enough to have another baby. Widows and widowers are told they can marry again. All of these superficial attempts to discourage the expression of grief are at best useless and at worst destructive. If the bereaved manage to ignore these suggestions they are recognising that the advice comes from a person who does not care or who doesn't understand. If they heed the advice, they are almost certainly heading for disaster because it is essential to realise (though this needs time) that the relationship has ended and will never be again. Only then is it possible to mourn, to grieve and to heal. Following the healing, they may form new and meaningful relationships, but only then.
What the bereaved need replaced is not the deceased but some of the things the deceased would have contributed to the relationship had they lived. These are individually determined depending on the relationship, but they include love, friendship, physical touch, money, support, listening, understanding and acceptance. They are not necessarily provided by only one person, it is more likely that several people will contribute.
I don't often give direct advice to people but I do suggest that you will probably find it in your best interests if you can avoid making major decisions in the first twelve to eighteen months after bereavement. The types of major decision I am talking about are another pregnancy, remarriage or selling the house. Some decisions which well-intentioned friends may make on your behalf should also be avoided. For instance, there is the situation where the widow is at the funeral and good friends at the home not only prepare for the guests who are to arrive but also pack up the belongings of the deceased and dispose of them. A similar example is where the mother is still in the hospital following a stillbirth and friends pack up the nursery to save the mother pain. By their actions the friends are removing the chances for the bereaved to go over memories, to think and feel about the death, and in their time consider what to do with the belongings. There is something very therapeutic for a person in being able to go through the belongings of a spouse or close relative and begin to pack up rather than having somebody take the things away. This is part of letting go. Imagine the feelings of a woman who, when going through her husband's clothes, finds the tickets from the last time they went to the theatre together. She sits down, reminisces, cries, knows they will never get to do this again. She may become so distraught that she has to stop the sorting out. But she will come back to it when she is ready. There is no time limit. If people are given the opportunity to grieve properly, without inhibition, it is most unlikely that the process will be delayed indefinitely.
Bereaved people often tell me about belongings which they choose to keep as memories of the deceased. They range from hats and jumpers to sox, pipes and jewellery. Many observers suggest that there is something undesirable about keeping belongings of the deceased. I totally disagree. It seems that some people believe the practice to be sensible providing the object which is kept has real value. But if the object has no real value, then they consider the bereaved's behaviour to be abnormal. In other words, if you keep your grandfather's old gold watch chain and wear it around your neck as a piece of jewellery, that's all right but if you want to keep grandpa's old gardening jumper because it smells like him and reminds you of the times you spent together in the garden, then that's abnormal. Don't listen to such people. They are just expressing their feelings of helplessness at your disclosure of grief - they feel uncomfortable and want you to change your behaviour. It is strange, but many bereaved people tell me they spend most of their time trying to make other people feel comfortable.
COPING WITH THE IMMEDIATE NEEDS OF THE BEREAVED
You have just been informed that someone you love has died. Shock and disbelief mark, the initial response to grief. It is impossible to believe, understand or even acknowledge. You begin to feel overwhelmed, faint and weak. You keep hearing in your mind the word dead, dead, dead. You want to answer No! No! It is unreal.
SEEING THE BODY
In the midst of this someone, perhaps a nurse, doctor or a relative, says "Would you like to see his/her body?" On the inside you say "No, I don't want to see him dead, I'd prefer to see him alive." But he is dead, and if you answer 'no' you will not get the chance to see that person ever again. It is such a difficult decision to make at such a time, yet it is the time when it has to be made. My concern is that if you don't see him or her now, you may have difficulty in future of ever believing, in your heart, that he or she is dead, really dead.
My experience is that where the bereaved is not able to see the deceased, the bereaved person will often remain in a state of partial denial. This denial may or may not be incapacitating; it depends on the intimacy of the relationship. An example of this partial denial is the death of Harold Holt, former Prime Minister of Australia, who disappeared while swimming and who is believed drowned. His body was never recovered. At the time of his disappearance there were numerous rumours about what had happened. They included his being picked up by a min-sub-marine from Russia or the CIA and, more recently, an allegation that he was as spy for China and has returned there. We have no way of proving or disproving any of the above so we remain in partial denial. This would not be a problem if you really did know him and your life was not personally dependent on him, but had you been his wife or children, and had you shared an intimate relationship, then this partial denial may well have been incapacitating. "What if he is not dead?" 'No knowing is even worse than seeing him dead'. You can see that some people believe that there are some things more painful seeing someone they love dead. One of these things is not seeing them when they are dead and having to live with the lack of reality. For some people that is a very large problem. There are, of course some people who do not need to see the body of those they love in order to recover. However, a significant number of people have great difficulty coming to terms with reality if they do not get a chance to experience it.
I don't think it's a matter of wanting, or even liking, to see the body of a person you love and I do not use those words when encouraging someone to view the body. I would make a statement like 'I believe it will be beneficial in the long-term if you are able to see your husband before you go', or 'I think it will help in the long-term if you are able to see your mother before you go'.
I make this statement because of my professional knowledge and experience and I do encourage you to view the body after death. As painfully sad as it might be, it does present reality, so that when you are able to accept what has happened you will have a picture, a memory of reality, to put with the acceptance.
Even those who have told me initially that they would prefer not to view the body, after they changed their minds have told me how grateful they were, and how beneficial and important the experience was to them.
BEFORE VIEWING THE BODY
There are several steps one can take to make the experience more beneficial.
First, it is important for someone to describe the scene you are about to enter. If you yourself are ever responsible for taking someone to view a dead person, you might follow this process, especially with children, (children are discussed later).
It is necessary to explain what to expect when the bereaved enter the room. To illustrate I will share an experience and give you the case history:
Marie aged forty and divorced, had three children - a boy, Brian aged 9, and two girls, Samantha aged seven, and Cathy, aged five. Marie died following a two year history of cancer. I was involved with the family prior to the mother's death and the family requested that I remain involved and help to support the children. I encouraged the children to come with me to see their mother, who they knew was dead.
When we arrived at the funeral director's, the conversation went something like this:
Mal: 'You know that were here because Mummy died?'
Mal: "have you ever seen anyone who has died?"
Mal: "Well, when we're alive and if you are white-skinned like me, your blood helps to make the colour you are. If I grip my thumb around the middle and squeeze it, you can see it goes a real pink colour. That's because I'm squeezing the blood up to the the surface. But if I extend my hand as much as I can and straighten out my palm, you can see that my palm goes a much lighter colour in the middle. That's because I'm squeezing the blood out. It's not moving around much any more. When we die it's a bit like that, because the blood doesn't move around our body anymore and we look really pale. Also, when we're alive our blood helps to keep us warm, but when we're dead we can't feel the cold, so we don't need to be warm any more. If you touch Mummy when we go in, she'll feel cold to you, but she can't feel it because she's dead."
In any such circumstances I would use language suitable to the individual person, but I would explain in a similar way irrespective of the age of the bereaved person.
Because we are viewing at the funeral director's I went on to say "When we go inside Mummy will, be in a coffin, with the lid off. Has any of you seen a coffin before?'
I think it is important to explain the situation fairly well so that the person who is going to view the body is not unduly shocked by the presentation. As already explained, one reason for encouraging a person to view the body is to enhance the reality, but another is to allow the bereaved to say goodbye, or to complete unfinished business.
I would encourage the person to say the things he or she never had a chance to say. "If there's anything you wish to say, or if there is anything you wish you had had a chance to say before he/she died, I think now is the time." Often people wish to say something like, I love you or I'm sorry. Sometimes they are very gentle and sincere things, sometimes other emotions, which have been bottled up. "" told you not to do it, you silly old so and so." This is just love and sorrow expressed another way and it all needs to come out. It also helps sometime to think "If he could have heard what I just said what would he say in response?"
This experience takes time and should not be hurried. It should be done in a situation which permits the open expression of grief.
When the body has been seen, the bereaved should be encouraged to sit down for a while and, if possible, to share their response to their experience.
WHAT THE BEREAVED PERSON NEEDS
Let them share what they feel
A bereaved person really needs someone who will take a risk and get involved; someone who is not afraid of the intensity of feelings, but who will encourage them as part of healing. Statements like "I know how you feel are to be discouraged. You do not know how they feel. Besides, one of the best ways to heal is through the sharing of feelings, being able to tell others how you feel. Telling them you already know how they feel will often stop them from telling you because there's no point if you already know.
Permission to grieve
Bereaved persons are very vulnerable and susceptible to the criticism and judgements of others. Grief is a healing process and is dynamic, ever changing. The bereaved need people who will let them be themselves rather than people for whom they have to change their behaviour.
They need to be allowed to cry. There is a pervasive myth in our society that crying is bad for you. On the contrary, it is essential to let out the tears you have inside, because if you don't they will cause damage at a later time.
At the risk of sounding trite, you are an individual. You are the only one who can feel what you feel; you are the only one who can determine how to express what you feel.
Others affected by the bereavement have their own feelings and their way o expressing them, but if you feel like going to bed for a couple of days - do it! If you feel you want to stay with a friend for a couple of days - do it! If you want to yell scream, cry, curse -do it! If you want to withdraw and have time to yourself -do so!
My philosophy for surviving bereavement is simple. If it works -don't alter it! Many friends, with the best intentions will give you unwanted advice. Listen if necessary, but don't do anything that doesn't suit you.
They are trying to help, but you don't have to behave as they think. Tel them that it's alright to talk about the person who ahs died, mention the name. Many people don't know what to do and you can help them and yourself by being open.
This is a misleading word as it is used currently. It seems somehow that observers base their ability to judge your wellbeing on how they feel about what you are doing. For example, if you are very distresses and crying, you will be described as not coping very well, but if you don't show your feelings, or at least if you don't show too many of them and the observer's feel uncomfortable about what you are doing, they will describe you s coping well.
So, in the future when someone says that you are not coping, just interpret that as meaning that they feel uncomfortable with the way you're responding. You will need to work out what is best for you to do, and who will be best to be with. Don't worry about going 'mad' like a lot of people seem to, you are just trying to survive a crisis.
FROM EARLIEST TIMES HUMANS HAVE PRACTISED DEATH CEREMONIES AND PROCEDURES OF GREAT VARIETY. Such procedures are important to the healing process. No human being lives in a social vacuum; our speech, habits, values, the very meaning of our lives, derive from our association with one another. hence the death of one individual is traumatic for the survivors and, recognising that death ceremonies and related customs are important in meeting the social and emotional needs of survivors, we should plan these ceremonies carefully. The function of the funeral is threefold:
First, to dispose of the deceased in a manner which reflects their way of life;
Second to reinforce the reality of death remembering that until this point, the bereaved was experiencing numbness and disbelief; third to bring together friends and relatives to share in the experience thus helping the bereaved reestablish the group relationships which will be so important in the recovery period. Because this ritual is an important part of healing, it must be remembered that it should be available to all who mourn, especially those most affected by death - spouse, children, parents and close friends. If, for any reason, one of the significant survivors is unable to attend and if delaying the funeral is not possible, it will help to record the process for the future reflection of the person unable to be present. Where possible record on a cassette audio/video take photographs, keep flowers and cards so that the person who is absent can feel involved even though he/she could not attend. Another way to meet the needs of someone who could not attend the funeral is to have a memorial service.
Children should be encouraged to be involved in the funeral. They are capable of experiencing the same emotions as adults. They may not present the same reactions, but the emotions are there just as strongly. Involving children in the funeral service itself is often a creative way to helping them say the things which they never have had the chance to say.
People often say "You can't take children to a funeral. They don't understand and it will only upset them." Maybe they don't understand, but how will they ever understand if we don't teach them? Maybe they will get upset but that is appropriate when a loved one dies. I have been involved with very many children in viewing parents, grandparents and siblings, as well as attending funerals and at times even helping them organise the funeral. They have much to teach us about simplicity of emotion and uncomplicated good-byes.
In planning the funeral it is customary to engage the services of a funeral director. Though not necessary, it usually makes a difficult task less distressing. But remember that you are hiring the funeral director. You can design the funeral in whichever way you wish.
If you choose, you can have the deceased at home for a while after death. You can have the ceremony anywhere you choose, in a church, in a funeral director's chapel, at the crematorium, at home in the garden. Bear in mind, though that if you wish to carry out a ceremony in a public area, you will need prior permission from local authorities.
The funeral is the time when you gather together with others who care and grieve to say goodbye to the deceased. Plan it in a way that will be meaningful to you.
If you have a religion, you may prefer a minister to conduct the ceremony.
However, understand that you or anyone can conduct the ceremony. This is not a legal procedure like a wedding, it can be conducted by a friend or relative, or a combination of both.
A funeral is a ceremony conducted with the body present, a memorial service is a ceremony conducted in the absence of the body. A memorial service may also be conducted anywhere and allows for creative expression.
Whether you choose burial or cremation, remember that wanting to get it over and done with as quickly as possible is not necessarily going to decrease the upset. On the contrary, it is often more harmful to attempt to cut a service short thereby preventing full expression and reflection.
It would help if you are able to check with the funeral director to find out for how long you have the facilities and for how long you have the church, chapel or crematorium chapel. If you have a crematorium service only, most crematoria make premises available for one hour overall. While this seems enough for most people, I have known some who have become resentful at the production-line nature of the experience, and who are unable to reconcile the meaningfulness of the moment with the brevity of time. If a longer time is required, this can be provided on request. This may increase the fee slightly, particularly in urban crematoria. In contemporary funeral services, it has become a familiar occurrence to include favourite music tracks as part of the service. I have found this adds many things to the ceremony. Special music can trigger memories and use words which are often difficult to say in any other way.
But above all, allow yourself to experience and express the pain. Take the support of friends and relatives. Accept their love and condolences and offers of contact. Share your grief; it will help you survive.
Often, after the ceremony and committal service, people congregate in an informal group. Some people find this a source of comfort and support. Others find it a most painful and arduous task. Follow your feelings. You do not have to attend the function in order to please everyone. They will understand if you say no. Ask a close friend or relative to excuse you, no-one expects you to be functioning well. On the other hand, if you prefer to attend the function, feel free to do so and don't criticize yourself for relaxing or trying to put the knowledge of the death aside momentarily. This is called survival.
BEREAVEMENT AND ITS EFFECT ON HEALTH
You will recall that I mentioned the effect shock has on the pituitary gland. The pituitary is a pea sized gland which sits on the base of the brain and secretes a hormone known as ACTH. This hormone is the chemical which helps to produce the adrenalin responsible for the fight or flight mechanism. Coupled with the production of adrenalin is the production of cortizol (similar to cortisone). Cortizol is an immuno-suppressant which decreases the production of T-lympho-cytes. That may sound a little confusing but what is important is the decrease in the T-lymphocytes because these lymphocytes are our surveillance cells. They are responsible for keeping infection and other abnormal cells under control so that when they are depleted for any reason, we are said to be immuno-suppressed. That means we cannot fight off infection and have difficulty in controlling abnormal cells in our body.
If all the viruses and bacteria in our bodies, usually kept under control, have a free reign, we get sick with, for example, influenza, cold sores, upper respiratory tract infections, urinary tract infections, boils, conjunctivitis. If our bodies are not returned to normal soon, we also at risk of developing more serious conditions. If we block our grief and don't release the natural healing chemicals of grief, we will be more prone to be immuno-suppressed. Our immune system will remain dysfunctional, and we will be more likely to develop illnesses and disease. If we inhibit grief, if we are prevented from expressing the grief in a healthy manner, we will remain shut off from that grief but more open to serious illness.
Recent studies in Australia and North America have found that illness increased significantly among bereaved women. The studies also showed that the death rate increased markedly over that of non-bereaved women.
Some of the serious illness suggested as a result of unresolved grief are anorexia nervosa, ulcerative colitis, neuro-dermatitis and asthma. Bereavement is a traumatic experience and unless people give way to grief they can develop a variety of illnesses, many of which are serious, some life-threatening.
If we know in advance that someone we care about has a serious illness from which he/she is likely to die, we can actually begin our grieving while they are alive.
This means that when we are able to be honest with that person about their future we can speak with little reservation about the impending threat. We can share our fears, our hurt, love and comfort in a way that prevents the build-up of emotion. We can prepare for the inevitable in emotional and practical terms. This does not suggest that the death is not difficult, only that it does not come as such a shock as sudden death. There is still a shock sensation but you have prepared yourself for the shock, you have the opportunity to reduce unfinished business, to say things you want to say and, where possible, do the things you want to do. As hard as it may seem, when you are aware of the inevitable you can begin the process of detachment so that, when death does occur, you have less distance to travel. Most of this, by the way, is unconscious, it happens outside your awareness.
Sometimes a problem can arise as a result of anticipatory grief. This can occur when someone is given a definite idea of their life expectancy, for example, no more than two years. This will often be inaccurate but since the prognosis comes from an authority figure the emotions are charged and the disengagement process begins. A husband who is expected to die and his wife begins the conscious and unconscious steps in anticipatory separation. If, two years later, the husband is not ready to die, we may find that these two people who had previously shared a loving relationship, have now experienced a high degree of separation, to the extent that they have almost discontinued intimate levels of communication. This can leave them in limbo, wanting to enjoy whatever remains of life, but scared to re-invest in the relationship, in case the man dies. There is in these cases a need for specialist counselling to help salvage the relationship.
Anticipatory grief not only functions in adults, but also in children. In my experience, many children with a life-threatening disease know all about it, even if their parents and others don't tell them about it formally. They eavesdrop and are told by other kids whose parents have told them. (If you want a child to hear what you are saying, tell him not to listen.)
CHILDREN AND GRIEF
With children as with adults, an understanding and acceptance of death can best begin in the absence of family sorrow. Parents should help their children to become familiar with the world of nature, of which we are a part.
Through the woods and fields and keeping pets, children can have first-hand contact with birth and death, and with parental encouragement, learn to accept and have reverence for the whole process of life. Don't discourage children from touching dead things.
Apart from the very young, children can learn as adults do that we are all part of one another, and that when one of us dies, it is the responsibility of the rest to carry on his life and ideals. That is how we can express our love. This concept can be a great source of comfort and inspiration for children and adults alike, and can infuse their lives with fresh meaning and purpose. Then, too, death is an occasion for drawing the family together in closer affection. The child should be fully involved in this as fully as possible; it will strengthen the family and contribute to social development, even if the child doesn't understand everything that is happening. A child should remain with the family during the period, both for the benefit of the child and because he can be a source of strength and comfort for the adults. If sent away to stay with relatives the child will return to an altered family, one which has shed a lot of grief, whilst the child's grief will remain as it was prior to being sent away. This creates many difficulties of readjustment. The
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