TYPES OF LOSS

Loss can be actual or perceived, temporary or permanent, and occurs when someone or something can no longer be seen, heard, known, felt or experienced (Box 14.1). Feelings of loss and grief can apply to many events. Losses include those that relate to:

Loss can be symbolic and strong when it relates to cultural and spiritual matters, for example, the loss of homeland or the effects of dispossession experienced by Indigenous people in Australia, New Zealand and other countries (Kellehear 2002). Losses can be multiple and all losses impact on self-concept (Varcarolis 2006). While grief is commonly profound when a loved one dies, profound grief often accompanies other types of loss. The perception of the degree of loss relates to the value placed by the individual on that which is no longer present. In a global sense, loss and associated grief cannot be quantified, so it cannot be generalised that one person’s loss is greater or less than that of another person. The impact of loss ranges from minor to catastrophic.

Loss of an aspect of the self can be devastating and can severely affect a person’s body image and self-esteem. Individuals commonly experience much grief over the loss of a body part or loss of a physiological function. They may also experience temporary or permanent changes in body image and self-esteem, as self-esteem is influenced by how personal physical characteristics and abilities are perceived.

To nurses, an event such as admission to a health care facility may seem fairly routine; however, a person who is admitted, even electively, is separated from a familiar environment and is therefore potentially experiencing a loss. If the admission is for a short time only, the effects of this loss are not likely to be great, but if a person is deprived of a known environment for an extended period, the effects of that loss can be severe. Some people experience several losses at the one time; for example, a terminally ill person may experience loss of independence, body image, social status, financial security, plans for the future and relationships. People who are ageing often face similar types of losses; in particular, older people admitted to residential care facilities are confronted with significant important losses, including leaving the family home, loss of privacy and independence, loss of a familiar lifestyle, surroundings and belongings, loss of health and separation from loved ones (Clinical Interest Box 14.1). Adjustment to multiple losses may be difficult and grief may accumulate. (Chapter 13 provides further information concerning older adults, multiple losses, stress and adaptation.) However, it should not be forgotten that many people cope with significant loss and change throughout their lives, many adapt successfully, even when losses accumulate, and some people find they gain in confidence and are strengthened personally after coping successfully with grief (Howarth 2000).

GRIEVING RESPONSES TO LOSS

Reactions to loss are influenced by a variety of factors including:

Clinical Interest Box 14.2 illustrates how children respond to loss.

Reactions to loss are influenced by the type of loss experienced; for example, loss of a loved person through death usually results in deep grief. It is important to remember that people respond to loss in different ways, depending on the significance of the loss. Grief is a natural but unique response to loss. Grieving, or mourning, are normal reactions that help an individual to recover slowly from a significant loss. It is considered normal and healthy to experience intense and painful emotions relating to loss. It is also recognised that painful feelings diminish with time but may never totally disappear. After any great loss, people may return to an apparently normal life, but it is likely that they are ‘different’. A person faced with a serious loss may begin to grieve before the loss actually occurs. For example, older people may experience anticipatory grief as they anticipate the lifestyle changes and losses that old age brings. The process of grieving for a dying person before death occurs is also anticipatory grief. It enables a degree of preparation and ‘letting go’ but, ultimately, the depth of grief is still acute when death eventually does occur (Cicero 2007; Old & Swagerty 2007).

Acute grief is a reaction that begins at the time of a loss, for example, loss of a person through sudden death, who perhaps leaves for work and does not return, or the loss of a limb as the result of an accident. Later, grief is described as still present but less acute and less overwhelming.

While people experience grief in different ways, certain patterns of grieving have been observed and documented. The concept of phases of grieving can be useful in helping the nurse to recognise and support grieving persons.

THEORETICAL FRAMEWORKS

Theorists often describe grief as a process that involves several stages or phases. The stages are identified according to descriptions of the responses commonly experienced by people as they face up to a loss. One well-known theory or model of the grieving process is that described in the late 1960s by Dr Elisabeth Kubler-Ross, a psychiatrist and renowned authority on the process of dying, who describes the grieving process as having five stages:

By recognising the stages that a grieving person may experience, nurses are better able to understand what is happening and respond appropriately to that person. The grieving person may not experience every stage, or experience the different stages in any given order. Although grief may be observed to follow a logical sequence, it is not necessarily a linear process. For many people it is not simply a matter of ‘moving on’ if and when a previous stage is ‘complete’. It is sometimes impossible to differentiate clearly between stages, as a person rarely moves neatly from one to another. Generally a person moves back and forth between the feelings of grief until final resolution or acceptance occurs.

Theorists generally have focused their work on grief associated with death and dying, but the stages they have identified can be applied to grieving individuals facing sadness from many other types of loss. Other theorists have proposed somewhat different stages to Dr Kubler-Ross, but the themes are similar. Engle (1964), for example, describes the grieving process as occurring in three stages — shock and disbelief, developing awareness, and reorganisation and restitution — while Parkes (1986) describes four stages — shock and disbelief, protest, disorganisation and reorganisation. Table 14.1 identifies some of the behaviours associated with various phases of the grieving process.

TABLE 14.1 Phases of grieving

More recently, O’Nians (1993) has also described the grief process as characterised by stages of mourning, in which people shift in linear fashion from one stage to another. However, more contemporary writings on the grieving process tend to describe it as being more random than do the earlier theorists. Grief is described as cyclic, oscillating, ‘coming in waves’, or like walking through a maze. People often describe their grief experience as a wide and chaotic range of feelings that may come randomly, or perhaps all at once — shock, sadness, anger, guilt, depression and despair, as well as relief, hope and acceptance. Feelings are often said to be confusing, swinging forwards and backwards, with peaks and troughs of intense emotion being common. This is represented in the form of a cyclic model rather than one that is linear or staged (Shives 2007; Varcarolis 2006).

A similarity of contemporary thinking to linear models is in the outcome that, with working successfully through the grief experience, people do survive their grief and are able to re-establish themselves within their new situation. Eventually hope emerges and they find a new way to relate to their changed world.

Periods of intense grieving and mourning vary widely and it should be remembered that while some people may apparently return to normal life functioning within a few months, many people require much longer to work through their grief. Ferrell and Coyle (2006) provide an explanation of many models of grief, stressing that the task of grieving is hard work. It is expected that the grieving person may experience a wide range of feelings. Expressions of these feelings may include:

Box 14.2 provides a summary of some common symptoms associated with grief.

DYSFUNCTIONAL GRIEVING

Total absence of feelings normally associated with grief is believed to be an unhealthy psychological response, and unresolved grief can lead to delayed or distorted reactions. Ongoing dysfunctional emotions, and health problems can occur if grieving work is ignored or denied (Varcarolis 2006; Stuart & Laraia 2005; Boyd 2007). Clinical Interest Box 14.3 identifies some of the symptoms of dysfunctional grieving.

THE TASKS OF SUCCESSFUL MOURNING

Professionals specialising in grief work may be required to promote a return to wellness in people who have not successfully achieved the tasks of mourning and are displaying symptoms of dysfunctional grieving. The tasks of successful mourning are identified as:

It is considered that the tasks of mourning have been completed successfully when the bereaved person can reflect and realistically remember the good and bad times of the relationship with the deceased loved one and can think about the pleasures and the disappointments without distress. This does not mean that there will not be times when sadness emerges afresh, but these will be brief and may be related to triggers that include birthdays and anniversaries. The time that it takes to complete the tasks of mourning may be harder to accomplish and take longer when a parent loses a child, as this is not in the usual scheme of things, or when death is unexpected, particularly if it has occurred by suicide or violent means such as homicide. However, as stated previously there are no rules or set time lines for grieving and mourning. The response to any loss is unique to each individual.