CHAPTER 10: GRIEF AND LOSS

Chapter 10: Greif and Loss

Key Terms:
o Acculturation: altering cultural values or behaviors as a way to adapt to another culture
o Adaptive Denial: the client gradually adjusts to the reality of the loss, can help the client let go of
previous (before the loss) perceptions while creating new ways of thinking about him or herself, others
and the world
o Anticipatory Grieving: when people facing an imminent loss begin to grapple with the very real
possibility of the loss or death in the near future
o Attachment Behaviors: affectional bonds with significant others
o Attentive Presence: being with the client and focusing intently on communicating with and understanding
him or her
o Bereavement: refers to the process by which a person experiences grief
o Complicated Grieving: a response outside the norm and occurring when a person is void of emotion,
grieves for prolonged periods, or has expressions of grief that seem disproportionate to the event
o Disenfranchised Greif: grief over a loss that is not or cannot be mourned publically or supported socially
o Greif:
o Grieving:
o Grieving Tasks:
o Homeostasis:
o Mourning:
o Outcry:
o Recovery:
o Spirituality:
o Theories of Grieving:
Objectives:
o Identify the types of losses for which people may grieve
Physiologic Loss: amputation of a lib, a mastectomy or hysterectomy, or loss of mobility;
essentially, its the loss of function and/or part of the body
Safety Loss: loss of safe environment is evident in domestic violence, child abuse, or public
violence; a persons home should be a safe haven with trust that family members will provide
protection, not harm or violence; some public institutions such as schools and churches are often
associated with safety as well; feeling of safety is shattered when public violence occurs on
campus or in a holy place
Loss of Security and a Sense of Belonging: the loss of a loved one affects the need to love and the
feeling of being loved; loss accompanies change in relationships, such as birth, marriage, divorce,
illness, and death; as the meaning of a relationship changes, a person may lose roles within a
family or group
Loss if Self-Esteem: any change in how a person is valued at work or in relationships or by
himself or herself can threaten self-esteem; it may be an actual change or the persons perception
of a change in value; death of a loved one, a broken relationship, loss of job, and retirement are
examples of change that represents loss and can result in a threat to self-esteem
Loss Related to Self-Actualization: an external or internal crisis that blocks or inhibits strivings
toward fulfillment may threaten person goals and individual potential; a person who wanted to go
to college, write books and teach at a university reaches a point in life where it becomes evident
that those plans will never materialize; or a person loses hope that he or she will find a mate and
have children; these are losses that the person will grieve
o Discuss various theories related to understanding the grief process
Kubler-Rosss Stages of Grieving:
Elizabeth Kubler-Ross (1969): attended to clients with terminal illness, a process of
dying became apparent to her; observed and worked with dying clients and families
5 stages to explain what people experience as they grieve and mourn:

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CHAPTER 10: GRIEF AND LOSS
o Denial: is shock and disbelief regarding the loss
o Anger: may be expressed toward God, relatives, friends, or health-care workers
o Bargaining: occurs when the person asks God or fate for more time to delay the
inevitable loss
o Depression: results when awareness of the loss becomes acute
o Acceptance: occurs when the person shows evidence of coming to terms with
death
Model became a prototype for care providers as they looked for ways to understand and
assist their clients in the grieving process
Bowlbys Phases of Grieving:
John Bowlby: British psychoanalyst, proposed a theory that humans instinctively attain
and retain affectional bonds with significant others through attachment behaviors
Attachment that is maintained is a source of security, an attachment that is renewed is a
source of joy
Bond is threatened or broken, however the person responds with anxiety, protest, and
anger
Four phases:
o Experiencing numbness and denying the loss
o Emotionally yearning for the loss loved one and protesting the permanence of the
loss
o Experiencing cognitive disorganization and emotional despair with difficulty
functioning in the everyday world
o Reorganizing and reintegrating the sense of self to pull life back together
Engels Stages of Grieving:
George Engel (1964)
Five stages of grieving:
o Shock and Disbelief: initial reaction to a loss is a stunned, numb feeling
accompanied by refusal to acknowledge the reality of the loss in an attempt to
protect the reality of the loss in an attempt to protect the self against
overwhelming stress
o Developing Awareness: as the individual begins to acknowledge the loss, there
may be crying, feelings of helplessness, frustration, despair, and anger that can be
directed at self or others, including God or the deceased person
o Restitution: participation in the rituals associated with death, such as a funeral,
wake, family gathering, or religious ceremonies that help the individual accept
the reality of the loss and begin the recovery process
o Resolution of the Loss: the individual is preoccupied with the loss, the loss
person or object is idealized, and the mourner may even imitate the lost person.
Eventually, the preoccupation decreases, usually in a year or perhaps more
o Recovery: the previous preoccupation and obsession ends, and the individual is
able to go on with life in a way the encompasses the loss
Horowitzs Stages of Loss and Adaptation:
Mardi Horowitz (2001)
Divides normal grief into 4 stages:
o Outcry: first realization of the loss; may be outward, expressed by screaming,
yelling, crying, or collapse; can also be suppressed as the person appears stoic,
trying to maintain emotional control; either way, these feelings take a great deal
of energy to sustain and tend to be short-lived
o Denial and Intrusion: people move back and forth during this stage between
denial and intrusion; during denial, the person becomes so distracted or involved
in activities that he or she sometimes isnt thinking about the loss; at other times,

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CHAPTER 10: GRIEF AND LOSS
the loss and all it represents intrudes into every moment and activity, and feelings
are quite intense again
o Working Through: as time passes, the person sends less time bouncing back and
forth between denial and intrusion, and the emotions are not as intense and
overwhelming; person still thinks about the loss, but also begins to find new
ways of managing life after loss
o Completion: life begins to feel normal again, although life is different after he
loss; memories are less painful and dont regularly interfere with day-to-day life;
episodes of intense feelings may occur, especially around anniversary dates, but
are transient in nature
Stages of Grieving: Comparison of Theorists Table 10.1 pg 166
o Describe the five dimensions of grieving
Tasks of Grieving:
Rondo (1984) describes tasks internet to grieving that she calls the six Rs:
o Recognize: experiencing the loss, and understanding that it is real, it has
happened
o React: emotional response to loss, feeling the feelings
o Recollect and Re-experience: memories are reviewed and relived
o Relinquish: accepting that the world had changed (as a result of the loss), and
that there is no turning back
o Readjust: beginning to return to daily life; loss feels less acute and overwhelming
o Reinvest: accepting changes that have occurred; re-entering the world, forming
new relationships and commitments
Worden (2008) views the tasks of grieving as:
o Accepting the reality of the loss: its common for people initially to deny the
loss; its too painful to acknowledge fully; over time the person waivers between
relief and denial in grappling with this task; traditional rituals, such as funerals
and wakes, are helpful to some
o Working through the pain of grief: a loss causes pain, both physical and
emotional, that must be acknowledged and dealt with; attempting to avoid or
suppress the pain may delay or prolong grieving process; intensity of pain and
the way its experienced varies, but needs to be experienced to move on
o Adjusting to an environment that has changed because of loss: it may take
months for the person to realize what life will be after the loss; when a love one
dies, roles change, relationships are absent or different, lifestyle may change, and
the persons sense of identity and self-esteem may be greatly affected; feelings of
failure, inadequacy, or helplessness at time are common; individual must develop
new coping skills, adapt to the new or changed environment, find meaning in
new life, and regain control over life to continue to grow; person can be in a state
of arrest development and get stuck in mourning if this doesnt occur
o Emotionally relocating that which has been lost and moving on with life: the
bereaved person identifies a special place for what was lost and the memories;
the lost person or relationship isnt forgotten or diminished; but relocated in
mourners life as this person forms new relationships, friend, life rituals, and
moves ahead with daily life
Dimensions of Grieving:
Cognitive Response of Grief:
o Loss disrupts if not shatters, basic assumptions about lifes meaning and purpose
o Grieving often causes a person to change beliefs about self and the world, such as
perceptions of the worlds benevolence, the meaning of life as related to justice,
and a sense of density or life path

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CHAPTER 10: GRIEF AND LOSS
o Questioning and Trying to Make Sense of the Loss:
Grieving person needs to make sense of the loss
Loss challenges old assumptions about life
Searches for answers to why the trauma occurred
Goal of search is to give meaning and purpose to the loss
Questioning may help the person accept the reality of why someone died
Questioning may result in realizing that loss and death are
realities that everyone must face one day
Finding spiritual meaning or explanations can be a source of
comfort as people progress through the grieving process that
serve to keep the lost one present
o Attempting to Keep the Lost One Present: belief in an afterlife and the idea that
the lost one has become a person guide are cognitive responses that serve to keep
the lost one present
Emotional Response of Grief:
o Anger, sadness, and anxiety and the predominant emotional responses to loss
o Feeling of hatred and revenge are common when death has resulted from extreme
circumstances, such as suicide, murder, or war
o A common first response to the news of a loss is to be stunned, as though not
perceiving reality
o Eventually reality begins to set in, the grieving person may express irritability,
bitterness, and hostility toward clergy, medical providers, relatives, comforters,
and even dead person; grieving person may interpret sounds, sights, and smells
associated with the lost one as signs of the deceased presence, which may
intermittently provide comfort and ignite hope for a reunion
o As the bereaved person begins to understand the losss permanence, they
recognize that patterns of thinking, feelings, and acting attached to life with the
deceased must change
o Eventually, the bereaved person begins to reestablish a sense of personal identity,
direction, and purpose for living
Spiritual Response of Grief:
o Closely associated with the cognitive and emotional dimensions of grief are the
deeply embedded personal values that give life meaning and purpose to life
o Grieving person may become disillusioned and angry with god or other religious
figures or members of the clergy
o Anguish of abandonment, loss of hope, or loss of meaning can cause deep
spiritual suffering
o Providing opportunities for clients to share their suffering assists in the
psychological and spiritual transformation that can evolve through grieving
Behavioral Response of Grief:
o Grieving person may function automatically or routinely without much thought,
indicating that the person is numb- the reality of the loss has not set in
o Person actually may call out for the deceased person or visually scan the room
for them
o Seeking out as well as avoiding places or activities once shared with the
deceased, and keeping or wanting to discard valuables and belongings of the
deceased illustrate fluctuating emotions and perceptions of hope for reconnection
o Drugs or alcohol abuse indicate a maladaptive behavioral response to the
emotional and spiritual despair
o Suicide and homicide may be extreme responses if the bereaved person cannot
move through the grieving process

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CHAPTER 10: GRIEF AND LOSS
Physiologic Response of Grief:
o Those grieving may complain of insomnia, headaches, impaired appetite, weight
loss, lack of energy, palpitations, indigestion, and any changes in the immune and
endocrine systems
o Sleep disturbance are among the most frequent and persistent bereavement-
associated symptoms
o Discuss universal and culturally specific mourning rituals
African Americans: deceased viewed in church before curial in cemetery; public prayers, black
clothing, decreased social activities
Muslim Americans: five steps of burial procedure including washing, dressing, and position of
the body
First Step: traditional washing of the body by a Muslim if the same gender
Haitian Americans: practice vodun (voodoo) also called root medicine the practice of calling on
a group of spirits whom one periodically makes peace during specific events in life; seen in
Alabama, Louisiana, Florida, North Carolina, South Carolina, Virginia, and some communities in
New York
Chinese Americans: strict norms for announcing death, preparing body, arranging funeral and
burial, mourning after burial
Bowls of food on table for the spirt for 1 year after death
Japanese Americans: death as life passage; bathing with warm water and dressing in whit kimono
after purification rites
Filipino Americans: black clothing or armbands; wreath on casket; black cloth on home of
deceased
Vietnamese Americans: bathing deceases and dressing in black clothing; rice in mouth and
money so deceased can buy a drink as the spirit moves on in the afterlife; display of body for
viewing in home before burial
Hispanic Americans: novena (9-day devotion, prayers) and Rosary (devotional prayer); luto
(mourning) by wearing black or black and white while behaving in a subdued manner
Native Americans: tribal medicine man or priestly healer; baptism ceremonies to help ward off
depression of the bereaved; end of mourning with ceremony at burial grounds with grave covered
with blanket or cloth later given to tribe member
Orthodox Jewish Americans: relative staying with dying person so the soul doesnt leave the
body while the person is alone; body covered with sheet; eyes closed; body should remain
covered and untouched until family, rabbi, or Jewish undertaker can begin rites; organ donation
allowed, autopsy isnt unless required by law; burial with 24 hours of death unless Sabbath;
Shivah (7-day period begins on the day of the funeral, represents time for mourners to step out of
day-to-day life, and reflect on the change that occurred)
o Discuss disenfranchised grief
is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported
socially
Circumstances that can result in disenfranchisd grief include:
A relationship that has no legitimacy.
o Same-sex relationships, cohabitation without marriage and extramarital affairs
are some examples.

The loss itself is not recognized.
o Other losses not recognized or seen as socially significant include prenatal death, abortion,
relinquishing a child for adoption, death of a pet, or other losses not involving death such as loss
of a job, separation, divorce, and children leaving home.

The griever is not recognized
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CHAPTER 10: GRIEF AND LOSS
o Older adults and children expereicen limited social recognition for their losses
and the need to mourn. As people grow older, they "should expect" others their
age to die. Adults see their children as not understanding or comprehending.
CHildren may experience the loss of a "nurturing parental figure" from death,
divorce, or family dysfunction such as alcoholism or abuse.
The loss involves social stigma
o Death of someone incarcerated or executed for crimes carries a social stigma that
often prevents family members from publicly grieving or receiving support for
their loss.
o Identify factors that increase a persons susceptibility to complications related to grieving.
Low self-esteem
Low trust in others
A previous psychiatric disorder
Previous suicide threats or attempts
Absent or unhelpful family members
An ambivalent, dependent, or insecure attachment to the deceased person

o Discuss factors that are critical to integrating loss into life.

o Apply the nursing process to facilitate grieving for clients and families.

UNIT 3: CURRENT SOCIAL AND EMOTIONAL CONCERNS