BEREAVEMENT Department PowerPoint Presentation

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Managing Bereavement within the Health Care System Kara Z. McDaniel, NCC, LPC, Ph.D. Department of Family and Preventive Medicine-PA Program Behavioral Medicine Course

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Life is a series of experiences, each one of which makes us bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and griefs which we endure help us in our marching onward. -Henry Ford

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OBJECTIVES Participants will learn the definition of bereavement and grief in addition to the basic tasks/phases of grieving Participants will learn the psychological, social, and physiological effects of bereavement and factors that influence the process of grief Participants will learn the importance of their role in identifying and treating bereaved patients

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WHAT IS BEREAVEMENT? “To be deprived by death” (NMHA, p.1) “The state of having suffered a loss” (Rando, p. 16). Feelings of grief experienced following the death of loved one

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WHAT IS GRIEF? The process in which one reacts, psychologically, socially, and somatically, to the perception of loss Develops continuously and involves many changes Reaction that is natural and expected Reaction to many types of loss, not just death Loss does not need to be recognized or validated by others in order for person to experience grief (Rando, 1984).

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TYPES OF LOSSES Physical (tangible) Loss of possession or death of loved one House fire Pet loss ??????

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TYPES OF LOSSES, cont. Symbolic (psychosocial) usually not identified as a loss persons may not realize that time is needed to grieve Some losses are clearly recognized e.g. death or theft Other losses may not be recognized as clearly and may not result in negative events. Response to normal change and growth e.g. having a baby Some are competency-based e.g. terminating therapy, graduating from college Why am I feeling sad during a time that is supposed to bring happiness?

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TYPES OF LOSSES , cont. Physical loss may also result in symbolic loss e.g. mastectomy associated with breast cancer (Rando, 1984). Additional types of symbolic losses divorce Loss of job Demotion Move Empty nest children leaving home to go to college, get married, etc.

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BASIC TASKS OF GRIEF Must understand the basic tasks of grief in order to fully understand what one experiences during the grief process Conceptualized by pioneer in grief investigation, Erich Lindemann, in 1944 Three tasks constitute what Lindemann termed “grief work” (Rando, 1984, p. 18). Can be applied to both symbolic and physical losses Basic Tasks of Grief Emancipation Readjustment Formation (See Tasks/Phases of Grief handout on Blackboard)

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PROCESS OF GRIEF There exists numerous conceptualizations describing the process of grief may have different names and focus on different topics but all entail loss e.g. Elisabeth Kubler-Ross’ work with death and dying (Kubler-Ross, 1969) Theory was developed by Bowlby in 1961; included last three phases (Bowlby, 1980) In 1974, Parkes revealed that Bowlby omitted one important phase, numbness (Parkes & Weiss, 1983).

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PHASES OF GRIEF Numbness Yearning and searching Disorganization and despair Reorganization See Tasks/Phases of Grief handout on Blackboard

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EXPRESSION OF LOSS Utilize conceptualization to explain loss in terms of reactions, not stages Reactions do not form rigid phases Person grieving may move back and forth; not sequential Person may not experience all the reactions presented Respond to those grieving based on needs at that time, not in terms of what stage Duration may last from months to years and may experience ups and downs during this time

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EXPRESSION OF LOSS, cont. Psychological View within three categories Avoidance Phase Confrontation Phase Reestablishment Phase Social Physiological

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EXPRESSION OF LOSS, cont. Psychological Avoidance avoid the acknowledgement of loss shocked physically and psychologically confused, dazed, unable to comprehend, numbness denial once shock wears off and one begins to recognize the loss

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EXPRESSION OF LOSS, cont. Psychological Confrontation Intense grief Shock wears off although denial may still exist Emotional extremes New reactions may prompt fear and anxiety Panic or generalized anxiety (e.g. unknown and unfamiliar) Angry (e.g. may be displaced onto other persons) Guilt (e.g. may remember just the negative about relationship; feeling guilty because loved one died and he/she didn’t )

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EXPRESSION OF LOSS, cont. Psychological Confrontation, cont. Depression Inability to concentrate Feeling of “mutilation” (expressing loss in physical terms) (Rando, 1984, p. 33) Preoccupation with deceased (e.g. obsessive rumination; dreaming) Yearning Psychological Reestablishment Grief gradually declines One begins to reinvest in other things and relationships Feelings of guilt and betrayal are possible as one moves forward in spite of loss

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EXPRESSION OF LOSS, cont. Social reactions to loss Restlessness Social withdrawal

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EXPRESSION OF LOSS, cont. Physiological reactions to loss Anorexia GI distress Insomnia Crying Weight loss Physical exhaustion Symptoms of anxiety e.g. heart palpitations; shortness of breath Lack of energy Loss in sexual desire

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FACTORS INFLUENCING REACTIONS TO GRIEF Psychological Social Physiological

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FACTORS INFLUENCING REACTIONS TO GRIEF, cont. Psychological nature and meaning of loss to person grieving e.g. pet loss vs. loss of parent quality of relationship e.g. conflicted Role-loss and object-loss role of deceased lost coping behaviors, personality, and mental health maturity and intelligence background, socially, culturally, religiously sex role characteristics of deceased

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FACTORS INFLUENCING REACTIONS TO GRIEF, cont. Psychological, cont. unfinished business sudden vs. expected death fulfillment in life issues surrounding death timeliness e.g. death of child vs. death of aging person preventability length of illness; anticipatory grief and involvement with dying loved-one concurrent stresses (Rando, 1984)

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FACTORS INFLUENCING REACTIONS TO GRIEF, cont. Social social support system religious/cultural/and ethnic background educational, economic and occupational status

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FACTORS INFLUENCING REACTIONS TO GRIEF, cont. Physiological Drugs and sedatives Need to be able to vent during crucial time when support available Heavy vs. mild sedation Nutrition Anorexia; taste altered; GI distress Encourage to maintain good eating habits to maintain strength Rest and sleep Some sleep distress is normal May result in further problems if insomnia exists Physical health Some physical distress is normal Attend to any physical symptoms to prevent further complications Exercise Not only keeps body healthy but serves as a good emotional outlet

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IS IT BEREAVEMENT OR DEPRESSION? Grieving individual may present symptoms that are similar to Major Depressive Episode (e.g. sadness, insomnia, poor appetite, weight loss) depressive symptoms usually transient and not many (Prigerson et al, 2001). Many bereaved persons meet criteria for MDD during first few months after loss (Bruce et al., 1990; Clayton et al., 1972; Prigerson et al., 1997) Diagnosis of MDD is usually not given until symptoms are still present 2 months following loss Differentiating between normal grief reaction and depression Morbidity and Mortality

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IS IT BEREAVEMENT OR DEPRESSION?, cont. Minority experience depressive syndromes beyond one year 1 month-42% 1 year-16% (Clayton et al., 1972) Bereaved individual may view depressed mood as normal but seeks treatment for alleviation of associated symptoms

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IS IT BEREAVEMENT OR DEPRESSION?, cont. There are specific symptoms that are not characteristic of a normal reaction to grief Assist in differentiating between MDD and bereavement “guilt about things other than actions taken or not taken by the survivor at the time of the death” “thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person” “morbid preoccupation with worthlessness” “marked psychomotor retardation” “prolonged and marked functional impairment” “hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person” (DSM-IV-TR, p. 741)

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BEREAVEMENT Bereavement Morbidity studies have shown that bereavement has a negative impact on health (Rogers & Reich, 1988). associated with high blood pressure (Prigerson et al., 1997) heart disease, and depressive and anxiety disorders (Chen et al., 1999; Devries et al., 1997). Heightens risk for sleep disruption (McDermott et al., 1997) increase in consumption of alcohol, tranquilizers, and tobacco (Maddison & Viola, 1968; Glass et al., 1995) suicide attempts (Birtchnell, 1970; Gregory, 1994) mortality (Schaefer et al., 1995 & Kaprio et al., 1987).

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BEREAVEMENT Bereavement Mortality studies dating back to 1959 suggest a strong mortality risk to bereavement Heart disease 1996 study conducted by Martikainen and Valkonen 1.5 million adults between ages 35 to 84 showed a 20%-35% excess mortality from ischemic heart disease within five years from spouse’s death adverse and long-term bereavement effects from sudden or traumatic death of loved one (Rynearson & McCreery, 1993; Lehman, et al., 1987). Showed a higher mortality and psychiatric morbidity among bereaved parents and spouses compared to nonbereaved control group 4-7 years after automobile accident that took loved one’s life (Lehman, et al., 1987)

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BEREAVEMENT CARE Physicians’ perception of bereavement care Exploratory study of physicians’ perceptions of bereavement care conducted by Lemkau et al., 2000 showed that physicians generally believed that bereavement presented significant health risks to patients and that their role in identifying and treating bereavement was important Role of physician in bereavement care An extremely important role Physicians care for many patients who may be experiencing grief, ailments, and distress (Prigerson et al., 2001). As stated previously, bereavement increases one’s risk for health problems. Persons are living longer According to study above, how physicians responded and treated bereavement varied

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BEREAVEMENT CARE, cont. Contact with bereaved patients When bereaved is not your patient telephone call, letter of condolence, or visit after death (Main, 2000; Bedell et al., 1998) According to Bedell et al. (1998), physician has one final responsibility to the patient who died which is to help care for bereaved family members. Acknowledge loss, express sympathy, and allow family to clarify unanswered questions (Prigerson, 2001) When bereaved is your patient offer condolences evaluate and monitor health care needs (Main, 2000) office visits may shift to education and support through process of grief (Prigerson, 2001) What to and what not to say Refer to list provided on Blackboard

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WHAT NOT TO SAY Call me. Casually ask, “How are you? I know exactly how you feel. It was probably for the best. He/she is happy now. It is God’s will. It was time to go. I’m sorry I brought up the subject. Let’s change the subject. You should be getting over this by now

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WHAT NOT TO SAY …cont I have had other patients with the same illness and they suffered for a long time. You should be glad your loved-one passed away so quickly. You’re strong enough to cope with the loss. Be thankful you have your other children. You can always have more children. I lost my loved one… I understand, my loved-one was very sick too. Be happy he/she was only 6 months old and not six years. Holly, Jacobs, & Selby, 2001; http://www.rollanet.org/~reb/docs/ThingsNotToSay.html

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WHAT TO SAY I’m sorry for your loss. I can’t imagine the pain you are going through. What do you remember about [the deceased’s name] today? Say [deceased’s] name. Talk about deceased. Do you have any questions about the illness and treatment provided? How are you feeling? How has loss affected you? Holly, Jacobs, & Selby, 2001

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BEREAVEMENT CARE, cont. Facilitating healing Develop new routines and skills For women, financial strain links widowhood to symptoms of depression; for men, strains of household management are linked to depressive symptoms (Umberson et al., 1992) encourage attempts to minimize strains Maintain active routine on daily basis Two studies involving elderly patients found that those who are bereaved and maintained a daily/busy routine slept better (Brown et al., 1996) and fewer symptoms of depression in comparison to those with less structure (Prigerson et al., 1994) Written or verbal disclosure e.g. journal associated with an improvement in physical/mental health (Pennebaker et al., 2001; Esterling et al., 1994) positive influence on one’s immune function (Esterling et al., 1994).

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BEREAVEMENT CARE, cont. Treatment When to intervene and/or make referral barriers to treatment with grieving patients if suspect psychiatric complications, health care provider needs to diagnose and treat and/or make referral to mental health professional e.g. psychologist, psychiatrist if suicidality exists at any time, refer to mental health professional (Prigerson, 2001)

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BEREAVEMENT CARE, cont. Treatment of psychiatric complications related to bereavement treatment chosen is dependent upon diagnosis Bereaved patients diagnosed with MDD SSRIs and TCAs randomized, placebo-controlled clinical trial of bereaved patients with MDD nortriptyline alone-56% remission rate nortriptyline with psychotherapy-69% remission rate psychotherapy alone-29% remission rate (Reynolds et al., 1999) open-label trial of paroxetine, SSRI, administered weekly for 4 weeks showed 54% decline in MDD symptoms although study is needed to confirm efficacy of SSRI for MDD secondary to bereavement, MDD following the death of loved one has been shown to not be different than MDD manifested in other ways (Reynolds et al., 1993)

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“Physicians who aid grief-stricken patients are afforded the rewarding, quintessentially human opportunity of transforming a personal sorrow they inevitably will experience into sympathetic and supportive aftercare” -George Eliot

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Questions or Comments?

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RESOURCES American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Washington, DC.: American Psychiatric Association. Bedell, S.E., Cadenhead, K. Graboys, T.B. (2001). The doctor’s letter of condolence. National vital statistics reports final data. New England Journal of Medicine, 344, 1161- 1162. Birtchnell, J. (1970).The relationship between attempted suicide, depression, and parent death. British Journal of Psychiatry, 116, 307-313. Bowlby, J. (1980). Attachment and loss: Loss, sadness and depression (Vol. III). New York: Basic Books. Brown, L.F, Reynolds, C.F., Monk, T.H., et al. (1996). Social rhythm stability following late-life spousal bereavement: Associations with depression and sleep impairment. Psychiatry Res., 62, 161-169.

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Bruce, M. L., Kim, K., Leaf, P. J., & Jacobs, S. (1990).Depressive episodes and dysphoria resulting from conjugal bereavement in a prospective community sample. American Journal of Psychiatry, 147, 608-611. Chen, J. H., Bierhals, A. J., Prigerson, H. G., Kasl, S. V., Mazure, C. M., & Jacobs, S. (1999). Gender differences in the effects of bereavement-related psychological distress in health outcomes. Psychol Med., 29, 367-380. Clayton, P.J., Halikas, J.A., Maurice, W.L. (1972). The depression of widowhood. British Journal of Psychiatry, 120, 71-77. DeVries, B., Davis, C. G., Wortman, C. B., & Lehman, D. R. (1997). Long-term psychological and somatic consequences of later life parental bereavement, OMEGA Journal of Death and Dying, 35, 97-117. Esterling, B.A., Antoni, M.H., Fletcher, M.A., Margulies, S., Schneiderman, N. (1994). Emotional disclosure through writing or speaking modulates latent Epstein-Barr virus antibody titers. Journal of Consulting and Clinical Psychology, 62, 130-140.

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Glass, T.A., Prigerson, H.G., Kasl, S.V., Mendes de Leon, C.F. (1995). The effects of negative life events on alcohol consumption among older men and women. J Gerontol B Psychol Sci Soc Sci, 50, S205-S216. Gregory, R.J. (1994). Grief and loss among Eskimos attempting suicide in western Alaska. American Journal of Psychiatry, 151, 1815-1816. Kaprio, J., Koskenvuo, M., Rita, H. (1987). Mortality after bereavement: A prospective study of 95,647 widowed persons. American Journal of Public Health, 77, 283-287. Kubler-Ross, E. (1969). On death and dying. New York: Simon and Schuster. Lehman, D. R., Wortman, C. B., & Williams, A. F. (1987). Long-term effects of losing a spouse or child in a motor vehicle crash. Journal of Pers. Soc. Psychology, 52, 218-231. Lemkau, J.P., Mann, B., Little, D., Whitecar, P., Hershberger, P. & Schumm, J.A. (2000). Questionnaire survey of family practice physicians’ perceptions of bereavement care. Arch. Family Medicine, 9, 822-829. Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141-148.

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Maddison, D.C. & Viola, A. (1968). The health of widows in the year following bereavement. J Psychosom Res., 12, 297-330. Main, J. (2000). Improving management of bereavement in general practice based on a survey of recently bereaved subjects in a single general practice. British Journal of General Practice, 50, 863-866. Martikainen, P. & Valkonen, T. (1996). Mortality after the death of a spouse: Rates and causes of death in a large Finnish cohort. American Journal of Public Health, 86, 1087-1093). McDermott, O.D., Prigerson, H.G., Reynolds, C.F.III, et al. (1997). Sleep in the wake of complicated grief symptoms: An exploratory study. Biol Psychiatry, 41, 710-716. National Mental Health Association (2004). General mental health issues: Coping with loss-bereavement and grief. Retrieved from world wide web, http://www.nmha.org/infoctr/factsheets/42.cfm. Parkes, C. M. (1972). Bereavement: Studies of grief in adult life. New York: International Universities Press. Parkes, C. M., & Weiss, R. S. (1983). Recovery from bereavement. New York: Basic Books.

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Pennebaker, J.W., Zech, E., & Rime, B. (2001). Disclosing and sharing emotion: Psychological, social and health consequences. In M.S. Stroebe, R.O. Hansson, W. Stroebe, & H. Schut, eds. Handbook of Bereavement Research: Consequences, coping, and care. Washington, DC: American Psychological Association. Prigerson, H.G. & Jacobs, S.C. (2001). Caring for bereaved patients: “All the doctors just suddenly go.” Journal of American Medical Association, 286, 1369-1376. Prigerson, H. G., Bierhals, A. J., Kasl, S. V., et al. (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry, 154, 616-623. Prigerson, H.G., Reynolds, C.F. III, Frank, E., Kupfer, D.J., George, C.J., & Houck, P.R. (1994). Stressful life events, social rhythms, and depressive symptoms among the elderly: An examination of hypothesized causal linkages. Psychol Res., 51, 33-49. Rando, T. A. (1984). Grief, dying, and death: Clinical interventions for caregivers. Illinois: Research Press. Reynolds, C.F. III, Hoch, C.C., Buysse, D.J., et al. (1993). Sleep after spousal bereavement: A study of recovery from stress. Biol Psychiatry, 34, 791-797.

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Reynolds, C.F. III, Miller, M.D., Pasternak, R.E., et al. (1999). Treatment of bereavement-related major depressive episodes in later life: A controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. American Journal of Psychiatry, 156, 202-208. Rogers, M. P. & Reich, P. (1988). On the health consequences of bereavement. New England Journal of Medicine, 319, 510-511. Rynearson, E. K. & McCreery, J. M. (1993). Bereavement after homicide: A synergism of trauma and loss. American Journal of Psychiatry, 150, 258-261. Schaefer, C., Quesenberry, C.P. Jr., & Wi, S. (1995). Mortality following conjugal bereavement and the effects of a shared environment. Am J Epidemiol, 141, 1142-1152. Umberson, D. Wortman, C.B., & Kessler, R.C. (1992). Widowhood and depression: Explaining long-term gender differences in vulnerability. J Health Soc Behav., 33, 10-24.