This post limit to discuss the characteristic of Pathological Grief and the Counselling methods in the Context of Pathological Grief.
Types of Grief
There are two types of Grief. They are normal grief and pathological grief.
Pathological (morbid, atypical, unresolved) grief is that the condition of the bereaved in which he/she does not reach the final stage of the process; or is not continuing to make progress towards a positive resolution within six or eight months after the loss.
Given this approximate period of time; a fixation on a particular symptom or particular segment of a specific stage of the normal grief process may note; with the adoption in a rigid and inflexible manner of one; or a small select number of mechanisms or behaviors of that stage.
Situations Leading to Pathological Grief
Situations that may lead to pathological grief are described below.
With a sudden death there is usually surprise, shock, and no preparation. By way of contrast, the death of an aged person might be expected.
With an aged person, some of the grieving work has already been completed, and ties to the aged person have loosened.
After a suicide, relatives have a strong tendency to feel guilt and self-blame.
Herzog and Resnick described the parents as refusing to think of the death as a suicide, and preferring to think of it as an ‘accident’.
Altered life situation:
An altered financial situation which leads to feelings of insecurity can also lead to resentment towards the deceased.
Bereavement causes anxiety and generally a sense that the world has become a dangerous place.
Characteristics of Pathological Grief
Self detrimental behaviour and lost social interaction:
Lindemann described these people as lacking initiative and being indecisive and restless. They look to others for direction and want to include in social activities.
They are apathetic and cannot make up their minds to do anything on their own. Nothing brings satisfaction, and it appears that they carry many daily routines out of habit.
Severe psycho pathology
Severe functional somatic symptoms such as persistent insomnia and weight loss indicate that the bereaved person is not resolving his/her loss. Patients with pathological grief may develop an agitated depression; with all of the characteristic symptoms and signs.
Along with other symptoms are the tendency for self-accusation, feelings of worthlessness, and a wish for self-punishment. These patients can be suicidal and require psychiatric intervention.
Volkan specifies the universality of love-hate ambivalence in the persons with pathological grief; whom he treated, through such ambivalence involve at least to some degree in all grief.
It is the presence of intense exaggerated or repressed ambivalence which seems to be involved in pathological grief.
This condition may look like any one of a number of disorders or forms of human unhappiness; depression, bitterness, anxiety, attacks, general irritability and/or outbursts of anger; or even more severe symptoms of emotional disorder.
Among children and adolescents pathological behavior
According to Kliman, if
(1) They exhibit regressive phenomena longer than several weeks, for example, an unusual (manic) cheerfulness;
(2) A disease occurs, lasting longer than six months;
(3) New symptoms appear after a certain period of time; such as diminution of school efforts (which is not uncommon for a child in the regressive stage and does not represent a serious disorder);
(4) Children or adolescents refuse to go to school; (this is a sign that they cannot leave the surviving parent for fear of separate from him or her also, or that they wish to withdraw completely);
(5) In adolescents, falling into sexual promiscuity.
Forms of Pathological Grief
Pathological grief can take various forms, from variants of normal grieving to such reactions as hypomania, dissociative reactions, drug abuse, etc.
With a resolution of grief, the person should be able to look ahead with op-atomism; although it is not unusual for grief to recur for a short time at anniversaries; or if there are strong reminders of the deceased.
In chronic grief, the reaction is prolonged and the person suffers intense sadness. Guilt and self-blame seem to be frequent symptoms in these people.
Parkes described this as a situation in which the total picture of grief is permanently absent and the patient shows little reaction to the death. This type of reaction is most commonly in children or in the elderly but may occur in others.
The inhibition of grief can be seen as a defense against a catastrophic reaction. The patient whose son committed suicide expressed a feeling of fragility; and wanted to “keep on top of things”. She was afraid of condolences from others because she feared being flooded with sadness.
With this reaction, a period of delay is followed by a typical grief reaction. The period of numbness which is the first stage of grief may be extended, or the numbness may be absent.
Lehr- man said questioning may reveal that patients suffering grief over a recent loss are still grieving for someone; who died many years ago. He gave the example of a 38-year-old woman who suffered a severe reaction over her mother’s death; but deeply engrossed in fantasies about her brother’s death from cancer 20 years earlier.
Patients can develop a hippomanic reaction. These individuals show joy, over-activity, and rapid thought processes and deny the significance of the loss.
When they are unable to ward off sad thoughts about their lose; their elation may change to sadness, but this is often short-lived.
In ‘splitting’, one part of the person is aware of the loss, and another part functions as if the loss never occurred. Volkan gave the following example. A 38-year-old housewife lost her daughter suddenly.
The daughter was a student nurse who had lived in another town and used to come home on Fridays. Although her mother consciously knew her daughter was dead; she continued to act and feel as if her daughter was still alive; and regularly cleaned the daughter’s room for her weekly visit.
In this way, people may fool themselves, believing that the loved object is gone, but behave as if this is not the case. Underlying this process is hope and an attempt to regain the lost love object.
When such a dissociative reaction occurs as part of a pathological grief reaction; the expected emotions of grief separate from the situation of death. Selective amnesia may occur whereby unconsciously the person attempts to avoid the emotional impact of the loss.
For instance, a 34-year-old woman admitted to hospital suffering from concussion; and other injuries after a car and train accident. When I saw this patient nine days later, she had amnesia for the accident as well as for the subsequent days.
Her husband and daughter had killed and she had unable to attend the funeral. Although her mother-in-law from England had come to attend the funeral; and was grieving and the patient had been told about the deaths; she continued to express surprise that her husband failed to visit.
Her unconscious acceptance of the death was signified by extreme concern about her other daughter who had also been in the accident. This patient gradually showed increasing awareness of her loss and left the hospital prematurely to return to England with her mother-in-law to “have a holiday to recover”.
Treating Grief Reactions
Participate in funeral
Mourners should encourage to participate in funeral rites and to allow themselves to experience the full impact of loss. Wishing to avoid the pain of grieving, certain family members may take on the task of making funeral arrangements.
Volkan described how often the only male or eldest male child in the family takes this role. As a result, the grief of these men may delay or inhibited.
Parkes described the person who makes the arrangements as “setting an example to the rest of the family” and acting as a. “tower of strength”.
Asking basic questions
The degree to which unresolved grief exists can detected by questioning. Basic questions that might ask to determine this.
When one has elicited that there has been a death of a family member or a friend, one can ask the patient: “Did you attend the funeral?“, “How did you feel about this person’s death?“, “Were you able to cry for this person?“, “Do you still feel a need to cry for him (or her)?“, or “Do you think that you have accepted the death?”
In cases of unresolved grief such questions might cause the patient to cry and recognize that he still pines for the deceased.
Management of unresolved grief
Parkes outlined certain principles for the management of unresolved grief. The helper must encourage the bereaved to express all feelings of sadness, anger, and guilt about the bereavement.
The bereaved person should also help to “review the relationship with the dead person” in order to understand the “nature of their emotional reactions”.
Part of grieving involves forming an acceptable relationship with the deceased in one’s mind, and gradually feeling free to move towards relationships with others.
Mourner in various ways
The family physician or helper can reassure the mourner in various ways. Many bereaved people surprised and frightened by the intensity of their emotions; and need reassurance that they are not going mad.
The bereaved person can be reassured that feelings of anger and guilt are a normal reaction to loss. If the bereaved person has fleeting hallucinations of the deceased or has tended to misidentify people like the deceased; he can again be reassured that this is a normal reaction.
In cases where the bereaved person has identified to such a degree with the deceased that he has developed similar symptoms of the illness suffered by the deceased; he can reassure that he does not suffer from this disease.
If the bereaved person is a mother, she can be reassured that she is not bad if she finds it difficult to cope with her children’s demands; and told that her children might express negative feelings towards her while they idealize their father.
Encourage the bereaved
The helper can encourage the bereaved to call upon the support of others. Visits and expressions of concern are appreciated by the bereaved as they are seen as a tribute to the dead and help to confirm for the mourner that the dead person is worth all the pain.
Parkes wrote of the need for the helper to give permission to the bereaved to stop grieving. People with a strong sense of loyalty may need indication after months of grieving that it is acceptable for them to reorient their lives in new directions.
Anything that tends to inhibit the grieving process including the use of medication should be avoided. However, when insomnia lasts for several weeks, it is advisable to give sedation at bedtime and tranquilizing medication for daytime anxiety.
The bereaved may also need help with legal, financial, and household problems. While each situation is different, treatment often involves medication (especially when symptoms of a Depressive Disorder are present) as well as psychodynamic psychotherapy. It is usually helpful for the individual to gain insight into the psychological roots of the unresolved grief.
The individual should also encourage to have an emotional support system in place, such as a network of good friends and/or a caring significant other. Exercise and diet as well as good sleep hygiene are also important.
Treatment of pathological grief
The treatment of pathological grief follows the same principles as those for the treatment of grief. The bereaved person must help to overcome the blocks that have interfered with the grieving process.
There are certain situations of grieving which require extra concern and tact. Families that have experienced suicide seem to be very vulnerable and manifest guilt; hostility and extreme sensitivity.
Herzog and Reznick said that the fathers in their study needed much help in dealing with a child’s suicide.
They discovered that the parents wished a professionally trained person could have talked with them immediately after the suicide; and that the parents who refused an interview were probably the parents who needed help most.
Individuals suffering grief can expect to visit their family physician much more frequently during the first year of bereavement. Obscure complaints may disguise grief, which the bereaved fails to express.
Awareness of factors leading to pathological grief can help the family physician to more effectively diagnose and treat this condition. Individuals suffering from pathological grief have a high morbidity rate and increased rates of physical disease and death.
The family physician can be very helpful to bereaved patients if he develops a technique for counsel them.