Delayed Grief: Stages And Coping

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Introduction

Losing a loved one can be a tailspin of emotions, a feeling of lack of control in one’s own life, and a chasm in the normalcy of daily life (Harden, Holding onto Motherhood during the Grief Process, 2018). According to (McCroby, 2018) grief is a serious of stages with a predictable start and end which involves every dimension of our lives – spiritual, psychological, physical, and social. Grieving is an encompassing process that can be observed from the biological through the interpersonal and personal to more broadly levels of discourse (Robert A. Neimeyer, 2014). This assignment is based are the vignette of a woman named Gail. She is a 38-year-old married woman who presented to the mental health services via referral from her GP in relation to severe throbbing headaches, difficulty falling asleep, fitful and disturbing sleep, upsetting dreams and poor appetite. The vignette highlights that Gail is married with two children with suggests that she has support. Gail’s feelings of guilt and sadness emerged in the last month when her late sons high school class graduated. Throughout this assignment I will outline theoretical perspectives that establish Gail’s delayed grief reaction. Also, in this assignment I will include the appropriate tools used in completing a mental health assessment I will also highlight the interventions used to help Gail.

Theoretical Perspectives to Loss and Grief

Feelings of loss and grief can be experienced after we lose someone or something, we care about like; the death of a loved one; loss of a relationship; loss of a pet; loss of a job; a change to your way of life; or loss of important possessions. This can make a person experience a wide range of emotions which can trigger a dip in their mental health. One of the worst life events that can occur is the loss of a child. According to (Asuman Buyukcan-Tetik, 2017) losing a child is a major stressor and it has severe effects on the physical and psychological wellbeing of the parents that are bereaving. It takes time to adjust and to learn to live our life without that person, thing or way of life. While grief is a universal and natural response loss, the process is unique to each person. A person who is grieving will experience a variety of distressing thoughts and emotions which can include anger, guilt, loneliness, sadness, relief even sometimes happiness as the griever comes to recognize the permanence and magnitude of the loss. (McCroby, 2018). According to (Videbeck, 2009) there are lots of different responses to grief which are; spiritual responses, cognitive responses, physiological responses, behavioural responses and emotions responses. It is clearly evident that Gail experiences these responses. For example, she worries about her two children and their safety, she is feels guilty for the death of he son which is an emotional response. Gail states that she feels “useless” to her family this shows the spiritual response. Gail presented herself to her G.P with “severe throbbing headaches, difficulty falling asleep, fitful and disturbing dreams when asleep, and poor appetite”, this highlights Gail’s physiological responses that she is presented with.

I have researched two theorists who in my opinion help to further understand the suffering and pain behind Gail’s loss. These are Kubler-Ross’s stages of grief and John Bowlby theory on Attachment.

Kubler-Ross’s Stages of Grief

Dr. Elisabeth Kubler-Ross developed a frequently used model of bereavement, in the “stages of grief” in her landmark book on Death and Dying in 1969. Kubler-Ross (1969) provided a foundation for an understanding that readily translated to the public (Harden, 2018). The model is described in a five-step linear process that consist of denial, anger, bargaining, depression and acceptance (Harvard Mental Health Letter, 2011). The five stages of grief are;

Stage 1- Denial: a person may be in a state of disbelief, shock, numb.
Stage 2- Anger: Frustrated outpouring of bottled up emotions. Irritation.
Stage 3- Bargaining: seeking in vain for a way out. Reaching out to others, telling one’s story.
Stage 4- depression: final realisation of the inevitable. Overwhelmed and helplessness.
Stage 5- Acceptance: finally finding the way forward. Exploring options, moving on.

Bowlby’s Theory on Attachment

John Bowlby was a psychoanalyst who researched the effects of separation between infants and their parents. The theory itself highlights the bond that is formed between a mother and their kid. From the vignette it is clear that Gail is attached to her son and that they had a strong bond with each other. This gives us the understanding of the grief that a mother would experience if they were to lose a child. Bowlby projected that grief and loss is incited through separation. During Bowlby’s work on attachment, he and his colleague Colin Murray Parkes noticed for stages of grief.

Shock and Numbness- person feels that loss in not real or that it is impossible to accept it.
Yearning and Searching- the person is very aware of the void in their life and may try and fill the void with something or someone else.
Despair and Disorganization- now accepts that things have changed and cannot go back to the way they were before.
Re-organization and Recovery- faith in life starts to come back, build new goals new patterns Ans new habits in life.

Nursing Assessment

For the nursing assessment to be holistic, Gail’s needs must be focused on. These needs include her biological, social and psychological aspects and including her spiritual and cultural needs. To obtain the important information that is required for the assessment the nurse will interview, talk and listen to the patient. The nurse will also use assessment tools to gather the relive information. A nurse’s toolbox is overflowing with various patient assessments, each of which is designed to help you in providing safe and evidenced based care. The tools that I have decided to use while assessing Gail are the Depression Anxiety Stress Scale (DASS) and the Birchwood Social Functioning scale. The DASS is a 42-itern test that aims to capture here dimensions of namely depression, negative emotional state, stress and anxiety (Andrew C, 2007). Another scale that would also be beneficial while assessing Gail is the Beck Depression Inventory, which is a system that measures characteristics attitudes and symptoms of depression. This system would be helpful because according to the vignette Gail is experiencing feelings of “sadness” and “guilt”.

The nurse will use the biopsychosocial approach to assess Gail. The biopsychosocial approach provides a background for the current assessment of symptoms and behaviours and includes a review of the patients current and past history. It stresses the importance a systemic, comprehensive perspective in functioning and human development and puts emphasis on a holistic integration of psychological, sociocultural and biological factors when attempting to understand human psychology (Lari Meyer, 2011). For example, Gail’s feelings (emotional response), changes to Gail’s body (physiological), her beliefs and values (spiritual response), her thoughts (cognitive responses) and how she behaves (behavioural responses). Its states in the vignette that Gail has no history of depression however the nurse would still conduct an enquiry regarding Gail’s background history. The nurse would also assess her safety in relation to suicide ideation, intent or plan to self-harm and death wish. The common assessment tool (CAT) is generally used in the Wexford Mental Health Service. This helps the nurse to obtain all the relevant information that is needed for example background information, information about the client, presentation, previous admissions, medical issues, early life, substance use, safety, and much more.

There are three components that are involved in the nursing assessment. These are: adequate perception regarding the loss, support while grieving for the loss and coping behaviours/techniques during the process.

Perception

The first step of the assessment conducted by the nurse is to evaluate Gail’s perceptive of her loss. This step is important as it highlights to the nurse how the patient is feeling, how they are affected by the loss and how they’re thinking. The nurse will ask the client questions in order to gain insight. To gain a clearer understanding on how the death of her son has changed Gail’s life the nurse would ask open ended questions like” how does this loss make you feel” or “do you feel the loss of your son has brought despair and negative thoughts upon you”. Gail could also use this opportunity to clarify with the nurse any concerns she may have. The nurse can help Gail to understand that each person has a unique grieving process. Another important assessment is to inquire into what the individual believes about the process of grieving (Videbeck S. , Mental Health Nursing , 2009)

Support

While grief is a natural process, many people benefit from the support and guidance of other people. It is highlighted in Gail’s vignette that she is married with two other children. These are the people who can help and support Gail through this tough time. They can help in meeting her spiritual and emotional needs. It is important that as a nurse we help Gail to identify these people as her support network and encourage Gail to accept their love and support at this time of need. According to (Videbeck S. L., 2009), assessment of support systems can provide the person grieving with the awareness of the people who are there for them to reach out to for security and love. By highlighting to Gail, the importance of have a support network, the nurse could advise Gail to reach out to her family and friends and ask for their support.

Coping Mechanisms

Coping mechanisms are the strategies people often use in the face of stress or trauma to help manage painful or difficult emotions. The nurse will assess the persons coping behaviours by the behaviours of the person. The use of effective communication is important and crucial in this step of the assessment in order to see how Gai’s behaviour reflects on her coping mechanisms. Asking Gail more comprehensive questions will allow the nurse to identify how the death of her son has impacted her life which will gain insight to Gail’s thoughts. Coping can be impacted by several factors and forces such as ones cultural/spiritual background, perception of death, past experiences with losses, level of social support and intrapersonal relationships.

Identify outcomes

When the assessment is completed, the nurse will set realistic goals for the individual. For example, the nurse will collaborate with Gail to set goals that are achievable. Examples of goals that would be determined for Gail are;

Avail of the support from family and friends.
To accept the loss of her son.
Practice coping mechanisms for when anxious or depressed.
To feel less guilty.
And lastly, to work with the interventions suggested to her.
Identify her own strengths and weaknesses.
Utilize effective coping mechanism.

According to (Alan B McGuire, 2015), an essential component of psychiatric rehabilitation is goal setting.

Tools for assessment

Two tools which I have chosen are the Sainsbury assessment tool and the Depression, Anxiety, Stress Scale (DASS) assessment tool. I believe these two tools will help aid in the assessment of Gail’s needs. Assessment tools are frequently used in psychiatry in an attempt to assess the patients mental state and in term should determine the management of the service user. (McPherson, 2005)

Sainsbury Assessment Tool

The Sainsbury risk assessment is an initial risk assessment tool for primary care mental health. It is an important part of a complete mental health assessment. According to (Stein, 2005) risk assessment must cover the risk of harm to others, risk of neglect and the risk of suicide. This assessment is included in the CAT initial screening assessment which I have already mentioned above.

DASS Assessment Tool

The DASS is a clinical assessment that measures the three related states of depression, anxiety and stress. It contains 21 questions. This assessment tool helps the nurse to develop a treatment plan and assess symptoms severity or treatment progress. I believe in my opinion that this tool is more focused in helping with Gail’s assessment as she shows signs of distress. It measures the negative emotional states of depression, stress and anxiety.

Intervention and Management of Grief and Loss

No parent is prepared for their child’s death. Parents are simply not supposed to outlive their children. The death of an older child or adolescents difficult because children at this age re beginning to reach their potential and become independent individuals. It is evident that Gail is experiencing the common grief reactions e.g intense shock, confusion, disbelief and denial. The grief experienced after losing a child has been described as the most difficult and deepest sorrow that parents and mother (Kateja Raitio, 2015). For Gail the death of her child has caused immense suffering upon her.

The normal grief process is a fluid process that most individuals can resolve without the intervention of healthcare professionals (Waller A, 2016). However, when grief is prolonged, and the grief-stricken individual is unable to reconcile the grief and adjust to life without their deceased loved one, psychotherapeutic interventions ore warrant (Wittouck C, 2011). With the guidance from the nurse Gail would be encouraged to make and identify changes which will benefit her with the grieving process. They will discuss different interventions that will aid Gail to manage the dis tress she is experiencing. Gail’s care plan will be based on the information gathered in the previous carried out assessment. The Multi-disciplinary team would discuss Gail’s case and recommend the most suitable interventions that she may use. They will discuss Gail’s short, medium- and long-term needs. A recovery plan will be developed for Gail and achievable goals will be discussed with Gail. Setting goals will help Gail in the recovery process.

Due to Gail’s anxiety, depression and her insomnia pharmaceutical drugs may be suitable for Gail. The use of drugs to treat Gail is very effective but other interventions should be taken into consideration too. Two interventions that I believe would be appropriate for Gail are Anxiety Management and Cognitive Behavioural Therapy.

Anxiety Management

Anxiety is a common feeling that everyone experiences at some stage. It can be a normal emotional response to many stressful situations. Anxiety is also a natural, understandable emotional response that can help us prepare for challenges. Anxiety Management is a detailed programme for stress related problems. It is offered to people who have difficulties with anxiety and want to learn more about how to manage it. It consists of six sessions which can be group or individual where clients learn about how their anxiety and how it can affect them. Anxiety is a normal reaction to stress which can be describe by different characteristics for example difficulty concentration, fatigue, restlessness, tremors, and sleep disturbances (Marcia Astres Fernandes, 2017). Gail can reduce her anxiety by learning how to cope with her stressors.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy is psychosocial intervention that aims to improve mental health. It focuses on challenging and changing unhelpful cognitive behaviours and distortions, developing personal coping strategies that focus on solving current problems and improving emotional regulations. CBT uses an evidence-based approach to aid clients to cognitively revaluate their interpretations neutralize their emotional and psychological responses to present stimuli through systematic desensitization process and awareness building (Amy H. Gaesser, 2017). CBT has been shown to be effective in treating anxiety, depression and a wide range of other disorders (Magnus Olason, 2018). It can take up to five to ten months to complete a course in CBT. Improving Gail’s emotional and cognitive behaviour will benefit her as it will allow Gail to become more involved in her treatment.

Conclusion

At some stage in our life we all experience death and grief, it is an inevitable part of life. Unfortunately for Gail she has experienced the tragic loss of a child which no parent should experience. The grief that Gail is experiencing is affecting all her human dimensions, her health and wellbeing and making her everyday life more difficult. Understanding the grieving process and the theories of loss can provide us with the knowledge to utilise frameworks in order to deliver the most appropriate care which is specific to Gail’s case. Throughout this assignment I have mentioned theoretical perspectives regarding the grieving process and the most suitable interventions and management for Gail. It is very important for Gail to utilize the discussed interventions for her to participate in the road to recovery. As psychiatric nursing students, our role is to guide people in similar situations who are going through difficult and emotional periods in their life, to manage their individual grief and support them with any difficulties they may face during the way, which will improve their quality of life.

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