Part of the “Enhancing Prostate Cancer Care” MOOC

Catherine HolbornSenior Lecturer in Radiotherapy & Oncology

Sheffield Hallam University

IntroductionPeople living with and supporting people with prostate

cancer may experience many different emotions throughout their journey and react in a way that is different from how they would usually.

This presentation highlights some of the theories surrounding loss and bereavement, but always remember that everyone's grief is individual.

Grief - not a new phenomenon'Well everyone can masters grief, but he that has it'

Much Ado about NothingShakespeare (1564 -1616)

Walter (1999) On Bereavement: The Culture of Grief

Grief is like sex. It can be done on your own, it is best done with other people and is disapproved of if done in public’.

Talking about dying is not an easy subject. If you are facilitating another person's grief you have to be able to hear and acknowledge what they are saying.

Bowlby's Theory of AttachmentBowlby a psychiatrist Important to understand this theory before

comprehending the impact of loss and bereavement on individuals (Worden, 2009)

Theory developed nearly 40 years ago but still relevant (Harris, 2009)

Theory of Attachment (1980)Originally concerned the attachment between a mother

and child

Theory - Parkes (2006)When a child is separated for more than a few minutes

from their mother the following reactions occurProtest - may be exhibited by crying

DespairFeelings of hopelessness

Detachment May seem as though the child has recovered, but he/she

has withdrawn from surroundingsNot playing with other childrenNot seeking attention

Relevance to loss and griefThere is no loss without an attachment.Sometimes a person may not know how much they were

attached to e.g. a part of the body, fertility, sexual activity or person until it has been taken away.

The theory can be applied to experiences in adult life. For example, an adult may avoid or deny the reality of the situation (Walsh, 2012).

Facilitating Loss and BereavementBefore being able to explore the loss experience of a carer

prior to the death of a loved one or the person's own death, consider the following about your own mortality.

Also, it is useful to know about the different reactions people may experience in relation to their loss or bereavement.

Sometimes people may feel they are 'going mad' so understanding that these are 'normal' grief reactions can be helpful.

Worden (2009) uses 4 different categories to explore these reactions. A person may experience some of the following...

Individual reactions to loss and bereavement (Woodhouse, 2011, Worden, 2009)

FeelingsANXIOUS, ANGRY, BITTER, DEVASTATED, RESENTFUL, EMPTY,

INFERIOR, GUILTY, REMORSE, HAPPY, HIGHTENED SEXUALITY, ABANDONED, RELIEVED, EMOTIONAL MOOD SWINGS, EXAUSTED, USELESS, FRUSTRATION, HELPLESS, LOST IDENTITY, MISUNDERSTOOD

CognitionsQUESTIONING, CHAOTIC THINKING, INABILITY TO COPE WITH

DECISION MAKING, LOSS OF USUAL ABILITIES, FEAR, ISOLATION, MEMMORY LOSS, IRRATIONALITY, LOSS OF FOCUS, CONSCIENCE

 

Cont...Behaviours

CRYING/WAILING/SHOUTING,WITHDRAWAL,ANGER/VIOLENCE, REGRET, EUPHORIA, RELIEF, BEING PRACTICAL,BECOME HYPERACTIVE/LETHARGIC, SEARCHING

Physical SensationsAPPETITE CHANGES, DIGESTIVE DISORDERS,

SLEEP DISTURBANCE, EXAUSTION, NUMBNESS, BREATHLESSNESS, HEADACHE, CHEST CONSTRICTION, MORE PRONE TO INFECTION, MIRROR SYMPTOMS OF PERSON WHO HAS DIED, LETHARGY, CRYING, PAIN, HAIR LOSS; CHILDREN – REGRESSIVE BEHAVIOUR e.g. SOILING, ENURESIS

Facilitating GriefHow may we respond to people who are experiencing a

loss or bereavement?

The next slides give some models that can be utilise to aid this process

Worden's Tasks of Mourning (2009)Task I: To accept the reality of the lossThis can be very difficult to achieveGive the person shortly to be bereaved the opportunity to be with

the person who is dying. If possible, inform the person that death is approaching

Have a chair near the bed so that they can sit with the person who is dying or has just died

Give them the opportunity to hold the person e.g. their hand, kiss the person who has died, hold them in their arms

Stay as long as they wish or is practicableGive them the opportunity to see the person who has died between

death and the funeralUse the terms e.g. 'has died', rather than euphemisms for death e.g.

passed awayTalk about the person who has died in the past tense

Task II: To process the pain of griefGive the newly bereaved person the opportunity to express

how they are feeling if they wish toTo do the above, you need to be able to hear and

acknowledge what the person is saying by using communication skills e.g. empathy

Give them the opportunity to cry, show anger, shout etc... if they wish to

Facilitate them to talk about the death, the funeral, what its like now for them

A tissue sometimes gives permission to cryAlthough painful talking about what arrangements need to be

made can help facilitate this task

Task III: To adjust to a world without the deceased

This is a more practical task although new activities can be difficult. Enable the bereaved person to make their own decisions and do what is right for them

Make new friendsLearn a skill that the person has never done beforeTake on activities that the deceased person has

previously done e.g. financial issues, cooking a mealChoose to go on holiday to a new placeAllow self to laugh or have a good time without feeling

guilty

Task IV: To find an enduring connection with the deceased in the midst of embarking on a new lifeVisit the cemetery as part of other activitiesBe able to include mentioning the deceased person in

conversationsShare experiences of the deceased person with new

acquaintancesAllow time to think about the deceased personDevelop new activities

The Dual Process Model of Coping with Loss (Stroebe and Schut, 2008)

As a result of their research, these authors found that people oscillated between the emotional aspect of grief and a more restorative approach

Therefore they recommend that the bereaved can be supported in doing just this

Wilson (2014) acknowledges that this is a useful model for practitioners

The Dual Process model of coping with loss Stroebe and Schut (2008) cont... Loss OrientedGrief workIntrusion of griefBreaking bonds/tiesDenial/avoidance of

restoration changes

Restoration orientedAttending to life changesDoing new thingsDistraction from griefDenial/avoidance of griefNew roleNew identities or

relationships

Biography of Grief, Walter 1996Walter challenges the dominant contemporary model of

grief, which he believes to be the working through of emotion, with the eventual goal of being able to move on and live without the deceased.

By analysing his own experience of loss, and drawing from recent related research, he suggests an alternative, more sociological model.

Survivors typically want to talk about the deceased, particularly to those who knew the person. Together they are then able to construct a story which places the dead person within their lives, and is, thus, able to endure through time.

How may this be facilitated?By talking about the person who has died, or if a loss,

what it means to the personLooking at photographs of the deceasedSharing happy and sad times Responding to the bereaved when they broach the

subject of the person who has died, rather than changing the subject.

And finallyWe have only just touched on the complex aspects of

loss and bereavement. If you want to learn more about this important, but often neglected area, or other aspects of supportive and palliative care; please contact me at;

b.a.beard@shu.ac.uk for more details about a MSc modules in this area

References HARRIS T (2009) John Bowlby revisited - a retrospective review Bereavement Care 28(1) MACHIN L (2006) The landscape of loss Bereavement Care 25(1): 7-11 STROEBE MARGARET, SCHUT, HENK (2008) The dual process model of coping with

bereavement: overview and update Grief Matters 11(1): 4-10. STROEBE M, STROEBE W, SCHUT H (2003) Does ‘grief work’ work? Bereavement Care

22(1): 3- 5 STROEBE M, SCHUT H (1999) The dual process model of coping with bereavement:

rationale and description Death Studies 23:197-224 STROEBE M, SCHUT H (1998) Culture and grief Bereavement Care 17(1): 7- 11 TONKIN L (1996) Growing around grief – another way of looking at grief and recovery

Bereavement Care 1591): 10 WALTER T (1996) A new model of grief: bereavement and biography Mortality 1(1): 7-

24 WALSH Katherine (2012) Grief and Loss - Theories and skills for the helping professions,

London, Pearson WILSON, John (2014) Supporting people through loss and grief - an introduction for

counsellors and other caring practitioners. London, Jessica Kingsley WOODHOUSE, Jan (2011) Loss, grief and bereavement in (Eds) Moyra Baldwin and Jan

Woodhouse, Key Concepts in Palliative Care, London, Sage Worden W (2009) Grief Counseling and Grief Therapy: a handbook for the mental health

practitioner 4th Ed. Hove, Brunner-Routledge