The Prevalence of Unresolved Grief Among Bereaved Parents Implications for Counselling
Chapter One
Objectives of study
- To explore the prevalence of unresolved grief among bereaved parents towards the loss of a child.
- To determine the attitude and practice of health care providers towards the loss of a child.
- To ascertain the relationship between parents’ practice as regards autopsies and their sociodemographic characteristics i.e.: age, ethnicity, level of education, and religion.
CHAPTER TWO
LITERATURE REVIEW
Grief and Loss
Bereavement is ubiquitous in our existence. Nearly every human being at some point in his or her life will encounter the death of a significant other. It is assumed that most people will react with intense distress when they experience the loss of someone close to them. Therefore, the grief response is considered to be a normal and natural reaction to the loss of a loved one, a reaction that subsides over the passage of time (Stroebe, Hanson, Schut & Stroebe, 2008). Individuals are expected to adjust to the death of their loved one and return to a normal state of functioning.
The field of grief and bereavement has undergone a major transformation in terms of how the human experience of loss is understood. Long-held beliefs about the grief experience have been discarded, with research evidence failing to support early stage-based models, which construed grief as a predictable emotional trajectory.
Modern theorists suggest grief is no longer conceptualised as a rigid or linear process leading from distress to ‘recovery’ (Hall, 2014). In addition, ‘successful’ grieving is no longer presumed to require a severance of attachment bonds. Instead, a gradual shift is occurring towards the potential healthy role of maintaining continued bonds with the deceased (Field, 2006; Klass, Silverman, & Nickman, 1996).
Historical Perspectives of Grief
In order to understand current conceptualisations of grief and grief theory, it is necessary to provide a historical overview. The first major theoretical contribution which shaped professional intervention for nearly half a century, was provided by Freud in his book Mourning and Melancholia (1917/1957). Freud suggested that grief is a process to be worked through, whereby the bereaved must detach emotionally from the deceased and redirect this energy into other avenues of their lives. This psychic rearrangement involved three elements: (1) freeing the bereaved from bondage to the deceased; (2) readjustment to new life circumstances without the deceased; and (3) building of new relationships. Freud believed that this separation required the energetic process of acknowledging and expressing painful emotions such as guilt and anger. The view was held that if the bereaved failed to engage with or complete their grief work, the grief process would become complicated and increase the risk of mental and physical illness and compromise recovery. Consequently, Freud’s work has been referred to by subsequent theorists to justify the concept of ‘pathological mourning’ (i.e. Archer, 1999; Stroebe, Hansson, Stoebe, & Schut, 2001).
In Mourning and Melancholia, Freud professed that ‘mourning’ and ‘melancholia’ are two distinct entities, because they are context-specific. He defined grief as a result of being bereaved as ‘mourning’, and grief as a result of other losses as ‘melancholia’ (Freud, 1917/1957). He asserted:
“In mourning we found that the inhibition and loss of interest are fully accounted for by the work of mourning in which the ego is absorbed. In melancholia, the unknown loss will result in a similar internal work and will therefore, be responsible for the melancholic inhibition. The difference is that the inhibition of the melancholic seems puzzling to us because we cannot see what it is that is absorbing him so entirely.” (p. 254).
Hence, Freud construed mourning as a normal but time-consuming response to bereavement, whereas melancholia had the potential to become pathological because it was a reaction that occurred outside of any explicable context (Granek, 2010). Another theorist, Abraham (1927) conceded with Freud, professing mourning and melancholia as two distinct conditions. However, whilst Freud focused on the redirection of cathartic energy following bereavement, Abraham (1927) focused on the integration of the deceased into oneself in order to heal from the loss. Abraham (1927) stated: “The process of mourning now brings with it the consolation: ‘My loved one is not gone, for now, I carry it within myself and can never lose it” (p. 437).
Whilst Freud (1917/1957) and Abraham (1927) both conceptualised grief as a process to be worked through that never reaches completion, Deutsch (1937) proposed a different theory. In her essay, The Absence of Grief, Deutsch (1937) wrote that:
“The process of mourning as a reaction to the real loss of a loved person must be carried to completion. As long as the early libidinal or aggressive attachments persist, the painful affect continues to flourish, or vice versa, the attachments are unresolved as long as the affective process of mourning has not been accomplished.” (p. 21).
Deutsch’s main assertion was that in order to become resolved, grief must be brought into consciousness because otherwise it will manifest in other ways (1937). This unmanifested energy, which she labelled ‘absent’ or ‘repressed’ grief, could result in the bereaved becoming psychologically unbalanced if they did not do their ‘grief work’(1937). This interpretation remains crucial to contemporary psychological research on the notion of grief, as it suggests that unmanifested grief can be just as pathological as chronic grief (Granek, 2010).
While Freud (1856-1939) is generally conceived to be the first theorist to introduce the concept of grief into the realm of psychology, there were a few researchers who came before him. Burton (1577-1640) was the first theorist to define the concept of grief in psychological terms, when he wrote about bereavement in his book The Anatomy of Melancholy, published after his death in 1651 (Archer, 1999). Burton understood grief as a form of ‘transitory melancholy’ that each individual must experience at some point in his or her lives in response to a melancholic event (such as loss and bereavement). However, he also emphasised the distinction between melancholy as a normal reaction to loss and melancholy as a disease whereby an individual is habitually melancholic in character (Burton, 1938). This notion of grief as a disease was evident in later publications on grief, such as the works of Benjamin Rush (1745-1813), who wrote about grief in his book The Diseases of the Mind (Rush, 1812). Rush described an array of emotional and physiological symptoms characteristic of grieving people such as fever, sighing, loss of memory, aphasia, and even the development of grey hair (Rush, 1812). Accordingly, Rush professed a number of interesting treatments thought to cure grief, including the use of opiates, crying, and in severe cases, bloodletting and purging (Rush, 1812).
Darwin (1809-1882) has also been acknowledged for his important contributions to grief theory. In his book, The Expression of Emotions in Man and Animals, Darwin described in detail the expressions of depression and grief in people as well as apes (Darwin & Ekman, 1998). Darwin also differentiated between an active, anxious form of grief, and a passive, more depressive form, which he claimed had different aetiologies (Darwin & Ekman, 1998). This propelled further work on the expressions and manifestations of grief, and Shand (1858-1936) is credited as the first researcher to conduct a comprehensive study of the psychology of grief. In his book, The Foundations of Character, Shand defined four types of grief reactions: active and aggressive; depressive and lethargic; suppressed; and hysterical and frantic (1920).
Shand (1920) also discussed other influences on grief, including the need for social support, the trauma associated with sudden death, and relationship bonds with the deceased.
CHAPTER THREE
RESEARCH METHODOLOGY
Study Design
This was a cross-sectional descriptive study utilizing qualitative and quantitative methods of data collection.
Study Population
The study population included parents of children who had died aged 0-60 months and health care providers working at the NNH paediatric wards and newborn unit.
Study Period
The study was carried out in the year 2020 (July – December).
CHAPTER FOUR
DATA ANALYSIS
A total of 190 respondents were enrolled in the study, 95 bereaved parents and 95 health care providers.
Bereaved Parent’s knowledge, attitude and practice
CHAPTER FIVE
CONCLUSION AND RECOMMENDATION
CONCLUSIONS
Bereaved parents had adequate knowledge as regards autopsy (79% of those recruited) with a positive attitude being significantly associated with the level of education. Majority (67.4%) of parents were not asked to consent to an autopsy on their deceased child. Of those asked to consent majority declined mainly due to religious beliefs while those who agreed did so to confirm cause of death. Parents with a higher understanding of autopsy were more likely to consent.
Health care providers had a positive attitude to autopsy which was significantly associated with their cadre and years of experience. Consultants and paeadiatric residents had a more positive attitude compared to interns and nurses. Clinical experience also showed a significant influence on attitude towards death. The main reasons given for not obtaining consent for autopsy were lack of formal training in obtaining consent and the failure to obtain autopsy results in timely manner.
RECOMMENDATIONS
Bereaved parents need to be counseled on the need for autopsy on their deceased child as well as counseling around potential barriers to consent including religious beliefs.
Health care providers should be trained on how to counsel parents after death of their child as well as on how to request for an autopsy. Their participation in autopsies should also be encouraged.
Further qualitative and quantitative research, with a larger number of participants, should be performed to further describe bereaved parents and health care providers’, attitude and practice towards death in our setting.
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