NCM 116 – Care of Clients with Maladaptive SEM 02
Patterns of Behavior, Acute and Chronic FINALS
Lecturer: Dr. Cefer S. Sales, RN, MD, MHM, CHA
UNIT 3 – CHAPTER 10: GRIEF AND LOSS
INTRODUCTION
• Loss allows a person to change, develop, and fulfill
innate human potential. It may be planned, expected,
or sudden.
• Grief refers to the subjective emotions and normal
response to the experience of loss.
• Grieving, also known as bereavement, refers to the
process by which a person experiences grief.
o Anticipatory grieving is when people facing an
imminent loss begin to grapple with the possibility
of loss or death in the near future.
o Mourning is the outward expression of grief.
TYPES OF LOSSES
KÜBLER-ROSS’S STAGES OF GRIEVING
• One framework to examine different types of losses is
Abraham Maslow’s hierarchy of needs as it motivates • Elisabeth Kübler-Ross (1969) established a basis for
human actions. However, when these human needs understanding how loss affects human life. As she
are taken away or not met for some reason, a person attended to clients with terminal illnesses, a process
experiences loss. of dying became apparent to her.
o Physiologic loss. Examples include amputation • This model became a prototype for care providers as
of the limb, a mastectomy or hysterectomy, or loss they looked for ways to understand and assist their
of mobility. clients in the grieving process.
o Safety loss. Loss of a safe environment is evident • Kübler-Ross developed a model of five stages to
in domestic violence, child abuse, or public explain what people experience as they grieve and
violence. mourn:
o Loss of security and a sense of belonging. The o Denial is shock and disbelief regarding the loss.
loss of a loved one affects the need to love and the o Anger may be expressed toward God, relatives,
feeling of being loved. Loss accompanies changes friends, or healthcare providers.
in relationships, such as birth, marriage, divorce, o Bargaining occurs when the person asks God or
illness, and death; as the meaning of a relationship fate for more time to delay the inevitable loss.
changes, a person may lose roles within a family o Depression results when awareness of loss
or group. becomes acute.
o Loss of self-esteem. Any change in how a person o Acceptance occurs when the person shows
is valued at work, in a relationship, or by him or her evidence of coming to terms with death.
can threaten self-esteem. Death of a loved one, a
broken relationship, loss of a job, and retirement BOWLBY’S PHASES OF GRIEVING
are examples of change that represent loss and • John Bowlby, a British psychoanalyst, proposed a
can result in a threat to self-esteem. theory that humans instinctively attain and retain
o Loss related to self-actualization. An external or affectional bonds with significant others through
internal crisis that blocks or inhibits striving toward attachment behaviors.
fulfillment may threaten personal goals and • An attachment that is maintained is a source of
individual potential. A person who wanted to go to security; an attachment that is renewed is a source of
college, write books, and teach at a university joy. When a bond is threatened or broken, however,
reaches a point in life when it becomes evident the person responds with anxiety, protest, and anger.
that those plans will never materialize or a person • Bowlby described the grieving process as having four
loses hope that he or she will find a mate and have phases:
children. o Experiencing numbness and denying the loss
o Emotionally yearning for the lost loved one and
THE GRIEVING PROCESS protesting the permanence of the loss
• Regardless of the type of loss, nurses must have a o Experiencing cognitive disorganization and
basic understanding of what is involved to meet the emotional despair with difficulty functioning in the
challenge that grief brings to clients. everyday world
• The therapeutic relationship and therapeutic o Reorganizing and reintegrating the sense of self to
communication skills, such as active listening, are pull life back together
paramount when assisting grieving clients.
• Recognizing the verbal and nonverbal communication ENGEL’S STAGES OF GRIEVING
content of the various stages of grieving can help • George Engel (1964) described five stages of grieving
nurses select interventions that meet the client’s as follows:
psychological and physical needs. o Shock and Disbelief. The initial reaction to a loss
is a stunned, numb feeling accompanied by a
THEORIES OF GRIEVING refusal to acknowledge the reality of the loss in an
, o Developing awareness. As the individual begins • Worden (2008) views the tasks of grieving as:
to acknowledge the loss, there may be crying, o Accepting the reality of the loss. It is common
feelings of helplessness, frustration, despair, and for people initially to deny that the loss has
anger that can be directed at self or others, occurred. Over time, the person wavers between
including God or the deceased person. belief and denial in grappling with this
o Restitution. Participation in the rituals associated task. Traditional rituals, such as funerals and
with death, such as a funeral, wake, family wakes, are helpful to some individuals.
gathering, or religious ceremonies helps the o Working through the pain of grief. A loss
individual accept the reality of the loss and begin causes pain, both physical and emotional, that
the recovery process. must be acknowledged and dealt with. Attempting
o Resolution of the loss. The individual is to avoid or suppress the pain may delay or
preoccupied with the loss, the lost person or object prolong the grieving process.
is idealized, and the mourner may even imitate the o Adjusting to an environment that has
lost person. Eventually, the preoccupation changed because of the loss. It may take
decreases, usually in a year or perhaps more. months for the person to realize what life will be
o Recovery. The previous preoccupation and like after the loss. The individual must develop
obsession end and the individual are able to go on new coping skills, adapt to the new or changed
with life in a way that encompasses the loss. environment, find meaning in the new life, and
regain some control over life to continue to grow.
HOROWITZ’S STAGES OF o Emotionally relocating that which has been
LOSS AND ADAPTATION lost and moving on with life: The bereaved
• Mardi Horowitz (2001) divides normal grief into four person identifies a special place for what was lost
stages of loss and adaptation: and the memories. The lost person or relationship
o Outcry. The first realization of the loss. This may is not forgotten or diminished in importance but
be expressed by screaming, yelling, crying, or rather is relocated in the mourner’s life as the
collapsing. Outcry feeling can also be suppressed person goes on to form new relationships,
as the person appears stoic, trying to maintain friends, and life rituals, and moves ahead with
emotional control. daily life.
o Denial and Intrusion. People move back and
forth during this stage between denial and DIMENSIONS OF GRIEVING
intrusion. During denial, the person becomes so People have many and varied responses to loss.
distracted or involved in activities that he or she Therefore, nurses must use a holistic model of
sometimes isn’t thinking about the loss. At other grieving that encompasses cognitive, emotional, spiritual,
times, the loss and all it represents intrude into behavioral, and physiologic dimensions.
every moment and activity and feelings are quite
SYMPTOMS OF A GRIEVING CLIENT
intense again.
o Working through. As time passes, the person Cognitive • Disruption of assumptions and
spends less time bouncing back and forth between Responses beliefs
denial and intrusion, and the emotions are not as • Questioning and trying to make
intense and overwhelming. The person still thinks sense of the loss
about the loss but also begins to find new ways of • Attempting to keep the lost one
managing life after the loss. present
o Completion. Life begins to feel “normal” again, • Believing in an afterlife and as
though life is different after the loss. Memories are though the lost one is a guide
less painful and do not regularly interfere with day- Emotional • Anger, sadness, anxiety
to-day life. Episodes of intense feelings may Responses • Resentment
occur, especially around anniversary dates but are • Guilt
transient in nature. • Feeling numb
• Vacilitating emotion
TASKS OF GRIEVING • Profound sorrow, loneliness
• Grieving tasks, or mourning, that the bereaved • Intense desire to restore bond with
person faces involve active rather than passive lost one or object
participation. It is sometimes called “grief work” • Depression, apathy, despair during
because it is difficult and requires tremendous effort phase of disorganization
and energy to accomplish. • Sense of independence and
• Rando (1984) describes tasks inherent to grieving confidence as a phase of
that she calls the “six Rs:” reorganization evolves
o Recognize. Experiencing the loss, Spiritual • Disillusioned and angry with God
understanding that it is real and that it has Responses • Anguish of abandonment or
happened. perceived abandonment
o React. Emotional response to loss, feeling the • Hopelessness, meaningless
feelings.
Behavioral • Functioning “automatically”
o Recollect and Reexperience. Memories are
Responses • Tearful sobbing, uncontrollable
reviewed and relived.
o Relinquish. Accepting that the world has crying
changed (as a result of the loss) and that there is • Great restlessness, searching
no turning back. behaviors
o Readjust. Beginning to return to daily life; loss • Irritability and hostility
feels less acute and overwhelming. • Seeking and avoiding places and
activities shared with lost one
Patterns of Behavior, Acute and Chronic FINALS
Lecturer: Dr. Cefer S. Sales, RN, MD, MHM, CHA
UNIT 3 – CHAPTER 10: GRIEF AND LOSS
INTRODUCTION
• Loss allows a person to change, develop, and fulfill
innate human potential. It may be planned, expected,
or sudden.
• Grief refers to the subjective emotions and normal
response to the experience of loss.
• Grieving, also known as bereavement, refers to the
process by which a person experiences grief.
o Anticipatory grieving is when people facing an
imminent loss begin to grapple with the possibility
of loss or death in the near future.
o Mourning is the outward expression of grief.
TYPES OF LOSSES
KÜBLER-ROSS’S STAGES OF GRIEVING
• One framework to examine different types of losses is
Abraham Maslow’s hierarchy of needs as it motivates • Elisabeth Kübler-Ross (1969) established a basis for
human actions. However, when these human needs understanding how loss affects human life. As she
are taken away or not met for some reason, a person attended to clients with terminal illnesses, a process
experiences loss. of dying became apparent to her.
o Physiologic loss. Examples include amputation • This model became a prototype for care providers as
of the limb, a mastectomy or hysterectomy, or loss they looked for ways to understand and assist their
of mobility. clients in the grieving process.
o Safety loss. Loss of a safe environment is evident • Kübler-Ross developed a model of five stages to
in domestic violence, child abuse, or public explain what people experience as they grieve and
violence. mourn:
o Loss of security and a sense of belonging. The o Denial is shock and disbelief regarding the loss.
loss of a loved one affects the need to love and the o Anger may be expressed toward God, relatives,
feeling of being loved. Loss accompanies changes friends, or healthcare providers.
in relationships, such as birth, marriage, divorce, o Bargaining occurs when the person asks God or
illness, and death; as the meaning of a relationship fate for more time to delay the inevitable loss.
changes, a person may lose roles within a family o Depression results when awareness of loss
or group. becomes acute.
o Loss of self-esteem. Any change in how a person o Acceptance occurs when the person shows
is valued at work, in a relationship, or by him or her evidence of coming to terms with death.
can threaten self-esteem. Death of a loved one, a
broken relationship, loss of a job, and retirement BOWLBY’S PHASES OF GRIEVING
are examples of change that represent loss and • John Bowlby, a British psychoanalyst, proposed a
can result in a threat to self-esteem. theory that humans instinctively attain and retain
o Loss related to self-actualization. An external or affectional bonds with significant others through
internal crisis that blocks or inhibits striving toward attachment behaviors.
fulfillment may threaten personal goals and • An attachment that is maintained is a source of
individual potential. A person who wanted to go to security; an attachment that is renewed is a source of
college, write books, and teach at a university joy. When a bond is threatened or broken, however,
reaches a point in life when it becomes evident the person responds with anxiety, protest, and anger.
that those plans will never materialize or a person • Bowlby described the grieving process as having four
loses hope that he or she will find a mate and have phases:
children. o Experiencing numbness and denying the loss
o Emotionally yearning for the lost loved one and
THE GRIEVING PROCESS protesting the permanence of the loss
• Regardless of the type of loss, nurses must have a o Experiencing cognitive disorganization and
basic understanding of what is involved to meet the emotional despair with difficulty functioning in the
challenge that grief brings to clients. everyday world
• The therapeutic relationship and therapeutic o Reorganizing and reintegrating the sense of self to
communication skills, such as active listening, are pull life back together
paramount when assisting grieving clients.
• Recognizing the verbal and nonverbal communication ENGEL’S STAGES OF GRIEVING
content of the various stages of grieving can help • George Engel (1964) described five stages of grieving
nurses select interventions that meet the client’s as follows:
psychological and physical needs. o Shock and Disbelief. The initial reaction to a loss
is a stunned, numb feeling accompanied by a
THEORIES OF GRIEVING refusal to acknowledge the reality of the loss in an
, o Developing awareness. As the individual begins • Worden (2008) views the tasks of grieving as:
to acknowledge the loss, there may be crying, o Accepting the reality of the loss. It is common
feelings of helplessness, frustration, despair, and for people initially to deny that the loss has
anger that can be directed at self or others, occurred. Over time, the person wavers between
including God or the deceased person. belief and denial in grappling with this
o Restitution. Participation in the rituals associated task. Traditional rituals, such as funerals and
with death, such as a funeral, wake, family wakes, are helpful to some individuals.
gathering, or religious ceremonies helps the o Working through the pain of grief. A loss
individual accept the reality of the loss and begin causes pain, both physical and emotional, that
the recovery process. must be acknowledged and dealt with. Attempting
o Resolution of the loss. The individual is to avoid or suppress the pain may delay or
preoccupied with the loss, the lost person or object prolong the grieving process.
is idealized, and the mourner may even imitate the o Adjusting to an environment that has
lost person. Eventually, the preoccupation changed because of the loss. It may take
decreases, usually in a year or perhaps more. months for the person to realize what life will be
o Recovery. The previous preoccupation and like after the loss. The individual must develop
obsession end and the individual are able to go on new coping skills, adapt to the new or changed
with life in a way that encompasses the loss. environment, find meaning in the new life, and
regain some control over life to continue to grow.
HOROWITZ’S STAGES OF o Emotionally relocating that which has been
LOSS AND ADAPTATION lost and moving on with life: The bereaved
• Mardi Horowitz (2001) divides normal grief into four person identifies a special place for what was lost
stages of loss and adaptation: and the memories. The lost person or relationship
o Outcry. The first realization of the loss. This may is not forgotten or diminished in importance but
be expressed by screaming, yelling, crying, or rather is relocated in the mourner’s life as the
collapsing. Outcry feeling can also be suppressed person goes on to form new relationships,
as the person appears stoic, trying to maintain friends, and life rituals, and moves ahead with
emotional control. daily life.
o Denial and Intrusion. People move back and
forth during this stage between denial and DIMENSIONS OF GRIEVING
intrusion. During denial, the person becomes so People have many and varied responses to loss.
distracted or involved in activities that he or she Therefore, nurses must use a holistic model of
sometimes isn’t thinking about the loss. At other grieving that encompasses cognitive, emotional, spiritual,
times, the loss and all it represents intrude into behavioral, and physiologic dimensions.
every moment and activity and feelings are quite
SYMPTOMS OF A GRIEVING CLIENT
intense again.
o Working through. As time passes, the person Cognitive • Disruption of assumptions and
spends less time bouncing back and forth between Responses beliefs
denial and intrusion, and the emotions are not as • Questioning and trying to make
intense and overwhelming. The person still thinks sense of the loss
about the loss but also begins to find new ways of • Attempting to keep the lost one
managing life after the loss. present
o Completion. Life begins to feel “normal” again, • Believing in an afterlife and as
though life is different after the loss. Memories are though the lost one is a guide
less painful and do not regularly interfere with day- Emotional • Anger, sadness, anxiety
to-day life. Episodes of intense feelings may Responses • Resentment
occur, especially around anniversary dates but are • Guilt
transient in nature. • Feeling numb
• Vacilitating emotion
TASKS OF GRIEVING • Profound sorrow, loneliness
• Grieving tasks, or mourning, that the bereaved • Intense desire to restore bond with
person faces involve active rather than passive lost one or object
participation. It is sometimes called “grief work” • Depression, apathy, despair during
because it is difficult and requires tremendous effort phase of disorganization
and energy to accomplish. • Sense of independence and
• Rando (1984) describes tasks inherent to grieving confidence as a phase of
that she calls the “six Rs:” reorganization evolves
o Recognize. Experiencing the loss, Spiritual • Disillusioned and angry with God
understanding that it is real and that it has Responses • Anguish of abandonment or
happened. perceived abandonment
o React. Emotional response to loss, feeling the • Hopelessness, meaningless
feelings.
Behavioral • Functioning “automatically”
o Recollect and Reexperience. Memories are
Responses • Tearful sobbing, uncontrollable
reviewed and relived.
o Relinquish. Accepting that the world has crying
changed (as a result of the loss) and that there is • Great restlessness, searching
no turning back. behaviors
o Readjust. Beginning to return to daily life; loss • Irritability and hostility
feels less acute and overwhelming. • Seeking and avoiding places and
activities shared with lost one
