GRIEF, MOURNING & BEREAVMENT like sleep problems, decreased concentration,

Dr. Victor A. Amantillo Jr. decreased level of activity

July 24, 2013 -Acceptance – the affect is one of peace (Amantillo)
Group 1 – N1nja StONEs - no emotions involved (Kubler-Ross)

DEATH and DYING Continuation… Definitions:

 Grief – subjective feeling precipitated by the
Factors in Adaptation death of a Loved one
 Socio-cultural - Loved one usually refers to a person
- Societal attitudes about death although grief can also come about
- Socioeconomic resources with a loss of pets or some
- Social support inanimate objects
 Personal - Normal grief definitely has an end
-personality, strength of coping, level of  Mourning – process by which grief is resolved
maturity  Bereavement – refers to being in a state of
-psychiatric history mourning
-spiritual, religious, philosophical views about - Necessary part of life
death and the meaning of life
-prior experiences with illness and death Normality of Bereavment
 Medical - Bereavement is normal. In fact bereavement is
-diagnosis necessary in other for you to live a life that is
-nature of symptoms complete.
-skills and knowledge of care givers  Uncomplicated bereavement is a NORMAL
-place where care is given response
- It is a very difficult process but most of the
Essential Features in the Care time the process is normal no matter how
 Competence bizarre one’s experience might be
 Concern  Symptoms and course are
 Comfort PREDICTABLE(timetable)
 Cheerfulness  There is WIDE VARIABILITY in the normal
mourning process, depending on the nature of
 Consistency and perseverance
the relationship with the deceased and the
 Cohesion and integration of family
circumstances of the loss
 Children
-its absence in a time of loss may be problematic
 Communication
Grief and bereavement is inevitable. No matter how you
protect yourself from it. You will still undergo it
How to tell the bad news
*it is unusual or abnormal not to grieve at all
 It should be rehearsed and calmly delivered
 Brief but to the point Functions of Bereavement
 Designed to encourage further dialogue  The function of grief is to FREE the person from
 Reassuring of continued care and attention some of ties with the lost loved one
- When a person dies, our ties with that
Grief, mourning and bereavement refer to psychological person even strengthen but unlike to a live
reactions of someone who has undergone or is person, relating to a dead is complicated
undergoing a loss of a loved one. because we cannot negotiate with the dead.
- The process of grieving allows you to free
-it is a process people undergo to deal with the death of yourself from that tie
a loved one  The person will then be free to begin new
-normal process, consider the timing activities and start new relationships
 Grief is INEVITABLE, painful yet necessary
Depression vs Acceptance -freedom from such ties can only be achieved by
-Depression – feeling of sadness & anhedonia + other sx undergoing the process
Phases of Bereavement
– comes in order but may blend each other; people can
revert back to earlier phase;some gray areas still
need to be clarified
1. Phase of Protest
2. Phase of Disorganization
3. Phase of Reorganization
I. Phase of Protest
- Parallels to phase of denial and anger
(Kubler-Ross)
- Comes about initially, at the start when the
diagnosis is known
-it is a period of intense emotion but is actually
protecting the psyche threats to its integrity that it may
not be able to cope with
…why is the phase of DENIAL necessary?
- Denial is a defense mechanism (unconscious)
where the person really believes that the
information is NOT entirely true;
- Different from lying
- The mind allows you not to recognize it for a
certain period of time to preserve the emotional
integrity;
- You cannot believe it because believing it at this
time would be devastating; unconscious process
protects you from breaking down
- Allows you to buy time
 Disbelief and numbness – massive defense
against acknowledgement of loss
 Frantic attempts to maintain relationship
with the departed loved one, or recover it
-e.g. attempts to awaken the deceased loved
one by shaking the body, loud cries, etc.
 Strong attempts to bring person back to
life (eg. Shaking the body – magical thinking
that maybe the act may bring the dead
person back to life)
 Weeping, anger, hostility
- This is a STRONG phase; You need to be strong
at the earliest phase of the mourning process;
makes one feel stronger despite the intense
sadness
-STRONG PHASE but also a SHORT one.
-occurs in the first few hours/days of grief and coincides
with the wake.
II. Phases of Disorganization
- Most difficult and painful part
- Usually happens after the funeral; when the
family is left for themselves
- Most of the denial has already been gone
 Developing awareness of the loss
 Emotions are extremely painful –SADNESS,
guilt; anger and hospitality are not as strong
as during Phase of Protest
- Feelings are less strong but are more
intense
 Preoccupation w/the lost person
-everything reminds the bereaved
person of the lost loved one.
-may manifest in dreams and transient
hallucinations (normal)
-abnormal if prolonged
- most prominent manifestation in this
phase
 Waves of somatic distress
- Suffers a lot of sickness; some may or
may not have organic cause
- Sakit likod; sakit ulo….
-not a waking day feels well
 World is experienced as very poor, empty
and meaningless
 Sense of unreality, withdrawal from world
- One wants to be alone by himself
 Disorganized aimlessness and restlessness
III. Phase of Reorganization
- Little by little goes back to normal
-sadness is not so intense anymore
 Intensity of investments in the lost person
gradually given up – memories no longer
evoke intense sadness
Pleasant memories take over.
 Energies and interests are refocused on the
world
The person starts doing activities s/he used
to enjoy
 New activities and relationships are begun
- Some might feel guilty; remind
them that these are all parts of the
normal grieving process
 But some aspects of the old relationship
remain
Bowlby Stages
-by John Bowlby
-more popularly used; classic staging
1. Stages of Acute Despair
2. Stages of Intense Yearning and Searching for
the Lost Person
3. Stages of Deorganization
4. Stages of Reorganization
Grief Among Filipinos
FILIPINO EXPRESSION OF GRIEF
(Santiago, 1993)
-involves psychological and social dimensions
Three Stages
1. Resisting (Salaghati)
2. Carrying (Dalamhati)
3. Extrusion (Lualhati)
I. Resisting (Salaghati)
 Social Stage: Wake  Burial  Novena 
40th day
 Custom: Vigil (Lamay), mourners, gambling,
drinking
-Very functional. Helps mourners cope.
Burial - big feast, last will and testament is
opened
 Behavior, Feelings, Cognition: sadness,
crying, annoyance, anger, ambivalence
-coincides with the phase of protest with some aspects
of disorganization
II. Carrying (Dalamhati)
- Social Stage: mourning period
- Custom: mass
- Media-luto (half black/white)
- People wear black or white
all the time; wears a black
pin; no colorful clothes
- Behavior, Feelings, Cognition: carrying the
pain of loss
III. Extrusion (Lualhati)
 Social Stage: after annual commemorations
 Custom: 1st anniversary mass,
“babangluksa/wakas”, big feast
- Hukas lalaw – end of mourning;
celebrated after the anniversary
(not on the day)
Length of Grief
 Usually, 6 months to a year
-Just for exams. It actually varies from person to person.
“My son died 30 yrs ago, so, I don’t know yet.”
-from a mother who joined a parents’ support group
- Sometimes it may last for a very very long
time
- It is not usual that we will continue grieving
until we ourselves are about to die
Features of Normal Grief
 Somatic distress
 Preoccupation w/ image of deceased
- transient hallucinatory
experience/behavior
- some may hear the voice of the lost
loved one
- normal as long as it is TRANSIENT;
abnormal if it continues throughout the
day
 A slight sense of unreality
 Increased emotional distance from others
 Feelings of guilt
 Hostility, irritability and disconcerting loss of
warm feelings towards others
 Disruption of normal patterns of conduct
Pathological Mourning
- no or delayed feeling
- so intense that it can result to disorderly conduct or
suicidal ideas
-co-morbid with the following: clinical anxiety,
depression, psychosis
 Persistence of denial, with delayed or absent
grieving
 Depression, with IMPAIRED SELF-ESTEEM,
suicidal thoughts and impulses, with self-
destructive behavior
 In mourning, there is sadness, but there is no
impaired self-esteem
…..Depression vs sadness (normal grieving)
- Sadness - there is intact self-esteem
- Does not feel that she is a bad person
because her husband died
- wanting to be reunited vs wanting todie
 Progressive social isolation
 Persistence of anger and hostility, leading to
paranoid reactions, or suppression of any
expression of anger or hostility
 Continued disruption of normal patterns of
conduct
 Continued preoccupation with memories of the
deceased to the point of searching for reunion
  Conversion symptoms similar to the symptoms
of the deceased
- Psychological defense where you
develop symptoms; usually similar to
the symptoms of the lost loved one;
- Exams and labs are normal;
- Symptoms usually neurological; cannot
be explained
CONVERSION – Production of physical symptoms usually
neurologic without physical basis
e.g. suddenly can’t feel or move one part of the body,
can’t talk (aphonia)
 Development of actual organic disease and
medical illness
Bereavment and Depression
-Depression is the major differential dx for abnormal
bereavement
- Bereavement (normal) – after awhile symptoms
will disappear; does not need major
interventions
- Major depression is a psychological problem
that responds to psychotherapy and
medications; sometimes it is can be an
emergency especially if suicidal behavior is
present
 Morbid feelings of guilt and worthlessness and
suicidal ideation are rare(bereavement)
- (bereavement) Sadness is triggered by
the reminders of the deceased person
- (major depression)person just feel sad;
not related to the memories of the
deceased
Bereavement vs Depression
In bereavement…
 Dysphoria triggered by reminders of the
deceased
 Usually starts within 2 months of death
- Depression can come anytime
 Duration of acute symptoms usually less than 2
months
 Functional impairment mild and transient
- Severe in major depression
 Absent prior history of depression
High Risk of Abnormal Grief
 Those with sudden, unexpected loss
 Those whose losses occurred under horrific
circumstances
 Those who are socially isolated
 Those who believe they are responsible for the
death
 Those with history of traumatic losses
 Those with ambivalent or dependent
relationship with the deceased
-better outcomes if the relationship clearly positive
or clearly negative
 Those with prior history of mental illness
Helping the Bereaved
“People in mourning, like those in dying, are
outcasts of society. Their presence is painful to many
who surrounded them, and efforts to silence, impede or
stop mourning are common.”
- This should not be so
Tasks of the Mourner
 To experience and reflect upon his feelings
towards the dead person during life of this
person and the feelings evoked by death
 To review the history of the attachment
- How beautiful/ painful it was… how
happy/sad he was in some moments
 To examine his own wounds, attend to their
healing, and confront the task of continuing w/o
the lost object
Our task, as people who wants to help the bereaved, is
to facilitate the completion of the tasks
Helping the Bereaved
 Allow the bereaved to express his feelings
truthfully
 Avoid maneuvers that nullify grieving – “may 3
bata ka pa man nga bilin”
 Assure the bereaved that his actions, even if
bizarre, are generally normal
 Presence, more than words, is helpful
 Sharing memories may help complete the
memory of the deceased
 Persevere over the long haul–especially after
the burial
 Remember anniversaries
 Encourage return to activity
The Physician and the Grieving Process
 Facilitate viewing of the body
- It is hard to believe if you can’t see the
dead loved one
- even with psychotic patients
 - RULE: People who grieve should see the CRITERIA ON DEPRESSION
body
 Listen to the bereaved and talk to them
 Serve as new object of trust and confidence for
the bereaved
 Watch out for abnormal reactions
-richness of Philippines rituals is positive from a psych
viewpoint

Importance of Rituals
 Wakes
 Shivas
 Funerals
 Burial services

 Provide an occasion for gathering of social

network of support
 Those gathered activate important memories
 Tribute to the dead person emphasizes both his
worth, and the fact that he is worth the pain of
grieving
 Rituals permit expression of sorrow, set limits
on grieving, and provide legitimate outlets for
expressing positive feelings
 Rituals allow other people in the community to
pay their respects and initiate their own
grieving
 Provides occasions for other people to grieve
for losses unrelated to the deceased

Grief Therapy
 Seldom necessary in uncomplicated
bereavement
 If initiated, focus is on successful performance
of the tasks of the mourning process
 Some medications, including hypnotics, may be
helpful
- For those who cannot sleep, cannot rest
-anti-anxiety rarely indicated

*italicized phrases are transcribed from doc amantillo’s

lecture