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  Developing awareness of the loss
– comes in order but may blend each other; people can  Emotions are extremely painful –SADNESS,
revert back to earlier phase;some gray areas still guilt; anger and hospitality are not as strong
need to be clarified as during Phase of Protest
1. Phase of Protest - Feelings are less strong but are more
2. Phase of Disorganization intense
3. Phase of Reorganization  Preoccupation w/the lost person
-everything reminds the bereaved
I. Phase of Protest person of the lost loved one.
- Parallels to phase of denial and anger -may manifest in dreams and transient
(Kubler-Ross) hallucinations (normal)
- Comes about initially, at the start when the -abnormal if prolonged
diagnosis is known - most prominent manifestation in this
-it is a period of intense emotion but is actually phase
protecting the psyche threats to its integrity that it may  Waves of somatic distress
not be able to cope with - Suffers a lot of sickness; some may or
…why is the phase of DENIAL necessary? may not have organic cause
- Denial is a defense mechanism (unconscious) - Sakit likod; sakit ulo….
where the person really believes that the -not a waking day feels well
information is NOT entirely true;  World is experienced as very poor, empty
- Different from lying and meaningless
- The mind allows you not to recognize it for a  Sense of unreality, withdrawal from world
certain period of time to preserve the emotional - One wants to be alone by himself
integrity;  Disorganized aimlessness and restlessness
- You cannot believe it because believing it at this
time would be devastating; unconscious process III. Phase of Reorganization
protects you from breaking down - Little by little goes back to normal
- Allows you to buy time -sadness is not so intense anymore
 Disbelief and numbness – massive defense  Intensity of investments in the lost person
against acknowledgement of loss gradually given up – memories no longer
 Frantic attempts to maintain relationship evoke intense sadness
with the departed loved one, or recover it Pleasant memories take over.
-e.g. attempts to awaken the deceased loved  Energies and interests are refocused on the
one by shaking the body, loud cries, etc. world
 Strong attempts to bring person back to The person starts doing activities s/he used
life (eg. Shaking the body – magical thinking to enjoy
that maybe the act may bring the dead  New activities and relationships are begun
person back to life) - Some might feel guilty; remind
 Weeping, anger, hostility them that these are all parts of the
- This is a STRONG phase; You need to be strong normal grieving process
at the earliest phase of the mourning process;  But some aspects of the old relationship
makes one feel stronger despite the intense remain
sadness
-STRONG PHASE but also a SHORT one. Bowlby Stages
-occurs in the first few hours/days of grief and coincides -by John Bowlby
with the wake. -more popularly used; classic staging

II. Phases of Disorganization 1. Stages of Acute Despair

- Most difficult and painful part 2. Stages of Intense Yearning and Searching for
- Usually happens after the funeral; when the the Lost Person
family is left for themselves 3. Stages of Deorganization
- Most of the denial has already been gone 4. Stages of Reorganization
Grief Among Filipinos - Sometimes it may last for a very very long
FILIPINO EXPRESSION OF GRIEF time
(Santiago, 1993) - It is not usual that we will continue grieving
-involves psychological and social dimensions until we ourselves are about to die

Three Stages Features of Normal Grief

1. Resisting (Salaghati)
2. Carrying (Dalamhati)  Somatic distress
3. Extrusion (Lualhati)  Preoccupation w/ image of deceased
- transient hallucinatory
experience/behavior
- some may hear the voice of the lost
I. Resisting (Salaghati) loved one
- normal as long as it is TRANSIENT;
 Social Stage: Wake  Burial  Novena  abnormal if it continues throughout the
40th day day
 Custom: Vigil (Lamay), mourners, gambling,  A slight sense of unreality
drinking  Increased emotional distance from others
-Very functional. Helps mourners cope.  Feelings of guilt
Burial - big feast, last will and testament is  Hostility, irritability and disconcerting loss of
opened warm feelings towards others
 Behavior, Feelings, Cognition: sadness,  Disruption of normal patterns of conduct
crying, annoyance, anger, ambivalence
-coincides with the phase of protest with some aspects Pathological Mourning
of disorganization - no or delayed feeling
- so intense that it can result to disorderly conduct or
II. Carrying (Dalamhati) suicidal ideas
- Social Stage: mourning period -co-morbid with the following: clinical anxiety,
- Custom: mass depression, psychosis
- Media-luto (half black/white)  Persistence of denial, with delayed or absent
- People wear black or white grieving
all the time; wears a black  Depression, with IMPAIRED SELF-ESTEEM,
pin; no colorful clothes suicidal thoughts and impulses, with self-
- Behavior, Feelings, Cognition: carrying the destructive behavior
pain of loss  In mourning, there is sadness, but there is no
impaired self-esteem
III. Extrusion (Lualhati) …..Depression vs sadness (normal grieving)
 Social Stage: after annual commemorations - Sadness - there is intact self-esteem
 Custom: 1st anniversary mass, - Does not feel that she is a bad person
“babangluksa/wakas”, big feast because her husband died
- Hukas lalaw – end of mourning; - wanting to be reunited vs wanting todie
celebrated after the anniversary
(not on the day)  Progressive social isolation
 Persistence of anger and hostility, leading to
Length of Grief paranoid reactions, or suppression of any
expression of anger or hostility
 Usually, 6 months to a year  Continued disruption of normal patterns of
-Just for exams. It actually varies from person to person. conduct
“My son died 30 yrs ago, so, I don’t know yet.”  Continued preoccupation with memories of the
-from a mother who joined a parents’ support group deceased to the point of searching for reunion
  Conversion symptoms similar to the symptoms  Those who believe they are responsible for the
of the deceased death
- Psychological defense where you  Those with history of traumatic losses
develop symptoms; usually similar to  Those with ambivalent or dependent
the symptoms of the lost loved one; relationship with the deceased
- Exams and labs are normal; -better outcomes if the relationship clearly positive
- Symptoms usually neurological; cannot or clearly negative
be explained  Those with prior history of mental illness
CONVERSION – Production of physical symptoms usually
neurologic without physical basis Helping the Bereaved
e.g. suddenly can’t feel or move one part of the body, “People in mourning, like those in dying, are
can’t talk (aphonia) outcasts of society. Their presence is painful to many
 Development of actual organic disease and who surrounded them, and efforts to silence, impede or
medical illness stop mourning are common.”
- This should not be so
Bereavment and Depression
-Depression is the major differential dx for abnormal Tasks of the Mourner
bereavement  To experience and reflect upon his feelings
- Bereavement (normal) – after awhile symptoms towards the dead person during life of this
will disappear; does not need major person and the feelings evoked by death
interventions  To review the history of the attachment
- Major depression is a psychological problem - How beautiful/ painful it was… how
that responds to psychotherapy and happy/sad he was in some moments
medications; sometimes it is can be an  To examine his own wounds, attend to their
emergency especially if suicidal behavior is healing, and confront the task of continuing w/o
present the lost object

 Morbid feelings of guilt and worthlessness and Our task, as people who wants to help the bereaved, is
suicidal ideation are rare(bereavement) to facilitate the completion of the tasks
- (bereavement) Sadness is triggered by
the reminders of the deceased person Helping the Bereaved
- (major depression)person just feel sad;  Allow the bereaved to express his feelings
not related to the memories of the truthfully
deceased  Avoid maneuvers that nullify grieving – “may 3
bata ka pa man nga bilin”
Bereavement vs Depression  Assure the bereaved that his actions, even if
In bereavement… bizarre, are generally normal
 Dysphoria triggered by reminders of the  Presence, more than words, is helpful
deceased  Sharing memories may help complete the
 Usually starts within 2 months of death memory of the deceased
- Depression can come anytime  Persevere over the long haul–especially after
 Duration of acute symptoms usually less than 2 the burial
months  Remember anniversaries
 Functional impairment mild and transient  Encourage return to activity
- Severe in major depression
 Absent prior history of depression The Physician and the Grieving Process
 Facilitate viewing of the body
High Risk of Abnormal Grief - It is hard to believe if you can’t see the
 Those with sudden, unexpected loss dead loved one
 Those whose losses occurred under horrific - even with psychotic patients
circumstances
 Those who are socially isolated
 - 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