Models of bereavement - Part One

No two people, even from within the same family, have the same experience of bereavement. This is due to a variety of factors which include, inter alia, their relationship with the deceased, both physical and psychological, and actual or imagined; the cause and manner of death; the survivors' background; the age of the parent and the age of the deceased child.

This understanding led to the statement of intent, expressed in the closing remarks of the Third international Conference on Children and Death in Ontario in 1995,that there can be no prescribed schemas for dealing with death or grief.

Certainly, a number of useful but formulaic schemas exist, with Dr Elizabeth Kubler Ross’s model being the most famous.

Her model, and those of the post-Kubler Ross writers provide what often appears to be a prescriptive and culturally-locked or indeed, culturally-insensitive, model. Further, some patients and a few health workers,have expressed to me that there is an implicit suggestion that there is a finite time-line to the process.

And that the grief-process is linear.

In reality, it is anything but linear.

But they all only provide a framework on which really to 'keep score' of the mourning process;and often seem to benefit the bereavement counsellors more than the family.

The protocol developed in the Johannesburg Hospital draws from a number of models and it is implicit that several “scorecards” are kept mainly because nurses and doctors feel uncomfortable unless they have a life-raft of charts and tools and other aids to provide an emotional defence.

Principally though its focus is on specific cultural/language/ethnic imperatives, which also have a broad application beyond Africa.

In the end, the model suggests that the individual response to death and the grief work associated with it is like playing the children’s game of “Snakes and ladders”.

Whilst the end,-‘Block 100’/“some resolution” , is theoretically attainable there are all sorts of variables that will enhance and degrade the mourning process.

Literally, you may climb a spiritual ladder one day and fall down an emotional snake the next-,and be further back along the process.

There is also some debate on the purpose and process of grief work as discussed below. The dominant model sees grief as a “working through” of emotion, the eventual goal of which is to ‘move on’ practically and emotionally and to live without the deceased.

Whilst this is clearly predominant and the basis for virtually all interactions, including those of the author, it is a euro-centric model and may not take cognisance of the realities of African belief systems in particular.

The Kubler Ross model, which is detailed below, was seminal as one of the first attempts to codify and attempt to explain the grief process. Her schema and that of the others listed below all need to be read with the following caveats in mind: -

1. The dying patient or the relatives may traverse this ladder any number of times in a single day, never mind through the entirety of their acute, and long-term grief work.
2. Kubler Ross never implied that there was an external time frame applicable to the schema or any particular stage of it.
3. Whilst one would statistically expect the relatives to ‘get on with their lives’ within the framework of functional grief work (discussed elsewhere) ,this is still often open–ended.
4. Indeed, both the ‘academic’ and the anecdotal literature, particularly that written by bereaved parents, abounds with stories of ‘never-finished’ grief work, of ‘work-in-progress’ grief work.
5. Patients and relatives may get stuck at a particular stage-often at the “anger stage”; and again, may be stuck there for any amount of time.

The Kubler Ross model is as follows:-

1. Denial & isolation
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Much is made of parents who are angry or in despair in their acute grief and of those who appear “stuck in anger”in their longer term bereavement.

Two points should be remembered.

Firstly at the Ontario conference (as at the Edinburgh Conference) it was reiterated that parents should not routinely be given tranquillizers or sleeping tablets in the acute stage,as this may create further problems.

And as harsh as it seems, they do need to be able to ‘feel’ the pain and internalise the reality of the grief.

Secondly, there is simply no such thing as an abnormal grief reaction.

There may be reactions which appear to be “abnormal” to the health professionals and makes them feel uncomfortable , but this is about the parents and not about the staff.

The feelings evoked in the nurse or doctor by parents screaming or throwing themselves on the floor, are the result of the emotional baggage and psychological makeup of that nurse or doctor and it is their problem to deal with at another time and in another place.

The parents have enough to deal with.