Mental Health vs EMS - Part Two

Secondly a distinction needs to be drawn between what is functional versus is dysfunctional grief-work.

And, what is appropriate versus inappropriate grief work.

This distinction, and these terms lie at the heart of ‘adequate’ grief work.

“Functional” simply refers to basic physical and practical behaviour that needs to be performed just to stay alive and to help to resolve the grief work.

For example, it is necessary to eat and drink, no matter the level of bereavement otherwise the patient will not function on a purely biological level. Also, there would be a need for undertakers to be informed and for funeral services to held; these are all practical, physical things which will help the patient in their grief work.

However, “functional” is not to be thought of purely as a synonym for “biological”.

For example, it would make sense for a newly bereaved parent, at some future point, to pack away the baby clothes from both a functional and emotional viewpoint. The parent will do this in his or her own time moderated by their own inner grief-clock. 

It would become dysfunctional though if for example, six months after the funeral, the bereaved mother were still sitting in the bedroom all day, and not taking care of the physical and practical needs of herself or her other children.

“Appropriate” by contrast, generally refers to the unique, culture-sensitive, emotional or psychological or spiritual component of the patient.

This requires a (culturally relevant and generally-statistically) normal progression through the grieving process be achieved.

The point of the grieving process or of grief work is not to return the patient to a pre-bereavement state. That will not happen.

Their child is dead. It is to get them to a state of re-integration where they can emotionally relocate their child from the forefront of their everyday life to the background of their life.

The primary concern in EMS is for the patient or their family to be expressing functional behaviour. Too often, what is deemed to be appropriate or inappropriate are merely taught-, social-, or cultural- ‘rules’. So for example, the mother who has been notified at work that her son has died as a result of a traffic accident, will probably “break down” and cry and rail against fate. That is absolutely functional.

Her co-workers, because of their unique personal histories and narrative constructs in their heads, might think it inappropriate. If, for example, she is a lawyer and lies on the floor of an open plan office screaming and shouting out her anguish her colleagues will become embarrassed and think that her behaviour is “inappropriate.”

The rule is that whilst “functional” behaviour may sometimes manifest in an (culturally or social)  “inappropriate” emotional expression, “dysfunctional” behaviour always manifests in “inappropriate” emotions.

Note that “inappropriate” is defined in terms of the patients ‘normal’ (cultural/societal/religious) behaviour, whereas “dysfunctional” is defined in more objective terms using common diagnostic explanations.

My personal sense is that if it takes nine months for a life to be created, then it probably takes a minimum of nine months to begin to purposefully engage with the bereavement process.

The problem is the relative who simply gets stuck and is only able to express dysfunctional grief.

I had a mother call in to a radio program I was doing on the death of children. Her daughter had died some 12 years prior to her call. She spoke to me about how her daughter would be leaving school, if she was alive; how she would be going to the school farewell dance, if she was alive; how mum and daughter would have been shopping for her prom dress, if she was alive. As the conversation developed, it transpired that her relationship with her husband (the bereaved father) and her two other children, (bereaved brothers), had withered away. She and her husband were stuck in a loveless, indeed bitter marriage due to lack of money. Her sons could not wait to leave home. And she spent most of her time sitting in the cemetery, talking to her daughter.

So helping the patient to move towards functional grief, is the primary goal. This involves a number of different activities but would include doing the physical practical work of bereavement.

Sister Francis Dominica writing in the BMJ, (January 1987), says, “As we cope with life, so will we cope with death. Difficulties and conflict in relationships in the ordinary course of events may not disappear in the presence of death, indeed in the midst of distress they may be painfully exaggerated.

 It is not for those of us who are involved professionally to take sides, but rather to believe the best of each individual and to try to support without discrimination.

One relative may remain dry-eyed and controlled throughout; the other hysterical and seemingly out of control. We have to accept both and not be thrown off balance by either. To whom is the hysterical reaction of a newly bereaved teenager a threat? In the privacy of a room can that young person not be allowed to lie down beside (their) dead brother or sister or hold the child or scream to God to bring this person who he or she loves back to life again?

All this may be an essential part in the whole process of healing. Each member of the family, not just the chief mourner, has a right and a need to grieve and express that grief in his or her own way.”