Death has a tendency to trigger different reactions, one of which is the expression of grief by families and loved ones. To support bereaved relatives, counsellors, therapists, educationalists and researchers have relied on theoretical constructs they believe are best placed to be effective and enable the bereaved to adjust and ‘move on’ with their lives again. The constructs focus on different outcomes to be achieved by the bereaved. For example, in order to adjust and cope, the bereaved need to:
- Emotionally ‘let go’ of the deceased (Freud, 1917)
- Work through their grief (Worden, 1982)
- Relocate energies and psychologically move on (Marrone, 1999)
- Accept the person is dead (Kubler-Ross, 1970)
- Recover and reorganise life (Bowlby and Parkes, 1970)
- Find new meaning through symbolic interaction (Marris, 1991).
These ideas are influenced by a range of schools of thought, all aimed at helping the bereaved cope. While constructs have a place, we need to reflect on life and relationships we form with other people, and then tailor prevailing constructs to ensure individuality and achieve person-centred care.
While adults develop relationships with family members, close friends and acquaintances, Bowlby (1988) has indicated that with reference to children, these relationships develop into attachment bonds which are deeply held the closer (emotionally) the child gets with the other person. Arguably, this also happens in adulthood. Attachment bonds suggest deep emotional affection for the other person, and children often develop such bonds with parents as they grow up. Adults may widen their scope of bondage as they meet different people, but what is crucial to suggest here is that the closer the relationship is emotionally, the deeper the affectionate bonds between them. It follows that the deeper the bond, the harder the death (loss) is felt, and therefore, the grief that follows such death is expected to be painful. While this may seem logical and plausible, the question that would baffle many is why such reaction is often pathologised. For example, the bereaved find themselves being referred to counsellors and therapists, and yet, what they are doing is going through a normal reaction (sadness, crying, shock, feeling lonely and empty) to a very painful experience of breaking the affectionate bond. In such situations, grief should be viewed and treated as a normal reaction to a painful loss/death.
Over the last century, different theories and models have emerged to guide us on grief therapy to support the bereaved. The worrying thing is that each of them advocate a different end point (outcome) for the bereaved. It is plausible to argue that such outcomes reflect the subjectivity of human beings and their individual reactions to death. However, the real flaw in such prescribed outcomes is that they always start with a view that grief creates a pathological state within the bereaved and therefore, requires support and corrective therapy. This, in turn, denies its normality as genuine reaction to a painful event. Put differently, therapy suggests an attempt to suppress the reality of feelings, by finding ways to pacify the bereaved. However, people may not want or be ready to let go, relocate or even move on. There is a dangerous precedent here that if, for example, healthcare professionals subscribe to a particular approach like the psychodynamic theory, letting go is best for the bereaved people they support. By extension, if the bereaved person is being supported by several professionals who subscribe to different theories, they may be guided or encouraged towards a particular outcome with a real potential for confusion, if not distorting or damaging them.
This critique is not new because other theorists like Stroebe and Schut (1999) have now developed a dual process model that recognises that the bereaved tend to oscillate between two time frames. They propose that the bereaved should have time to grieve whilst also being able to carry on with everyday life. The idea that time is a ‘healer’ (Freud, 1917) is misplaced, as the enormity of the loss remains constant over time (Tonkin, 1996). Instead, the bereaved develop and grow through time to be able to carry on with their lives while remembering the deceased person at points in time that suit them. Tonkin (1996) has suggested that the bereaved use time to develop new strategies to cope with the loss (which remains the same) and eventually resume near normality.
Grief, some of which can be acute, signals a normal response to death and the symptoms presented should not be pathologised. After 100 years of pathologising the normalcy of grief stands contrary to earlier teachings by Freud, who, in 1917 wrote:
‘Although mourning involves grave departures from the normal attitude towards life, it never occurs to us to regard it as a pathological condition and to refer it to a medical treatment. We rely on it being overcome after a lapse of time, and we look upon any interference with it as useless or even harmful.’
Although the lapse of time is debatable, the overall message is valid and in line with commentators like Bayliss (2008), who have warned against trying to impose ‘order’ onto the ‘chaos’ of the bereaved; instead, we should let them find their own order. Working with predetermined constructs and their outcomes denies subjectivity. Therefore, it would be meaningful and caring to be guided by the bereaved as they experience the pain, distress and emptiness as to what outcome they want to achieve. This may take them some time to realise; they must not feel pressurised to ‘move on’ and make rushed decisions. In essence, this suggests that theories can be limited when trying to apply it to all individuals.
Finally, healthcare professionals and community nurses are in privileged positions as they form close and caring relationships with people as they approach death. It is important that caring at this end-of-life stage includes understanding peoples' stories and the affectionate bonds they have formed. Families and close friends have stories to tell, and having such understanding might be a necessary starting point when we support the bereaved. It is important for community nurses and others to appreciate the context of taught theories – that is, to broaden our understanding of different perspectives that may help the bereaved going forward. However, Bayliss (2008) is right to remind us of the bigger picture and the individual nature of the bereaved:
‘Learn your theories as well as you can, but put them aside when you touch the miracle of the living. Not theories but your own creative individuality must decide.’
Only by using theories as guides can we formulate caring strategies that are specific and balanced to individual needs and desires.