Discussion

It is apparent that there is no strong evidence base as yet to decide which interventions would be most beneficial to individuals who request help. The factors that have been assumed to increase risk of complicated grief are also questioned by Stroebe & Schut (2001) who argue that these factors are subject to mediating variables such as social support and are complicated further because some risk factors are not static, for example, self-care. It is beyond the scope of this chapter to examine all aspects of bereavement therefore specific areas of bereavement have been selected to illustrate the changing practice and debates.

Research evidence can follow clinical practice rather than lead it. In the UK the management of perinatal loss was changed by Bourne's observations that medical staff struggled with the emotional impact of stillbirth (Bourne, 1968). This work was developed by Lewis (1976) in a classic paper that changed the management of mothers who had experienced stillbirth. The customary practice had been to remove the baby promptly and not to encourage parents to view or hold their dead child. Lewis argued that stillbirth leaves a painful void, which is better overcome by facilitating memories and participation in funeral rituals rather than avoidance. There is some evidence for this practice from a later Swedish study of 380 women using a postal questionnaire (Radestad et al., 1996). This study reported that mothers who had tokens of remembrance and felt they had been able to spend as much time as they had wished with the child's body experienced fewer anxiety and depression-related symptoms.

Perinatal practice changed rapidly and extensively which resulted in Bourne & Lewis (1991) cautioning that there were iatrogenic dangers in extrapolating their comments on the management of stillbirth to early miscarriage This does not imply that sensitive communication and support is not desirable following miscarriage. A survey of 100 mothers using questionnaires, interviews and focus groups indicated that the balance of normalising the relatively common experience of early miscarriage and acknowledging the personal impact for an individual is not easy to achieve (Wong et al., 2003).

Rutter (1981) reviewed the effects of maternal deprivation on children and argued that other variables such as the quality of substitute parenting were not taken into account. Dowdney (2000) reviewed studies of childhood bereavement following parental death and noted the varying outcomes caused by methodological differences, for example, whether children were recruited from community samples or from referrals to mental health services. She concluded that mild depression was common and one in five children was likely to express non-specific disturbance with emotional and behavioural symptoms to such a degree that there should be referral to specialist services but only a very few would experience psychiatric disorder.

The view that most children are resilient is shared by Harrington & Harrison (1999) who caution that unnecessary professional counselling can do harm by fostering dependency. They acknowledge that some children such as those with multiple deprivations may require bereavement support but agree with Dowdney's view that bereavement is rarely a cause of major mental health problems. They argue that there is little systematic evidence that the majority of children benefit on any observable measures and that for most bereaved children the mental health and accessibility of the surviving parent is the key factor. Black's earlier research also indicates the mental health of the surviving parent was predictor of outcome in children one year after bereavement (Black, 1996).

There is increasing awareness of other problems that may co-exist with bereavement, such as PTSD, and this may be caused by witnessing a violent death or viewing a disfigured body. Societies had developed rituals to minimise the intrusive imagery of dead bodies many years before PTSD was described. It was a recent Scottish custom to touch the dead body on the forehead to avoid having nightmares (Bennett, 1992). The cause of the death may have destroyed the body or if it is damaged then statutory services are protective of bereaved relatives who may be advised not to view. There may be little opportunity for discussion to help make a choice but retrospective interviews indicate that very few of those who choose to view the body regret this subsequently whereas many of those who do not view the body do regret this. It is not possible to carry out a controlled study for ethical reasons. Singh & Raphael (1981) interviewed those bereaved by an Australian rail disaster and found one of the eight people who had viewed the body regretted this whereas 22 of the 36 who had not viewed now regretted this. A British study of over 100 bereaved parents by Finlay & Dallimore (1991) reported only one parent of 81 regretted viewing but 17 of the 28 who had not viewed regretted the lost opportunity deeply. This trend is supported by a study into the needs of the families of murder victims in the UK (Brown, Christie & Morris, 1990). It cannot be assumed that all of those who did not view would have been satisfied if they had done so and it should be remembered that some chose not to view and never regretted their decision.

The search for meaning is marked after traumatic death. Relatives endeavour to change systems so that their wider society can gain something from their personal tragedy and they can feel their loved one did not die in vain. Security systems are challenged in airports and safety mechanisms are modified on car ferries. Professional carers review procedures to identify lessons that might be learned.

One type of sudden death that is assumed to cause problems for those bereaved is suicide. It can be a respected social act in specific and carefully defined circumstances - for example, hara-kiri. The Christian Church forbade it and those who died by suicide were forbidden burial within consecrated ground and buried at crossroads or lonely places such as headlands. Their bodies could be used for dissection as were those of murderers. The tools used to make the coffin would be destroyed or buried with it. Suicide was a crime in England and Wales until 1959 and in Scotland until 1961.

The recent social disapproval and fear of suicide can cause increased isolation for those bereaved by it (Wertheimer, 1991). Death notification is a familiar task for police officers but dealing with a suicide remains challenging. A suicidal man telephoned his daughter at her work to inform her where his body could be found. The officer dealing with this suicide found it difficult to understand how a parent could do this (personal communication). There may be additional difficulties for a child if death was by murder or suicide in that the truth can be concealed or distorted by relatives or carers who may have different perspectives from the legal system (Hendriks, Black & Kaplan, 1993).

Jordan (2001) argues that bereavement after suicide is sufficiently distinct from those bereaved by other forms of sudden death to require specialist clinical services. He asserts there are qualitative differences with themes of loss of meaning, guilt and self-reproach for not preventing the death as well as a sense of abandonment and anger towards the dead.

The needs of bereaved spouses and bereaved children have been addressed in the bereavement literature, albeit inadequately, but the needs of people with learning disabilities were neglected until relatively recently. Oswin (1981, 1991) pioneered this work in the UK and during the 1990s there was increased awareness of the gaps in service provision and more resources have been developed to aid comprehension and discussion about death and bereavement (Blackman, 2003; Cathcart 1991, 1994, 1995; Harper and Wadsworth, 1993; Hollins and Sireling, 1991). A systematic study of 50 parent-bereaved people with learning disabilities compared them with a matched control group using a semistructured bereavement questionnaire, the Aberrant Behaviour Checklist, the Psychopathology Instrument for Mentally Retarded Adults and the Life Event Checklist. Highly significant differences between the groups were found but carers did not attribute behaviour problems or psy-chopathology to the bereavement (Hollins & Esterhuyzen, 1997). The authors concluded the impact of bereavement with its concomitant life events was underestimated. The cohort was followed-up for two years and it was found that there was a small increase in aberrant behaviour but an improvement on measures of psychopathology with a decrease in anxiety. Participants had adapted more easily when emotional needs were met but only a quarter of the group had received informal or formal bereavement support such as opportunities to talk about the death, attend the funeral or visit the grave (Bonnell-Pascual et al, 1999).

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