1 Is grief a medical problem?
Grief is a fertile area for debate and controversy within health care professions, and its significance as something in need of medical attention has been debated by both health analysts and social commentators alike. Is it a ‘natural’ phenomenon that should be respected and acknowledged, but one that requires that the bereaved individual is left alone to experience it in their own way? Or should the bereaved person be assisted with intervention which relies on the presumption that grief can be detected, quantified and treated?
Activity 1: A medical problem?
Read the following case study and then make notes in response to the questions.
Bernadette's husband, Fred, died in hospital at the age of 70. He had suffered from motor neurone disease for several years before his death, and she had been his primary carer. They lived in a large house, and their only child, Paul, lived with his partner about 50 miles away. Paul did not get on very well with Fred, although towards the end of Fred's life they spent quite a lot of time together.
Bernadette was 64 when Fred died. She tried to develop new interests, getting involved in her local bridge club and meeting a few people who became friends. She struck up a particularly close friendship with a widower, Jeff, but after a couple of years she decided that she was still committed to Fred and did not want to get more involved with Jeff, so cooled their relationship.
Ten years after Fred's death, Bernadette still lives in the same house and keeps his ashes next to her bed. She has mobility issues and is increasingly confined to the ground floor of her house. She no longer attends the bridge club. Paul is concerned about his mother's mental health. One part of this, he believes, is his mother's inability to detach herself from Fred's ashes. He wants her to do something with the ashes, saying he does not think it is ‘healthy’ to have his father's ashes so close to her bed.
Do you think that Bernadette needs medical help?
What resources might be available to help her?
What resources might have been available if a similar situation had developed 100 years ago?
In contemporary times the bereaved person and their family may well turn first to their local GP or primary care services. A century ago this option was not available to the vast majority of people (apart from the nobility and gentry who could afford to pay for help), and other forms of social support, such as the church, may have been the first port of call.
Paul may well, therefore, think of approaching the local GP for help. As well as the primary care team, there may be local bereavement support groups in the area where Bernadette lives. Bernadette may find it beneficial to get involved in all sorts of other ‘normal’ activities not directly associated with grief or having an explicitly helping or caring role.
Focusing on normal interests and activities may be more beneficial than specific bereavement-related groups or services.
However, many commentators and people in the caring professions consider that both grief and depression have become over-medicalised and over-diagnosed (Illich, 1976; Moynihan and Smith, 2002; Parker, 2007). Too much emphasis, they argue, has been put on ‘treating’ grief. Their argument suggests that grief should be placed alongside many other ‘new’ conditions that they claim have been artificially created in order to expand the reach of the medical profession and increase the market share of drug companies.
In contrast, other medical commentators, particularly American psychiatrists such as Selby Jacobs and Lorna Douglas (2004), and British psychiatrists such as Keith Hawton (2007), argue that grief, especially following a sudden death can be a serious clinical issue that should be recognised swiftly and treated intensively.
In attempts to answer this conundrum, at the time of writing (2008) there appears to be a growing consensus in the medical profession and among psychiatry researchers, such as BaoHui Zhang and colleagues in the USA, that there is a difference between normal forms of grief reaction that can be expected following a sad event, and complicated grief that may be associated with serious health outcomes (Jacobs and Douglas, 2004; Zhang et al., 2006).
Certainly, there have been efforts to test and measure the relationship between grief and health. It has been argued by Margaret Stroebe and colleagues (2007) that one of the best ways to do this involves longitudinal investigations. (A longitudinal study is one that follows a person or group over a period of time.) In such studies, some researchers will be looking for statistical differences that may be apparent between the two groups (quantitative data), while other investigators may want subjective responses from the two groups (qualitative data). There is a general consensus that research that includes both quantitative as well as qualitative data (‘multi-method’) will provide the most robust evidence. (Such research is sometimes referred to as ‘triangulation’, where several different methods are used to explore and examine social phenomena.)
Consequently, Stroebe et al. (2007) considered that 16 longitudinal studies were of sufficient quality to be included in their review of the health outcomes of bereavement, and concluded that:
Bereavement is associated with an increased risk of mortality from many causes, including suicide … the mortality of bereavement is attributable in large part to a so-called broken heart (i.e. psychological distress due to the loss, such as loneliness (Stroebe et al., 2005) and secondary consequences of the loss, such as changes in social ties, living arrangements, eating habits and economic support (Parkes, 1996)). For widowers, the increased risk will probably be associated with alcohol consumption and the loss of their sole confidante, who would have overseen her husband's health status.
It is important to note that there are considerable difficulties in conducting longitudinal research, however, and many problems can arise before ‘real’ differences in the health status of the two groups can be confirmed. For example, people going through an upsetting event in their lives might not be willing (or able) to take part in the research, and therefore the most deeply affected people may be excluded from the study. Some people may remarry during the course of the investigation; how should they be treated for the purposes of the research? Furthermore, there may be factors that relate both to the death of the deceased person and to the health of the surviving bereaved person who is being studied. For example, they might have been injured in an accident that killed the deceased person.
What underpins all of these issues, however, is the assumption that grief can be ‘measured’ in some way. What do you think of this claim? How can grief be objectively measured? On what grounds? Some physiologists have suggested that they have the answer.