I am Vimal Sheth, a 41-year-old chartered accountant. My younger brother Sunil, 37 died from a road accident before 5 months leaving behind his wife Sunita, 34 years old and a son Ruchir, 8 years old. Today, even after this much time Sunita seems to be mourning for him. Even though I know the impact of this loss on her, I am unable to help her overcome this grief. Does she require any medical help? What type of changes should I expect in her?
Bereavement reactions involve alteration in feeling states, coping strategies, interpersonal relationships, social functioning and self-esteem. It depends on the individual’s personality, previous life experiences, the significance of the loss, the nature of the relationship, the existing social network, intercurrent life events and other resources. There are 3 overlapping phases that Sunita may be going through or has gone through in this process. There is an initial shock and denial phase. Here disbelief and numbness predominate. The funeral, gathering of relatives and friends and other mourning rites help to accept the loss in a supportive environment. As numbness turns to intense feelings of separation, various searching behaviors such as pining, yearning and protest take over. The second phase is of acute anguish. There are waves of intense physical pain, tight throat, choking and sighing, an empty feeling in the stomach, weakness, tenseness and mental pain. There is withdrawal from the social network. Thoughts of her husband preoccupy her. She is filled with guilt and she may accuse herself of having mistreated or neglected her husband. Irritation and anger are directed inward or towards friends, relatives and God. Restlessness, agitation, aimlessness and lack of motivation are accompanied by abandonment of usual habit patterns. The acute anguish may last for weeks or months, gradually giving way to a return of well-being and the ability to go on. In the third phase of restitution or reorganization, Sunita recognizes the extent of the loss and that grieving has been accomplished. Attention shifts to life apart from the deceased husband. She returns to work, resumes old roles, acquires new ones as necessary, experiences pleasure and seeks companionship and love. Perhaps the most lasting manifestation of grief, when the husband has died, is loneliness. She may experience acute grief reactions when she hears his name or sees his pictures. Usually these reactions become increasingly short-lived over time, dissipating within minutes and may become tinged with positive and pleasant memories. Such bittersweet memories may last a lifetime. Thus, most grief does not fully resolve or permanently disappear, rather it becomes circumscribed and submerged only to reemerge in response to certain triggers. The changes that take place in Sunita may be multidimensional. There may be a continuing relationship with her deceased husband. Faced with the dilemma of balancing reality’s demands to accept life without the loved lost one and equally powerful inner forces dictating that she maintain her attachments by retrieving what has been lost and then she gradually learns to realign her attachment bonds. She may experience the transformation of a relationship that had heretofore operated on several levels of actual, symbolic and imagined relatedness to one in which the actual relationship has been lost but other forms of relationship remain and new ones develop. She may continue contact by dreaming of him, looking for him in crowds, sensing his presence, feeling him watch out for her or protecting her, reliving conversation or speaking with him. Symbolic representations or linkage objects such as the clothing, writings, and favorite possessions may be kept indefinitely and living legacies such as carrying out his mission become other means of perpetuating the relationship. Ultimately memories become the most powerful tool of continuing the relationship. This is perfectly normal. There may be changes in the ongoing relationships too. There may be conflicts in the expectations of the son over issues of emotional support, finances, decision-making and future directions. While there is opportunity for achieving greater intimacy, it may also become a time of exacerbation, conflict and disruption. Relatives and friends may become a major support especially when empathy and sympathy are feely given and the pain is shared as well as freely expressed. Sometimes a new relationship may develop and it is often a major source of embarrassment and awkwardness. Sunita may be challenged by continued devotion to the spouse, societal sanctions, fears of recurring loss and perceived disloyalty to the child. She may also turn to religion as her belief in God helps her to cope and find meaning in death. The other mechanisms of coping include suppression, intellectualization, rationalization, avoidance and passive distraction. Sometimes an anniversary reaction can occur. This is an acute grief reaction on special occasion such as a holiday or birthday. They generally become mild and brief over time. There is finally a change in identity. The initial feelings of being overwhelmed and helpless give way to increased capacity for tolerance of grief and finding new approaches to life. There is an evolving sense of strength, autonomy and independence. Having mastered acute grief, Sunita may experience existential growth and may become more compassionate, patient and balanced. In time, she may be able to transform her tragedy into a new career, relationship or personal evolvement. Sometimes the grief may go on for a longer period than normal (2-6 months, 12 months in Sunita’s case as she is a wife). If the relationship is very close, there is chronic grief, which is unremitting and highlighted by bitterness and idealization of her husband. This can occur if the social support is lacking and the sorrow is not shared. There is also the hypertrophic grief where the bereavement reactions are extraordinarily intense. Sometimes there is unresolved grief where there is a lot of depression and long-term mourning. You need to provide support, reassurance and information relating to the issues that she may feel insecure about like money, shelter and familial support. It is easy to underestimate the power most people have to cope with distress and master adversity. The restorative processes will help her deal with this tragedy.