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How to cope with death

Dr Raj Persaud
Consultant Psychiatrist
The Maudsley Hospital

Every nurse will at some point have to deal with someone who has suffered traumatic loss, such as losing a relative, friend or parent through an accident or a terminal disease. It's one of the fraught areas that nurses are often least prepared for in their training, and yet some new research suggests that professionals aren't much better off.
A group of research psychologists at Utrecht University, The Netherlands, are about to publish a paper in the  journal Clinical Psychology Review claiming that there is no scientific evidence that bereavement counselling works.
Ever since Sigmund Freud proposed the idea of "grief work" back in 1917, it has been generally accepted that a healthy process of adjustment requires that the bereaved confront and express their feelings and reactions to the death of a loved one, and that failure to do so is maladaptive, or even indicative and predictive of deep psychological problems. As a result, many popular forms of bereavement counselling prescribe that the therapist challenge the bereaved patient's "resistance" to mourning, compelling them to express sadness, in the belief that the releasing of suppressed emotion is at the core of successful treatment. How to protect the bereaved against extreme suffering and lasting health impairment remains a central research issue in medicine.
But the authors of this new paper, all leading authorities in the field of bereavement research, have extensively reviewed previous medical research on bereavement counselling and challenge a series of widely accepted "truisms" at the heart of the field. They conclude that the benefits of emotional disclosure following loss are far from proven scientifically. They report on their own Utrecht Longitudinal Study of Bereavement.
A total of 128 participants were assessed four times during the two years following their loss, and at each point in time emotional disclosure and psychological adjustment were assessed. Statistical analysis was used to test the central theory that disclosure was associated with reduced distress. None of the links between disclosure and subsequent distress even approached statistical significance. They concluded that there was no support for the assumption that sharing one's thoughts and feelings with others after the loss of a loved one alleviated distress.
Another raft of research work concerns the kind of investigation where subjects are asked to write about a recent traumatic loss. Psychotherapeutic theory suggests that being induced to write about a traumatic event should be beneficial, because the task would break down an individual's inhibition to confront threatening thoughts. The assumption implicit in this explanation is that inhibition is unhealthy.
But this new paper has found that 61 randomised controlled trials on this kind of disclosure task raise serious doubts about its effectiveness in improving mental health generally, plus the studies that have investigated the efficacy of "disclosure" specifically on bereavement have yielded generally negative results.
The authors of the new study go on to propose their own theory as to why the bereaved with uncomplicated courses of grief fail to derive benefits from assistance with their "grief work". The finding from their own research is that the most common emotional difficulty suffered by the bereaved is emotional loneliness - the missing of the deceased and the feeling of being utterly alone, even when in the company of friends and family. It is possible, they argue, that this type of loneliness only abates with time and that nothing can be done to further the recovery process.
The lead author of the new paper cautions, however, that this research does not mean that certain individuals - those suffering from severe psychiatric or psychological problems following bereavement - might not benefit from professional intervention. These include those who have experienced a particularly traumatic loss through a sudden or horrific accident, for example, or those who have a previous history of psychiatric difficulties.