Psychosocial Approach to Loss and Mourning

Headnote

Abstract

Every individual is confronted with numerous events and problems throughout his life, and they can get over most of these problems. However, some of these events affect their life significantly. Unexpected death of a loved one is such an event. Grief can be described as emotional, cognitive, and behavioral reactions given by individuals who lost their loved ones. The acute response after loss of loved one are usually not considered as abnormal because most of them are natural. The grief reactions can show a variety according to age, gender, culture and previous experience of person and because of this the reactions of people when they face to grief can show differences, it is important for healthcare professionals to consider these variety while approaching people experiencing loss. Supportive approach in grief include some techniques like psychoeducation, role modeling, encouragement, counseling and problem solving. Studies show that health professionals are lacking in information about communication with the individual who is experiencing mourning, and coping with mourning process. This review aims to emphasize the importance of the psychosocial approach in grief.

Keywords: Grief, loss, psychosocial care

Öz

Her birey yaşamı boyunca baş etmesi gereken sayısız olay ve sorunla karşı-laşmakta ve bu sorunların çoğunun üstesinden gelmektedir. Ancak bu olaylardan bazıları, yaşamı, belirgin bir biçimde etkilemektedir. Yaşamın doğal akışı içinde kayıp ya da kayıp oluşturacak bir tehditle zaman zaman karşı karşıya kalmak ve sevilen birinin beklenmedik ölümü bu tip olaylardandır. Kayıp karşısında verilen ilk tepkiler doğal bir tepki olduğu için hastalık olarak nitelendirilmemektedir. Yas ise, değer verilen ve sevilen bir kişinin ölümünün ardından kayıp yaşayan bireylerin verdiği duygusal, bilişsel ve davranışsal tepkiler olarak nitelendirilebilmektedir. Kayıp sonucu oluşan yas süreci, yaşam döngüsü içinde karşılaşılan farklı bir durum olup yaş, cinsiyet, kültür ve daha önceki yas deneyimine bağlı olarak özgün bir biçimde deneyimlenir. Çünkü her birey benzersizdir ve bu nedenle yas bireyden bireye değişiklik gösterebilir. Yas sürecinde bulunan bireye bu faktörler göz önünde bulundurularak yaklaşım sergilenmesi önemlidir. Yaşanan kayıplar sonrası veya yas sürecinde ihtiyaç olması halinde sağlık profesyonellerince (hemşireler, doktorlar, psikologlar gibi) yardım sağlanabilmektedir. Kayıp sonrası sağlık profesyonelleri tarafından profesyonel destek sağlanmaktadır. Bu destekleyici hizmetler, problem çözmeyi, rol model olmayı, cesaretlendirmeyi, öğretmeyi ve danışmanlığı içermektedir. Yapılan çalışmalar, sağlık profesyonellerinin yas sürecini yaşayan birey ile iletişim, yas süreci ile baş etme ve kayıp yas sürecindeki bireye psikososyal yaklaşım konusunda bilgi eksikliği olduğunu göstermektedir. Bu derlemede kayıp yas yaşayan bireylerde psikososyal yaklaşımın önemini vurgulanması amaçlanmıştır.

Anahtar sözcükler: Yas, kayıp, psikososyal bakım

EVERY individual is confronted with numerous events and problems that he/she has to deal with throughout his/her life and overcomes many of these problems. However, some of these events have a significant impact on life. The unexpected death of a loved one is a kind of these events (Berksun 1995). From time to time, human beings can be confronted with the loss or threat of loss in the natural course of life. Ending a close relationship, loss of a valued and beloved person, loss of work, loss of organ and loss of certain values are some examples of loss. In a conceptual context, mourning is defined as a severe and long-term painful situation that occurs after a loss (Weiss 2001, Gizir 2006, Bildik 2013, Kara 2016). In other words, mourning can be described as behavioral, cognitive and emotional reactions of individuals who are confronted with loss after the death of a valued and loved person (Gizir 2006, Ürer 2017). In addition to this, there is a pathological mourning situation that may occur if the functionality is deteriorated in the occupational and social life areas despite at least six months after the loss (Zhang et al. 2006). For this reason, the mourning process is a very difficult multidimensional situation that can affect the lives of individuals who are confronted with loss. The reactions to loss are not considered to be a disease since they are mostly natural reactions (Küçükkaya 2009, Bildik 2013).

For each individual, mourning is a different situation in the life cycle and is experienced in a unique way depending on age, gender, culture and previous mourning experience (Küçükkaya 2009). Because each individual is unique and therefore the extent of the mourning reaction may vary. People can be as deeply upset as they are upset about the death of a pet or the death of a family member when they do not achieve the desired goal. This is due to interpersonal differences in mourning reactions (Gorman and Sultan 2008). Individual reactions can range from a calm stance and attitude to a serious crisis (Bildik 2013). Although the mourning reactions after the loss of a valued person vary individually, a number of behavioral, emotional and cognitive common reactions can also be observed (Bonanno and Kaltman 2001, Benkel et al. 2009). Personality characteristics of the mourning person, the quality of the relationship with the deceased, religious and cultural beliefs related to mourning, mental health history, support systems, perception of death, presence of past losses, factors such as way of death and socioeconomic status affect the individual's reaction to the mourning process (Gorman and Sultan 2008, McCoyd and Walter 2016). Considering these factors, it is important to approach an individual in the process of mourning. Since each individual is subjectively experiencing the mourning process, health care workers should approach this with regard to the individual who is confronted with loss and mourning, and should plan these initiatives in this direction.

The focus of the care provided by health workers or mental health workers to the individual who is confronted with loss, is to establish a healing and complementary communication (Gorman and Sultan 2008). The important point here is to allow individuals to complete the appropriate mourning process. Because assisting these individuals in a difficult process is of great importance in terms of not having the negative effects of their reactions to loss throughout their lives. If the mourning process is not completed properly, long-term serious pathological and psychological problems may occur in the individual (Gorman and Sultan 2008). Thus, the individual may have to go back to the past experience and live an experience that he/she has to confront again with all the emotions he/she has suppressed. In addition, the individual may also be unable to find the social support that was present during the first period of loss. It is important to evaluate the reactions of the individual to loss, to support him / her to express his / her feelings easily and to provide consultancy in making important decisions. Professional support is provided by health professionals in case of individual needs after loss. These supportive services include problem solving, role modeling, encouragement, teaching and counseling (Longsdon and Dawis 2003). Therefore, understanding the experiences of individuals in the post-loss period and taking appropriate approaches will affect the quality of care provided by the health care team. Studies show that health professionals have lack of knowledge, attitudes and behaviors in communication with the individual who is in the process of mourning, loss and mourning, coping with the mourning process and psychosocial approach to the individual in the process of loss and mourning. This review was written in order to emphasize the importance of psychosocial approach and to raise awareness on the subject in individuals with loss-mourning.

Loss and mourning as a concept

Loss is an indispensable part of life. The individual goes through a process as a result of loss (Cummings 2015). The time of sadness after loss is defined as mourning. Mourning reflects the cultural dimension of the process (Bildik 2013). Mourning as a concept means severe and prolonged pain after a loss (Weiss 2001). The process of loss is related to people's beliefs and experiences in coping (Cummings 2015).

Individuals may experience loss in different ways throughout their lives. The mourning, which is known to have started after the death of the relative or any loss, refers to the process in which one experiences pain. Although it has been assumed since the beginning of human attachment and separation, Freud was one of the first theoreticians to bring about a scientific clarity of loss, melancholia, and mourning (Freud 1917). He argued that mourning does not only occur in reaction to death, but also for values and situations (Freud 1917, Walter and McCoyd 2009). Generally, mourning is one of the most difficult and challenging processes of human existince (Videbeck 2011). Mourning involves not only what a person thinks, says and feels, but also how a person thinks, says and feels. Therefore, it is seen that mourning is defined in different ways according to some characteristics. Behavioral, cognitive, emotional and physical reactions in the individual as a result of loss is normal, the progressive deterioration of social, occupational and personal functionality even after at least 6 months is complex, significant deterioration of functionality as a result of an unexpected and untimely event, and especially in reaction to deaths caused by violence or a frightening event is defined as traumatic mourning (Gizir 2006).

Factors affecting loss and mourning

Something changes due to losses in life and as a human being we have to adapt to this situation. With the completion of the mourning process, it is aimed to face loss, to cope with emotions and eventually to adapt to new relationships or targets with renewed energy (Küçükkaya 2009, Zara 2018). When the studies carried out on the subject are examined, it is seen that every individual who experiences mourning reacts in 4 different dimensions as emotional, physical, behavioral and intellectual (Küçükkaya 2009, Kara 2016, Zara 2018). There may be many factors that affect the person's perception and response to loss. These include developmental factors, personal relationships, culture, coping methods, spiritual beliefs, the nature of loss, and coping strategies.

Age and developmental stage

The age and developmental stage of an individual may affect the reaction. For example, loss or death in infancy is not fully understood, but often the baby may experience anxiety due to loss of objects or breast loss due to the mother's weaning (Bowlby 1960). This feeling of absence can sometimes be expressed as changes in eating, sleep, bowel and bladder patterns and disturbance (Bowly 1960). School-age children may perceive the concept of irreversible but may not always understand the causes of loss. Young people may experience many losses during the developmental period. They can leave home or have important relationships depending on school or business life. Disease or death can shake the future and self of the teenager. Middle-aged adults experience important life transitions, such as caring for aging parents, coping with marital changes, and adapting to new family roles. For older individuals, the aging process can lead to developmental losses. Some elderly people may experience this loss more intensely, especially when they are physically dependent or feel close to death; however, depending on their previous experience, they may show flexibility after the loss and develop coping skills (Yancey 2013).

Personal relationships

There are no reactions expressed as right or wrong during the mourning process. The intensity of reactions varies depending on the type of loss, the circumstances of death, and the individual's commitment to the deceased (Wright 2007). Personal relationships, the quality and meaning of the relationship with the deceased may affect the reaction to the mourning (Gorman and Sultan 2008). Since individuals may react to loss in different ways, the adaptation process varies considerably and may last for days, months or even years depending on many variables. When the relationship between two people is very good, survivor often find it difficult to overcome mourning. The analysis of mourning can be prevented by a sense of regret and unexperience. Receiving social support or help from others is one of the variables used to recover from loss and grief (Küçükkaya 2009). When a person cannot receive supportive behavior and attention from others, the mourning process may be prolonged.

Identity of the lost person

The loss of a loved one can have a very traumatic effect on the individual. It is stated that the individuals who give the most severe mourning reactions and who have prolonged mourning are parents who have lost their very young or adolescent children (Zara 2011). For this reason, the person who is lost has a significant effect on the mourning process.

Death type

Death can occur in different ways such as suicide, accident, murder and natural ways (Sezgin et al., 2004). Therefore, the type of death occurring is one of the factors that indirectly affect the mourning process and adaptation to loss (Gizir 2006). Unexpected deaths can lead to more difficult mourning. Expected losses are reasonably acceptable given the circumstances and conditions in which people live, work or reconstruct (Kü- çükkaya 2009). In an expected loss, such as cancer, the mourning process can begin before the loss occurs. This can give people more time to experience loss-related emotions and to initiate strategies to cope with losses to become less traumatized over time (Cummings 2015).

Culture

Mourning does not decrease in a linear, predictable manner as time passes, but is influenced by many factors, fluctuating over time (McCoyd and Walter 2016). The importance of the lost object for the person (generally, the more important the loss for a person is, the more severe the reaction is), the level of preparedness and previous unresolved losses, physical health, the degree of conflict or dependence in the relationship, support systems, and different stressors that occur simultaneously. Some of the variables that may affect the sense of mourning (Gorman and Sultan 2008, Küçükkaya 2009, McCoyd and Walter 2016). In addition, one of the factors affecting the individual's reaction to loss is culture. Many cultures are known to have certain rituals or traditions that provide support and confidence throughout the mourning process (Gorman and Sultan 2008, Rosenblatt 2008). Cultural rituals and traditions done after loss may allow mourning to be normalized. However, mourning patterns perceived as normal in one culture may not be perceived as normal in another culture. Therefore, it is important to obtain information about the cultural practices of the individual and cultural beliefs of mourning (Çelik and Sayıl 2003).

Coping methods

Life experiences can shape the methods used to cope with the stress of loss. The individual can first try his / her methods. When the usual coping methods do not work, they may need new ones. Emotional expression can be a way of dealing with loss. However, some individuals can better deal with loss situations when they focus on positive situations and optimistic emotions (Yancey 2013).

Mental disorder

Although the loss of a loved one is undoubtedly a unique stressful experience, research has shown that individuals experience significant regression in different ways (GalatzerLevy and Bonanno 2012, Lotterman et al. 2014). The presence of a mental disorder in the individual prior to loss is another factor affecting the mourning process. For example, in the presence of an underlying underlying depressive disorder, the loss of a loved one can trigger worsening of symptoms, or even a greater depressive episode. Therefore, it should be taken into consideration that the presence of mental problems before loss will affect the mourning process (Lotterman et al. 2014).

Spiritual and religious beliefs

Mourning-related practices may be related to spiritual or religious beliefs. Spiritual resources include belief, support communities, friends, hope and meaning for life, and religious practices. Spirituality can affect the ability of the individual and family members to cope with loss. Positive practices emphasize important aspects of death, such as spiritual well-being, peace, comfort, and tranquility (Yancey 2013).

Lack of social support

Social support has positive effects on both physical and mental health. It is stated that there is a positive relationship between social support and health, and loneliness and lack of social support may cause problems in adapting to death, especially in elderly individuals (Ringdal et al 2001).

In addition to the abovementioned factors affecting the loss and age experienced by the individual; factors such as being young, anxious / shy / insecure attachment style, personality traits, being a woman, age of the deceased, low education level, frequent losses, lack of family adaptation have an impact on the mourning process (Wilson 2014).

Mourning process

Mourning process is expressed as an individual and unique process (Küçükkaya 2009). There is no comprehensive theory explaining the normal mourning process. Research shows that mourning consists of a series of phase and stages with predictable symptoms that change over time, and that these stages do not develop in the same order and in the same way (Bowlby 1980, Weymont and Rae 2006, Gorman and Sultan 2008, Küçükkaya 2009, Zara 2018).

When the literature is examined, it is seen that the mourning process was defined by Freud for the first time and some elements that could be determinative in the normal mourning process were first expressed by Lindemann (Bowlby 1980, Gizir 2006, Küçükkaya 2009, Walter and McCoyd 2009). Freud (1917) expressed his basic ideas in his book "Mourning and Melancholy". He stressed that mourning should be regarded as a comprehensible (and normal) reaction to the disappearance of psychotic (distancing from reality) thoughts, feelings, and behaviors (Freud 1917). Freud put forward the theory that each baby develops a bond with important people in the libidinal (catexies) process (Freud 1917). This emotional attachment process is very important for healthy development. Because with these ties with others, the baby learns to trust that their basic needs (for food, protection and love) will be met (Walsh 2012). Freud also described the "release" process as an adaptive response to the loss of the important object (Freud 1917).

In many ways, Freud has proposed "a task-based theory" based on the idea that mourning must take place. Freud's theory states that people and loved beings are "destroyed" by libidinal energy that must be withdrawn after a loss occurs (Freud 1917). He stated that mourning people (what we now call dysthymia or depression) have not successfully recovered the libidinal energy (catexies) and need help to do so. According to Freud's conception, the next step is to transfer the catexies to a new object of love (Freud 1917). He stated that mourning can only be completed when libido is released from the lost object of love, when the ego is released (Freud 1917, Walter and McCoyd 2009).

John Bowlby is an important theorist who examines Freud's ideas about human loyalty and loss. Bowlby (1960) suggested that attachment behavior towards caregivers in infants helps create and maintain a sense of security (Bowlby 1960). He observed that infants and children react to search behaviors and reactions when separation from an important person occurs (Bowlby 1960). The baby strives to re-establish the sense of bond and safety provided by the mother / caregiver. According to Bowlby's theory, mourning is a reaction to the loss of someone important (Bowlby 1960). Bowlby stated that a mourning individual, such as a baby who reacts to separation behavior, may try to avoid or deny the fact of separation caused by death (Bowlby 1960). However, Bowlby stated that the bereaved individual must abandon his or her emotional energy (called libido by both Freud and Bowlby) to reorient other relationships (Bowlby 1960). These psychoanalytically oriented theorists have argued that the inability of those who could not finally free themselves from detention, resulting in emotional or psychological difficulties, often described as depression. Many grieving experts use these basic concepts to explain that the response to grieving is considered a normal process (Walsh 2012).

John Bowlby is an important theorist who examines Freud's ideas about human loyalty and loss. Bowlby (1960) suggested that attachment behavior towards caregivers in infants helps create and maintain a sense of security (Bowlby 1960). He observed that infants and children react to search behaviors and reactions when separation from an important person occurs (Bowlby 1960). The baby strives to re-establish the sense of bond and safety provided by the mother / caregiver. According to Bowlby's theory, mourning is a reaction to the loss of someone important (Bowlby 1960). Bowlby stated that a mourning individual, such as a baby who reacts to separation behavior, may try to avoid or deny the fact of separation caused by death (Bowlby 1960). However, Bowlby stated that the bereaved individual must abandon his or her emotional energy (called libido by both Freud and Bowlby) to reorient other relationships (Bowlby 1960). These psychoanalytically oriented theorists have argued that the inability of those who could not finally free themselves from detention, resulting in emotional or psychological difficulties, often described as depression. Many mourning experts use these basic concepts to explain that the reaction to mourning is considered a normal process (Walsh 2012).

Lindemann (1944) stated that the first reactions against loss were the most fundamental characteristics of the mourning process and defined these initial reactions after loss as "acute mourning". Lindemann (1944) was one of the first theoreticians to emphasize the importance of reactions in the acute mourning process. He stated that a period of 4-6 weeks after loss covers the acute mourning process and that this process can be eliminated with a short-term clinical intervention of 8-10 sessions (Lindemann 1944). In addition, it is noteworthy that the mourning process stages are defined differently by different researchers in the literature.

Elisabeth Kübler-Ross (2014) devised a five-stage mourning process model as a phase of adapting the mourning process to self-loss in order to guide expected behavior in reaction to mourning (Kübler-Ross and Kessler 2014). He expresses the model stages as follows:

1. Denial: This is the first stage of mourning. Life becomes meaningless, shock and denial begin. Denial is a state of avoidance that is used unconsciously to avoid the situation that is painful to the self. The person, at this stage can say expressions such as "It can not happen to me, why I am" (Kübler-Ross and Kessler 2014).

2. Anger: It is the state of attempting to control emotions by blaming others and behaving aggressively. At this stage, the individual may behave in a way that does not give the expected reaction, and that he / she can turn to unproven treatment methods (Kübler-Ross and Kessler 2014).

3. Bargaining: At this stage, the individual may try to change the truth by making agreements. This shows that acceptance has started (Kübler-Ross and Kessler 2014).

4. Depression: This stage includes the pain and suffering of the loss. Mourning begins to recover as awareness increases (Kübler-Ross and Kessler 2014).

5.Acceptance: This is the stage in which feelings related to death are analyzed. It is the stage where the truth is accepted, allowed, and the adaptation to the new life process begins (Kübler-Ross and Kessler 2014).

The mourning process is also defined as a 3-stage mourning process in the form of adaptation to loss, avoidance, confrontation and adaptation and it is stated that each individual goes through this process in a unique way and time (Gorman and Sultan 2008).

1. Avoidance process: This is the stage in which loss is accepted through mind first and then emotionally.

2. Confrontation process: This is the stage where the separation caused by the loss is reacted and there is a decrease in the level of old loyalty to the lost person. This is defined as the stage in which an individual makes changes in his / her life to adapt to life without a person and tries to change old habits and find new support systems (Gorman and Sultan 2008).

3. Adaptation phase: It is the stage in which life is restructured without forgetting the old. It is the situations in which an individual starts making healthy relationships by making changes in his / her life (Gorman and Sultan 2008).

When the literature was examined, it was seen that there were studies that indicated the different stages of the mourning process. Wright (2007) described Parkes' mourning as a major stressor affecting human health and described it as a mourning process consisting of numbness, seeking and longing, depression and recovery (Wright 2007). Küçükkaya (2009) argues that Worden should fulfill the mourning process in order to adapt to the mourning process; accepting the reality of the loss, adapting to life without the lost person, restoring emotional energy and continuing life are defined as four basic tasks (Küçükkaya 2009).

Loss and mourning confronted in children and adolescents

Loss is a non-normative event in a child's life. As the level of cognitive development determines the level of comprehension, it may be impossible to make generalizations about the child's reaction to mourning or trauma (Brooke and Miraglia 2015). Children may face various losses in life. Exposure to situations such as losing a mother, father, sister or brother through death, or losing daily contacts with one or more people he/she loves through divorce are some of these events. The most common loss experience children face is the death of his grandmother or grandfather. The loss of individuals who play an important role in the daily life of children from family members can often be very painful for them (Dyregrov 2008). If one parent dies, he or she can ask other family members questions about what will happen to him/her. A change in loss and a sense of developing a new understanding can be a problem for anyone who has lost someone in their immediate family (Brooke and Miraglia 2015). Therefore, the loss of a family member is one of the most important issues for many preschool children.

Mourning is limited to the child's ability to express and understand what he/she feels. While some children cannot express their concerns, others can comment on what has changed for their families (Brooke and Miraglia 2015). Adults often try to protect children by not including them in mourning crises for other family members (Gorman and Sultan 2008). However, children may experience the same situation when they lose a friend, move away from someone they care about, or die a pet that they own (Dyregrov 2008). Therefore, taking into account the developmental period, it is very important to involve children in this process. Thus, children do not feel abandoned to face fear and loss alone. Children often show their mourning differently from adults. Therefore, it is important that they do not make misinterpretations, which may mean that they do not feel sad or aware of what is happening. In fact, they feel sad and aware of what is happening. Children often use symbolic or nonverbal language to indicate that they are aware of the loss and may even be ashamed of their loss because they feel different from their peers (Gorman and Sultan 2008).

Mourning is also related to the cognitive development of the child (Oltjenbruns 2001). The way children perceive the concept of death and their responses to death varies according to their developmental periods. To understand the child's response to loss, it is important to understand what the child loses (Brooke and Miraglia 2015). Baker and Sedney (1996) mention three types of losses that affect the child: loss of a personally significant relationship, loss of attachment and secondary losses. Secondary losses are all ways in which the child's life changes after the primary loss. Secondary losses are stressful for the child; they are strong losses for the child. These include moving to a new home, the loss of a new school and an old friendship group, the economic changes the child may feel, the parent's return to work, and a new caregiver (Baker and Sadney 1996).

There is a big difference between the infancy and the school age in the way death is understood. In order for a child to understand death, he or she must have developed concepts that allow someone to understand what happened when they died (McCoyd and Walter 2016). Children under the age of two often fail to grasp this, but children between the ages of two and two and a half have a vague understanding of what death is (Dyregrov 2008, Bildik 2013, McCoyd and Walter 2016, Ürer 2017). It can be said that the understanding of death of children under the age of three is usually in the form of separation, fear of abandonment or inability to comprehend death. Therefore, individuals in this age group may exhibit behaviors such as fear and separation anxiety in reaction to mourning (Gorman and Sultan 2008, Bildik 2013). Because the understanding of death in these age ranges that cannot understand the permanence, universality and dysfunctional aspects of death is limited (Oltjenbruns 2001). In children between the ages of three and five, death may be perceived as drowsiness or the idea that the deceased will continue to live elsewhere and come back after a certain period of time (Gorman and Sultan 2008, Bildik 2013). In this age range, behaviors such as sadness, nightmare, sleep disturbance, regression in toilet habit, complaints of abdominal and headache, anger crisis and withdrawal are observed in reaction to mourning (Dyregrov 2008, Gorman and Sultan 2008, Bildik 2013, Ürer 2017). These concepts develop in childhood and most children up to the age of 11 have a more realistic understanding of death. For preschoolers, limited language skills and inadequate identification and naming of emotions also limit their ability to communicate verbally (Oltjenbruns 2001).

Pre-school and school-age children can describe their emotions orally (Oltjenbruns 2001). The emotions of some children can often emerge as sadness, anger towards siblings, carers and classmates (Ürer 2017). Mourning is primarily expressed in the game and in interaction with others. Preschool and school-age children are thought to be unable to tolerate loss for a long time (Brooke and Miraglia 2015). Because the concept of time develops in children in this period, they can comprehend that the deceased will never return and may exhibit intense sadness, regression, sleep disturbance, aggression, and withdrawal after loss similar to adults (Gorman and Sultan 2008, Bildik 2013, Ürer 2017).

Adolescence is a period in which the meaning of life begins to be questioned (Ürer 2017). Therefore, it is known that death in adolescence is now a process that cannot be reversed. In response to the law, in adolescents, such as alienation from the family, depression, substance abuse, suicidal behavior and mood fluctuations can be seen (Gorman and Sultan 2008, Bildik 2013, Ürer 2017).

Loss and mourning confronted in middle-aged and old adults

One of the psychological development characteristics of the old age is the process of developing a perspective on death (McCoyd and Walter 2016). The longer the individual lives, the more likely he is to witness the death of a spouse, an adult child, colleagues and friends. The experience of loss leads to a view of death (Walter and McCoyd 2009). In this stage, where aging has a biological and social impact, the deaths of spouses, loss of employment, gradual health, mobility, hearing, eyesight and social support losses begin to be observed (Walsh 2012). In old age, there may be more than one symbolic loss as well as the loss caused by the death of someone else. The longer life expectancy of individuals means prolonging the period of fulfilling their roles such as spouses, employees, parents, grandparents. Therefore, the number and types of symbolic losses associated with these roles can have a significant impact on mourning reactions (Walsh 2012).

In Western society, death is often associated with old age, and death is expressed as a predictable outcome of age. Most deaths during this period are caused by chronic diseases (McCoyd and Walter 2016). Although aging is a period in which losses can be experienced relatively more and as a result of this, mourning reactions may occur more frequently, the responses given to the law are similar to other age groups (Walter and McCoyd 2009). Individuals in old age lose their friends, spouses, homes and their own health and try to produce some meaning to eliminate these losses and to develop a perspective about death, including the possibility of their own death (McCoyd and Walter 2016). However, the death of a spouse or partner is still one of the biggest losses in life (Gorman and Sultan 2008). Although many older adults (especially women) expect to lose their spouses at this stage of life, the death of a spouse can still be devastating (McCoyd and Walter 2016). This loss can also lead to many life changes that are becoming increasingly difficult with increasing age (Gorman and Sultan 2008). While the old adult who is in the process of mourning tries to make sense of extinction and death, some of them turn to more religious beliefs; others may feel cold and alienated from life (McCoyd and Walter 2016). During the mourning process, dementia, depression, impaired immune function, sleep disturbance, suicidal ideation, and poor physical health responses in general may occur (Gorman and Sultan 2008, McCoyd and Walter 2016).

Adaptation to the loss of an elderly person may be influenced by internal factors such as health problems or disabling medical conditions, changes in family role and memory, starting to predict their own death, thinking about the end of his/her own life, as biological aging of older individual progresses. The external factors affecting the process may be culture, experiencing multiple casualties in external succession, making the individual feel that his or her death is expected by the social environment, poor socioeconomic status, and being geographically distant from children or close relatives. The deaths of others in later life can have a serious impact on social support. If one's independence depends on the spouse who has died in meeting the daily living activities, the individual may have difficulty in surviving the mourning process. The reduction in the social support network calls for a new adaptation process (Walter and McCoyd 2009). If important family members or friends die, the individual may need to adapt to the new environment in which they do not exist. Undesirable changes in roles and responsibilities resulting from retirement, illness or aging can have a negative impact on mourning reactions (Walsh 2012). Isolation and limited social support can lead to adaptation problems and changes in the economic situation, especially for widows, especially if their income is linked to their spouses and can contribute to increased stress. It can be difficult to distinguish between mourning and depression, especially when multiple biological, psychological and social changes occur against multiple losses (Walsh 2012).

Psychosocial approach to mourning person

A normal mourning process is usually completed without the help of an expert, mostly through social support (Çelik and Sayıl 2003, Bildik 2013). In the case of pathological mourning, the individual must seek help from health professionals in order to complete the mourning healthily (Bildik 2013). On the other hand, the professional support given in case of individual needs after the loss includes the services provided by the health professionals in the direction of counseling, training, problem solving and coping methods (Longsdon and Dawis 2003).

In a study published by McCoyd and Walter (2016), a general intervention strategy for mourning after death due to death is mentioned (McCoyd and Walter 2016). According to this strategy, the health professional who gives care to the individual who is in the process of mourning; (a) their attitudes towards death should be assessed from psychological, sociological, philosophical and religious perspectives; (b) they should investigate and analyze the factors affecting age, and (c) investigate and evaluate the process of adaptation to life without a lost individual. In addition, the assessment should be carried out in each of the biological, psychological and sociological areas to redefine the roles of the mourner, to ensure that his / her identity is not damaged, to complete the mourning process in a healthy way and to maintain mental health (McCoyd and Walter 2016).

Evaluation in the mourning process

The basic principles to be considered in evaluating the individual in the process of mourning are as follows:

Behavior and appearance: Crying, agitation, change in routine behavior pattern, distraction, nonconcentration, unresponsiveness to situations in which reaction is expected, lack of personal care and similar behaviors can be observed. (Küçükkaya 2009).

Temperament and emotions: Shock, numbness, depression, anxiety, panic behavior, an apparent emotional reaction or an inappropriate reaction to the situation, anger, guilt and regret etc. emotions can be observed (Kübler-Ross and Kessler 2014).

Thoughts, beliefs and perceptions: Self-blame, idealizing the deceased, recalling and expressing only the positive aspects of the deceased, thinking about events related to continuous loss, obsessive thoughts about the deceased, mind being engaged only in painful thoughts, imagining that the deceased person is watching the mourner, difficulty in making decisions can be seen (Çelik and Sayıl 2003).

Relationships and interactions: Expecting support from others and being dependent on others, fear of being alone because of the preoccupation with the loss of the mind, feeling that others do not understand the pain (such as How they have a good time while I'm hurting), reflection of anger in other people are at stake (Gizir 2006).

Physical reactions: Quick and deep breathing, sighing, sobbing, muscle tension, chest pain, fainting, loss of appetite, insomnia, constant fatigue, dehydration, digestive system disorder may be seen (Gizir 2006).

Relevant past family history: Unresolved or past multiple losses, ambivalent relationship to the missing person, psychiatric disorder, substance addiction, self-abstraction tendency should be particularly evaluated (Gorman and Sultan 2008).

During the mourning process, it is important to dissolve the unresolved feelings of the individual against loss and to increase the coping skills of the individual and to maintain a normal life in a healthy way (Lotterman et al. 2014). Coping methods are actions that people take to overcome problems and difficulties. The coping process is a cyclic process of action that proceeds simultaneously with discovery, evaluation and mourning and reactions to feelings of loss (McCoyd and Walter 2016). It is a series of cycles that include the effectiveness of previous coping actions and emotional reactions to the value attributed to loss (Wright 2007). With each new loss, it can take a lot of time for the individual to grasp the situation and fully understand and evaluate the extent of the loss before giving an emotional reaction. Instincts help people weigh their options and move around instantly (Cummings 2015). If the loss is emotionally destructive, people may think that they have no options at the beginning and may not know what to do or where to go for help. In this case, it may be necessary to make the missing persons realize their current potential. People affected by losses may not see options without this external assistance (Cummings 2015). For this reason, it is important that mental health workers first evaluate the adequacy of the coping methods of the individual and support and develop them in case of insufficiency. Awareness can be considered as a widely used practical method for the individual to adapt more to his / her inner feelings and reactions as well as to be in harmony with others (Turner 2009).

ATTEND support care model

Cacciatore and Flint (2012) synthesized the ATTEND support care model and emphasized that it should be used by the practitioner to both provide a therapeutic relationship and encourage the use of the patient. The basis of the ATTEND model is attunement, trust, therapeutic touch, egalitarianism, nuance and death education (Cacciatore and Flint 2012).

1.The adaptation phase is the first integrative principle of awareness. With emphasis on awareness, harmony, empathy, sensitivity and conscious attention, it can help every person see and accept positive emotions as well as pain and suffering (McCoyd and Walter 2016). The adaptive individual is more likely to become aware of his or her own emotional state, to adopt practices such as daily prayer or meditation, stress reduction activities. These practices enhance one's ability to express empathy and compassion even in the presence of painful fee- lings in the face of loss resulting from traumatic death (Cacciatore and Flint 2012).

2. The trust stage can be achieved through trust in the therapeutic relationship, healthy communication that focuses on the relationship. When the health worker makes the individual feel that his / her feelings are really understood and encourages emotional sincerity, an atmosphere of trust will be provided in the relationship. This process creates a "positive feedback cycle" that confirms understanding through repitition. The protection of compassion can be embodied by actions such as personal space, compassionate facial expressions, touch, posture, eye contact and tone of voice (Cacciatore and Flint 2012). For example, a physician who sits quietly next to the parent of a child with a fatal illness can use a soft, careful selection of words, a slow speech, and a careful speech that allows therapeutic silence when appropriate.

3. The stage of therapeutic touch is the stage in which a person is cared for with a slight touch on his / her hand or shoulder or sitting next to him / her (McCoyd and Walter 2016).

4. Equality focuses on the idea that there must be equality between individuals in a secure relationship (McCoyd and Walter 2016). Equality refers to a relationship that balances the power between the health worker and the individual. This allows the person to make informed decisions about shared procedures about medical procedures, end-of-life care and death rituals. This requires collaborative communication, where decisions are taken carefully and creatively, there is no pressure or fear, and the wishes of the family take precedence (Cacciatore and Flint 2012). For example, a family should be able to comfortably implement cultural mourning of their deceased children.

5. The nuance phase reflects all the unique aspects of the individual and practitioner when they come together with the caregiver to work on issues that the person has difficulty coping with, where appropriate reactions are found, and the decisions taken jointly by the person's thoughts (McCoyd and Walter 2016).

6. The death training phase is the stage in which psychoeducation is given to death in order to know and assist what is expected from both death and mourning (Cacciatore and Flint 2012, McCoyd and Walter 2016). When a patient dies, his or her family may have desires and concerns about seeing the body or postmortem evaluation. This psychoeducation can make family members more prepared to deal with their losses. It is also important that doctors, nurses and other caregivers are prepared for subjects such as avoidance, stress behaviors, compassion fatigue and poor work performance, and that education is taken with mourning family members (Cacciatore and Flint 2012).

Conclusion and Suggestions

Loss and mourning can affect people of all ages and can be encountered in the field of health services. Therefore, the psychosocial approach to individuals who have lost mourning plays an important role in providing health care services. As a result, interventions that include approaches to mourning individuals can be listed as follows:

a. All behaviors related to the law should be accepted by allowing the mourning to be experienced in the environment and it should not be forgotten that the reactions are individual.

b. A special environment should be provided for the individual to recognize the loss and express his / her mourning.

c. The individual should be helped to find meaning in new roles after loss.

d. Develop a strategy for trauma when it occurs.

e. The complexity of emotions should be normalized, that is to say, the sense of having both love and hate for the person as a result of the change in the personality of the individual before loss should be accepted as normal.

f. Therapeutic communication forms the basis of psychosocial approach to the mourning individual. Acceptance and providing a supportive environment is extremely important for sharing emotions. It is necessary to be aware that words are often less important than just being there at such times.

g. The mourning rituals of an individual's culture should be supported and it should not be forgotten that it will provide relief for someone who has lost a relative.

h. Emotions in the process should be acknowledged and tolerated by the mourner's expressions such as sobbing and lamenting the violent feelings.

i. Privacy must be provided for the mourner.

j. The individual needs to identify and include the available resources for the support system.

k. An attempt should be made to overcome the mourning situation and to control anger.

l. It should be recognized that speaking and expressing feelings about loss is not only acceptable but also preferable. It should be noted that not speaking or expressing emotions is a greater problem.

m. If someone who has already suffered death or other casualties is being assisted, information should be provided on where the body was kept before burial or on support groups. The information may need to be repeated several times. It should be focused on helping other family members or friends help to ensure that the mourner is not alone. Necessary help sould be supplied by making the necessary phone calls. Where it is possible, concrete and written information should be provided.

n. Assistance with other colleagues should be sought, if possible, as dealing with acute grief can be quite tiring.

o. Use therapeutic touch; touching the mourner can be quite supportive.

p. Considering that emotional fluctuations may occur, it should be taken into consideration that the individual will experience more emotional intensity while reliving the events causing death or other losses.

According to the results discussed above, it is recommended to plan certified education programs on psychosocial interventions for individuals and families experiencing loss and mourning at a basic level and area specific to related health professionals providing treatment and care for the individuals who are experiencing loss and mourning.

Sidebar

E Yasemin Özel, Kastamonu University, Tosya Vocational School, Kastamonu, Turkey [email protected]

Received: 28.11.2019 | Accepted: 06.01.2020 | Published online: 14.02.2020

Authors Contributions: All authors attest that each author has made an important scientific contribution to the study and has assisted with the drafting or revising of the manuscript.

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

Acknowledgement: This study was presented as a poster presentation at the 5th International Home Health and Social Services Congress held in Antalya on April 26-28, 2018.

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