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Physiology of bereavement: Discussion with Andrew Schuman GP

Physiology of Bereavement: Discussion with Andrew Schuman GP
So Andrew– bereavement. Again, I know it’s all so very difficult to define these terms, but how would you, if you can, describe bereavement? Or is there just not a way of describing it? Very difficult to describe. Elisabeth Kubler-Ross was one of the first to formalise a definition and a description of the process of grieving that was formulated, I think, in the late ’60s– 1969, that one doesn’t adhere to closely. I think we’re all aware of it. I think everyone’s aware, to a certain extent. Could you tell us what they are? Do you remember what they are? There’s an initial phase of shock, being stunned, disbelief.
And then many people– not everyone– many people move on to pangs of grief, uncontrollable crying. And at some point– again, everyone’s different– that can slide towards despair, depression. And in most people, you want that to be followed by– and no one prescribes how long or short that should be– a degree of acceptance and adjustment. So accepting what’s happened and readjusting. And the bereaved person remaining central in that person’s life, but not being overwhelming. So it allows them to move on. So is acceptance the last stage then? Acceptance, yes. Adjustment and acceptance of the loss of that person– the permanence of that loss and the fact that your life has to go on and will go on.
But as a GP you’re really at the coal face of this. This is something you’re probably dealing with most days. How do you do that? I think everyone’s– so the first thing, I wouldn’t prescribe that sort of and expect someone to follow. There’ve been many interesting commentaries and criticisms of the Kubler-Ross model as one that many people do follow loosely. But you certainly don’t have to follow each of those stages. You can follow them in any order you like. And you can, to a certain extent, they can contract and expand in terms of how long it takes you to adjust.
And it will depend on whether your relationship with the person who’s died, and whether it’s been a sudden, unexpected death, or one that’s been very long and you’ve had a time to adjust psychologically to that– So depending on the person, might you say, if a person came and said, I’m feeling really angry, would you ever say this is quite a normal– Yeah. –using that Kubler-Ross– That’s for me one of the most useful aspects is you could say, look, hey, we’ve got this model. This is what many people– not all– but many people follow. And what you’re experiencing is normal. And that, as a guiding principle in general practise, generally, is really helpful. What you’re experiencing is normal.
So if people come in and think they’re going mad, they can have all sorts of strange thoughts that we all do many times– feelings that because they have difficulty– not unnaturally– sharing them, think they’re the only one who’s experiencing it, and then, therefore, they’re going mad. And one of the most powerful things you can do is just reassure someone once you’ve heard everything that they said that you’re not going mad. This is normal. This is your normal response to grief. Or you’re depressed. It’s normal to feel these things. Do you think literature can help? Can books help people in the process of grieving, and how so? I’m sure they can do.
I think books generally can, in terms of their ability to transport, to move, to comfort. But also, books can introduce the concept of the transience of life, of impermanence, of loss. I was going through– Do you have an example, like a children’s– A good children’s book– I went through my children’s bookshelves last night. One that I’ve known for years, a John Burningham book, called Granpa. So this is a very simple board book about a grandpa and his granddaughter. And it’s very simply done with very few words. But the words are key. And they do many things together. And they play doctors and nurses. There’s a wonderful dialogue between them. And he reminisces about his childhood.
“When I was a boy, we used to roll our wooden hoops down the street after school.” They go fishing, skating. And Granpa becomes a little infirm. He’s getting ill. Granpa can’t come out to play today.
And he’s confined to his chair. Little, sort of, moment of comedy on television, watching television together. And then we see the blankness of that chair. So very extraordinary. And then you look and there’s this little drawing of the girl appears. And there’s an awful lot going on in that little face there– the proximity to the chair, the fixed concentration. What’s going on? Where is he? Everything she’s understood about death, loss, where people do or don’t go. And that’s hidden. And then you see, she’s moved on. Granpa’s still inside her head, but she’s rushing up the hill with a pram. The sun is shining. The dog’s running behind her.
So you’d have no problem prescribing this book to somebody who lost a mother from cancer, or would it be something as a GP you’d recommend? I might, well, I’d want to be very careful about what you prescribe to whom. But one might talk loosely about them or in a great, long list. That might be certainly one of the ones I’d recommend. Even loosely, Julia Donaldson’s, The Paper Dolls, introduces the concept– this is a newer one. I think it’s an extraordinarily moving story about introducing the idea of loss. This little girl makes paper dolls and a nasty boy cuts them up. And they go. They fly away in the wind. They’re lost.
But actually, in the story they remain in her memory, in her head. They remain there. And then they appear again in her own daughter, creating her own paper dolls. And there’s a sort of passage– so there’s something about impermanence, but permanence about handing over this baton about a very gentle introduction to loss. Just going back to think about loss and moving on, because one of the key texts is Hamlet. And there’s a moment in Hamlet that we’re using when Hamlet’s stepfather is saying it’s unseemly to grieve. And Hamlet’s very angry about this. He says, ‘you’ve grieved enough. You need to move on now’.
And I think that’s the most difficult thing because people surely need to move on when they are ready. But also, they never really move on, do they? I don’t know how you feel as a GP, but it seems to me that’s the point at which people do move on, if they ever do, is very, very different. So how, as a GP, do you– do you see a lot of different stages? You do. And I think it becomes increasingly obvious when someone’s unable to move on. So that phase of grief, unable to modify and adjust, but becomes more and more enmeshed with depression and major depressive disorder. It will become increasingly obvious. So they won’t be functioning.
They won’t be eating, sleeping, working. Relationships will be affected. And if that goes on for too long, either you know something’s wrong, or they do, or people around them know. And that’s when you need to act– or before that, actually– to prevent that. So you have these loose stages of grieving in your head, but everyone’s allowed to, and will, experience them at different rates. But you know, and they know, and people around them will know when something’s not right, something’s gone the wrong way, or the process is going on too long and someone just can’t adjust. I wonder again, as a GP, do people talk to you about various texts that have been helpful? Well, they often do.
And I can think of one in particular quite recently who – and I asked her more about what she found most useful – highlighted amongst many other poems one called “Sometimes”, which is in quite a few anthologies, so people may well know it. But it actually was the first time I’d come across it when she showed it to me. And should I read that? Yeah, do. So it’s something she has pinned to her desk. She’s a writer. Pinned to her desk. It’s clearly in her head as well. So she can– in fact, she told me– she often reads it.
But again, other times she’ll be recanting lines, little images, little bits of it that, at different times– and not when she’s in the pit of depression– but at other times, can help lift her out of it or prevent, actually, her sliding into depression. Just with the imagery with support, with the positivity of this poem. It’s called “Sometimes.” “Sometimes things don’t go, after all, from bad to worse. Some years, muscadel faces down frost; green thrives; the crops don’t fail. Sometimes a man aims high, and all goes well. A people sometimes will step back from war, elect an honest man, decide they care enough, that they can’t leave some stranger poor. Some men become what they were born for.
Sometimes our best efforts do not go amiss; sometimes we do as we were meant to. The sun will sometimes melt a field of sorrow that seemed hard frozen; may it happen for you.” Extraordinary. So I’d never come across that one. So for me, that was fascinating to be given something back, as one often is from patients actually giving things. You’re not giving all the time. You’re receiving. And this, I think, was about seven or eight years after her sister’s death– her sister’s suicide. And it’s clearly hugely important and central to her even now. So again, we talk about stages. But what stage, it doesn’t matter. She is functioning. She’s working. I’m not worried about her.
But this is a great preventative. This is a great way of her rationalising, framing the loss of her sister, but also her feelings surrounding that. Not least, the fact that initially she felt a relief as well. So one feels this stunned loss. But also for some people, there’s a relief and a release at that initial stage.
As a GP, Dr Andrew Schuman has a lot of experience of providing care and support for people in the aftermath of a bereavement.
We asked Andrew about the Kübler-Ross model, and about how literature might be of comfort to someone who has experienced bereavement. Andrew described how the intense emotional responses that can result from the loss of a loved one are often confusing and isolating. Although it might seem prescriptive, the Kübler-Ross model can be a helpful tool for reassuring people that their feelings are entirely normal, and literature, too, reminds people that they are not alone. Books can often be helpful for children who are bereaved, teaching them about loss and about remembrance, while poems can provide sources of comfort and hope in the face of loss, memorised and repeated whenever they are needed.
During the conversation, Andrew reads the poem ‘Sometimes’:
Sometimes things don’t go, after all,
from bad to worse. Some years, muscadel
faces down frost; green thrives; the crops don’t fail.
Sometimes a man aims high, and all goes well.
A people sometimes will step back from war,
elect an honest man, decide they care
enough, that they can’t leave some stranger poor.
Some men become what they were born for.
Sometimes our best intentions do not go
amiss; sometimes we do as we meant to.
The sun will sometimes melt a field of sorrow
that seemed hard frozen; may it happen for you.
Since publication of this poem the author has requested that their name is not attributed to it.
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