Spinal Cord Injury

Nov 12, 2018 | 0 comments

Nov 12, 2018 | Miscellaneous | 0 comments

Spinal Cord Injury

Table of Contents

1.0 Introduction 2

2.0 Bereavement and grief theories 3

2.1 Freud’s Model of Bereavement 5

2.2 Kübler-ross model- five stages of grief 6

2.2. 1. Denial 8

2.2.2. Anger 8

2.2.3. Bargaining 9

2.2.4. Depression 10

2.2.5. Acceptance 11

2.3 Attachment Model of Bereavement 13

2.3.1. Numbness and shock 15

2.3.2. Yearning and searching 15

2.3.3 Despair and disorganization 16

2.3.4. Re-organization and recovery 17

2.4 Erich Lindemann’s grief work 18

2.4.1. Emancipation from bondage from the deceased 21

2.4.2. Readjusting to the new environment whereby the deceased is absent 22

2.4.3. Creation of new relationships 22

2.5 Rando’s six “R” Model 22

2.5.1. Avoidance Phase 23

2.5.2. Confrontation Phase 23

2.5.3. Accommodation Phase 26

3.0 Conclusion 27

4.0 References 29

1.0 Introduction

Spinal Cord Injury (SCI) can be a devastating and sudden event that changes an individual’s life forever. It sometimes results in permanent neurological injury coupled with other related consequences such loss of functional abilities like walking, sexual and bladder function, changes to bowel, Loss of sensation and paralysis (Harvey 2008). Additionally, SCI does affect not only the physical function of an individual but also their psychological wellbeing. Several studies have indicated that after SCI, people have reduced their quality of life, life participation, subjective wellbeing and have increased their likelihood of developing depressive or anxiety disorders (Van and Kayes 2014). This shows that employing physical interventions only may not be enough for comprehensive and successful rehabilitation outcomes. According to Van and Kayes (2014), one SCI rehabilitation aspect that is challenging is the uncertainty that surrounds recovery. Depending on the SCI level and impairment level, some patients will have a much higher chances of improving compared to others; with the patients having incomplete injuries tending to gain more (Vazquez et al 2008). However, very few SCI patients recover fully. Despite the fact that an increasing number will walk again in some ways, courtesy to the improving acute and emergency care.In most instances, patients ask the healthcare workers, and in particular the physiotherapists, about the prognosis: “will I be able to use my limbs?,” “will I ever walk again?” no one can answer these questions from the SCI patients with absolute certainty, because of the SCI variable nature during recovery. The aim of this paper will be to outlining the typical stages of bereavement after sustaining a spinal cord injury.

2.0 Bereavement and grief theories

Spinal Cord injuries are situations that are frequently encountered by healthcare workers in the course of their duties. It is significant that the healthcare professionals have a good understanding of the responses and reactions to bereavement and grief so that they are in a better position in supporting the patients, relatives and family members during the process of bereavement and grieving (Van and Kayes, 2014).

Grief is a natural response by humans to loss, bereavement or separation, in particular, the loss of the family members or the l0oved ones. The term bereavement, mourning and grief are often used interchangeably, despite the fact that they have different meanings. According to Greenstreet (2004), grief describes a person’s response to his or her loss and has spiritual, social, cognitive, behavioral, physical and emotional dimensions. On the other hand, mourning is the active and outward expression of that grief. Greenstreet (2004) stated that it is through the mourning process that grief is resolved. Similarly, Bereavement is the period after loss whereby mourning and grief occur. It is the state after experiencing loss. According to Greenstreet (2004), a bereavement is a depression form that normally resolves over time spontaneously. The bereaved person may experience the feeling of helplessness, hyperactivity, inertia, insomnia or anxiety.

Bereavement, Mourning and grief may be affected by nature of the relationship with the individual traumatized or deceased and the way he or she was traumatized or died, religion, culture and personality. On the other hand, bereavement was defined by Stroebe et al (1993) as a state of loss, that triggers reaction which manifests in different behaviors referred to as mourning.

Many models or theories of grief have common stages or themes (Worden, 1991; Bowlby, 1980; Parkes, 1975; Kübler-Ross, 1969; Lindemann, 1944,). Diagrammatic presentations like the grief wheel are usually used in describing the process and the involved stages in grief, to suggest that it is rarely a process that is static. However, other theories or models, for instance, the dual process model of how to cope with bereavement, offer approaches to the grief interpretation and management that are more flexible (Stroebe and Schut 1999). The dual process model describes how a person who is bereaved copes with the loss in his or her daily life, along with other changes in lifestyle that develop due to that loss. Buglass (2010) stated that the dual process model is founded on the principle that when an individual is grieving, the way of coping is a two-way process. That is the individual moves between grieving and attempting to come to terms with his or her loss.

2.1 Freud’s Model of Bereavement

The study of grief and bereavement began with Freud, who for many decades has been credited with establishing the psychology of grief in the 20th century? Freud developed the grief work concept in 1917 based on the premise that the precise task of mourning is to function in detaching the survivor’s hopes and memories from the dead (Freud, 1961, pp. 253).

On the other hand, Freud (1961) regarded grief as a solitary process, in which the mourners withdrew from the world so that their letting go from their loss of the deceased could be in a process that is gradual. The griefs psychological function was believed to release the person from his or her bond with the loss of the deceased. This was realized by reflecting back at the past and forgetting the memories of the person deceased. Getting detached from the deceased person entailed working through the loss for the grief to be overcome. The process was referred to as “grief work.” According to Payne et al (1999), the focus of detaching from or letting go of the deceased accommodate grief is still a matter being debated among many theorists. Freud’s theory of grief came up as a result of clinical experience with the depressed people. Therefore, the understanding of Freud on loss and grief may be limited to his specific clinical group and may not be generalized to the population at large. However, Buglass (2010) indicated that the ideas of Freud about loss and grief, and most significantly, the need for confronting grief to let detachment have remained a characteristic of subsequent practice and theory.

Based on this model, the emphasis on the ideas of Freud about grief is on personal attachment. This theory emphasizes that the individuals who are grieving are searching for a lost attachment. Freud described mourning as the detachment from the people who are loved. According to Freud, Mourning is the melancholia state that suggests that when mourning goes wrong, the state of melancholia rises. The state of melancholia is viewed as a profound depression presentation that involves a complete loss of pleasure in almost or everything (Freud, 1961).

The mourning process is viewed as the task of rebuilding individuals inner world by experiencing the pain of loss that is intense that reawakens the effect of loving of what has been lost, which to the spinal cord injury patients are the lost functionalities due to the spinal cord injury. It is suggested that during the process of grieving, the bereaved is letting go of the several involved attachments in the relationship formation. When the individual have accepted the loss, the ego then accommodates the loss, and this enables the individual bereaving to look for new attachments (APS, 2016).

2.2 Kübler-ross model- five stages of grief

Elisabeth Kübler-Ross proposed pioneer methods for supporting and counselling grief and grieving, personal trauma, associated with dying and death. Moreover, she improved the practices and understanding with hospice care and bereavement. Her ideas and most importantly, the five stages of grief are transferable in different ways and to varying degrees, to emotional upset and personal change resulting from factors other than dying and death (KüBler-Ross & Kessler, 2005).

In most instances, alike reactions to the ones described by the grief theory are often witnessed in people who are facing less severe traumas than bereavement and death, such as enforced relocation, work redundancy, disability and injury like spinal cord injury, crime and punishment, bankruptcy, financial despair, and relationship break-up among others. This makes the Kübler-Ross’s grief model worthy of reference and study far outside bereavement and death. Actually, the grief model is a model of change for helping in understanding and dealing or counselling personal reaction to trauma like the spinal cord injury trauma, and not just for dying and death (Williams, 2007). This is because emotional shock and trauma are relative regarding effect on individuals. Whereas dying and death are the ultimate trauma to many people, people can experience emotional upsets that are similar when dealing with several challenges to life, especially if for the first time one is confronting something difficult, or if the challenge being confronted happened to threaten psychological weakness area, which every person possess in different ways.

The five stages of grief also referred to as the grief cycle, was intended by Kübler-Ross to be uniformly timed steps or a rigid series of the sequence. It is a framework or a model and not a process as such. A process means something that is quite consistent and fixed, while the model is less specific, that is more of a guide or shape. For instance, people do not always experience all of the five stages of the grief cycle. Some stages might not be experienced while other stages might be revisited. Moreover, the transition from one stage to the other can be more of a flow and ebb, instead of a progression. The five grief stages are not linear and are not also equal in their experience. The grief of people and other reactions to emotional trauma are personal to every individual just like a fingerprint (Van & Nel, 2011).

From the description, one might wonder what the models purpose is if it varies from person to person. The answer to that is that the grief cycle model acknowledges the existence of an individual pattern of emotional responses that are reactive that people feel when facing bereavement, death, trauma or great loss among others. The grief cycle model recognizes that individuals have to pass through their individual ways when coming to terms with bereavement and death among others, after which, they accept reality, which makes the person cope (Sánchez, 2007).

Moreover, whereas the focus of Kübler-Ross’s grief model was on death and bereavement, it is a useful perspective for understanding other peoples and own emotional reaction to change and personal trauma, irrespective of its cause.

The five stages of Kübler-Ross’s grief model include the following:

2.2. 1. Denial

This is a refusal to admit reality, information, facts among others that relate to the concerned situation either unconsciously or consciously. It is a mechanism for defence and is naturally percept. Some individuals can lock themselves in this stage when facing a traumatic change that can be ignored. Of course, death is not easy to evade or to avoid indefinitely. According to Sánchez (2007), the denial stage helps people in surviving the loss. At this phase, the world of the person who has spinal cord injury becomes overwhelming and meaningless. Life does not make sense, and the person is in the state of denial and shock. The person goes number and wonders how they can go on, and if he or she can go on, why they should continue going on. The traumatised individual try finding a way of going through every day. Shock and denial help the person in coping and making survival possible. Denial helps the traumatised people in pacing their feelings of grief. Cleiren & Clairen (1993) stated that in denial there is grace and it’s a way of nature of letting in only what an individual can handle. As an individual accept the reality of his or her loss and asking themselves questions, they are beginning the process of healing unknowingly. They become stronger, and the denial begins to fade. However, as they proceed, all the feelings an individual denied begin o surface.

2.2.2. Anger

This can manifest in various ways. Individuals that deals with emotional upsets sometimes can be angry with others and themselves, especially the people who are close to them. Understanding this helps in keeping non-judgemental and detached when experiencing someone’s anger which is very upset. Anger is an essential stage in the process of healing. A traumatised person or an individual who have had a spinal cord injury should be willing to feel their anger, despite the fact that the anger feeling may seem endless. The more they truly feel the anger, the more it will start dissipating and the more they will heal. According to KüBler-Ross & Kessler (2005), there exist other emotions during this stage, and the individual will get to them in time. However, most people are used to managing anger emotion. Moreover, there are no limits to anger, and it can extend to the doctors, friends, individually, the family, to God and to the loved ones who passed away. A person may as whether God exists and why He let everything happen. However, underneath anger is a person’s pain. Moreover, it is natural for a person at this stage to feel abandoned and deserted. However, people live in societies that fear anger. Williams (2007) asserted that anger is strength and can also act as an anchor, providing temporary structure to the loss.

According to Van & Nel (2011), grief, at first, feels like being at a sea and lost with no connection to anything. Then an individual get angry to some people, may be a person who is not around, maybe a person who has not visited him in the hospital, or may be a person who has started acting differently given that the individual is traumatised, immobile or is bedridden. Suddenly, the individual develops a structure that is channelling his or her anger to them. Having anger becomes the bridge that creates the connection from the open sea where the patient with the spinal cord injury is to the other people. It is something that they can hold onto, and the connection created from the strength of anger to them is better than nothing. Human beings understand better how to suppress their anger rather than feeling it. After all, anger feeling is just another indication of a person’s intensity of their love.

2.2.3. Bargaining

Traditionally the stage of bargaining for the individuals facing death involves an attempt to bargain with their Gods whom they believe. On the other hand, the people facing trauma that are less severe can seek negotiation or bargain for a compromise. According to Sánchez (2007), bargaining rarely offers a solution that is sustainable, especially if it’s a life or death matter

Similarly, APS (2016) pointed out that before a loss, it seems that an individual will do anything if only what they love, or the people they love will be spared. The patient with spinal cord injury will bargain, “please God,” “I will always do good if you let me live a normal life again.” Bargaining after the loss takes the form of a temporary truce. The individual get lost in a maze of “what if…” or “if only…” statements. The individuals want to be returned to what it was before; they want what they lost to be restored like their mobility. They want to go back in time to find what is causing them pain sooner, to stop the accident from occurring, to get healed quickly.

Dell & Power (2007) stated that guilt, in most instances, is often the companion of bargaining. The “if only…”makes the individuals find faults in themselves and what they think they could have done in a different way. The spinal cord injury patients may even start bargaining with pain. They will do anything so as not to feel the pain of the loss. The individuals will remain in the past, making attempts at negotiating their way out of the hurt.

People usually think that the stages last weeks or even moths. In reality, the stages are responses to an individual’s feelings that can last for hours or even minutes as they flip in and out of one stage to the other. Moreover, people do not linearly enter and leave each stage. They may feel on stage, and then the next one and back again to the initial one.

2.2.4. Depression

This stage is also referred to as the preparatory grieving stage. In some ways, this stage is the rehearsal or the preparation or the practice in readiness for the aftermath. However, Winokuer & Harris (2012) indicated that this stage means different things depending on the individual who is involved. It’s also a form of emotional attachment acceptance. It is also natural for the traumatized individual to feel regret, sadness, uncertainty, or fear since it shows that the individual, at least, has begun accepting the reality.

According to Wilson (2014), at the depression stage which is after bargaining, the attention of the spinal cord patient squarely moves into the present. Empty feelings get in and grief enters into their lives deeper than they ever imagined. This stage of depression feels as if it will last forever. Sanders (1989) stated that it is significant to understand that the depression that sets in is not a mental illness sign. It is simply the appropriate response to the patents great loss.

The spinal cord injury patients often are left in an intense sadness, withdraw from life, wondering perhaps, if is there any strong reason for going on, and even why continue going on at all? In most cases depression after a loss is seen as unnatural. The first question that the depressed patient should ask himself or herself is whether the situation they are going through is depressing. The loss of a body functionality like the mobility of the limbs is a situation that is very depressing, and depression is an appropriate and normal response. By not experiencing depression after losing a vital body functionality would be very unusual. When the loss fully settles in the soul of the spinal cord injury patient, their realization that their condition did not improve this time, and their main body functionality is gone forever is reasonably depressing. If grief is a therapeutic process, then despair is one of the essential footsteps during the journey (Van and Kayes, 2014).

2.2.5. Acceptance

This stage also varies according to the individual’s situation, despite the fact that generally it is an indication that there are some objectivity and emotional detachment. According to Ribbens (2006), the people dying can enter into the acceptance stage a long time even before their loved ones left behind, who necessarily must pass through their individual stages on how to deal with grief. The acceptance stage is sometimes confused with the notion that everything is “ok” or alright with what occurred, which is not the case. According to Stroebe (2008), most people do not ever feel alright about their loss. The acceptance stage is about accepting and living with the reality that what the individual loved, or the loved ones, or the core functions of the spinal cord are gone and recognizing that the new reality will be permanent. The spinal cord injury patients will never make it OK or like it, but eventually, they will accept it. They will learn to live with the aftermath of their spinal cord injury. It is the new norm that they must learn to live. They must try living in a world where their former abilities like mobility are missing. In trying to resist this new norm, at first, most of the patients want to continue maintaining their lives the way it was before they lose their spinal cord functionalities. In time, through pieces and bits of acceptance, however, they realize that they cannot maintain their past intact. It has been permanently changed and. Therefore, they must readjust (Sanders, 1989).

Additionally, KüBler-Ross & Kessler (2005) indicated that the spinal cord injury patients must learn to recognize roles, take them themselves or reassign them to others. As the people beginning living again and enjoying their lives, they will feel like they are betraying what they lost. People can never replace what they have lost, but they can try making new connections, new inter-dependencies and new relationships that are meaningful. They should listen to their needs rather than denying their feelings; people evolve, grow, change, and move. They may start by reaching out to others and becoming involved in their lives. The traumatised individuals invest in their relationships and friendships with themselves. They begin living again, but that cannot be done until grief has been given its time.

2.3 Attachment Model of Bereavement

The research on Grief and bereavement was spearheaded by John Bowlby and Colin Murray Parkes. The study by Bowlby on infant attachment assisted in informing the research on bereavement and grief. According to the researchers, an adult who is grieving is less like an infant experiencing separation anxiety when their parents disappear from view. They further indicated that as human beings evolved, they learn to form attachments and also protest when the people they love leave (Bowlby, 1969).

Bowlby took all his theories and observations about separation and attachment and applied them to bereavement ad grief. He stated that there existed a relational system in these relationships of attachment. These attachments create a system at this moment the individuals are impacting each other constantly, trying to maintain their relationships in various ways. Bowlby suggested that when a loss occurs, for instance, loss of mobility due to spinal cord injury, the normal adaptive response was grief. According to Cassidy & Shaver (1999), Bowlby felt that the response was grounded on the psychological and environmental makeup of the person grieving and that there were some usual reactions an individual might expect. The bond of affection has been broken which leads to grief

Being an ethologist, Bowlby regarded grief to be attachment behavioural system’s natural part which natural selection designed to discourage prolonged infant separation from his or her primary figure if attachment to increase survival chances and hence reproduction (Parkes, Hinde, & Marris, 1991).

Bowlby believed that since the many species infants need older individual’s protection for them to survive, they evolved both behavioural and physical adaptations so as to capture and get the attention of and also to maintain the proximity of their parents or potential caregivers. When the infant judges that the attachment figure is not available, the infant starts experiencing anxiety and tries to re-establish contacts using behaviours such as clinging, approaching, crying and searching. Bowlby believed that the infants “protest” against their separation served the adaptive function of the evolution of keeping nearby the protective attachment figures.

According to Leick & Davidsen-Nielsen (1991), Bowlby though that these similar psycho-behavioural tendencies by the infants to protest their loss to seek for a reunion with a figure f attachment get expressed when an adult loses a person he or she loves. This implies that the Bowlby believed that the similar psycho-behavioural phenomena are underlying both permanent and temporary separations from the attachment figures with no regarded to the age of the individual who is experiencing the loss.

Young & Dowling (2012) pointed out that Bowlby suggested that with the reaction of infant to separation from his or her caregiver, the grief of an adult generally also follows the predictable phases which involve first the intense protest, followed by despaired and then hopelessness when their protests are not bringing about their desired reunion with the people they love. Stroebe et al (2001) indicated that after the protest, typically there is a phase of reorganization that involve the renewal of interest gradually in other relationships and activities. Despite the fact that these phases are experienced sequentially in most instances, they are not necessary or always and may sometimes be experienced in a different order or even in a cyclical manner depending on the circumstances and the person.

According to Neimeyer (2011), Bowlby indicated that grief involved moving through the emotional reaction sequence. However, despite the fact that it is difficult to experience them, it is necessary for the bereaved wellbeing. He further stated that for a grieving individual not to experience these emotions after a significant loss, can result in physical and psychological ill health. Therefore, he considered both unresolved (unending) and the suppressed (unexperienced) grief as pathogenic.

The attachment model of bereavement by Bowlby and Parkes gives a description to the four predominant reactions to the death of the persons loved. These are the four phases that were broken down by the natural adaptive grief response. Pearlman et al (2014) indicated that the researchers pointed out that the reactions may overlap each other and should not be viewed as linear stages where one progresses through from one to the next. These reactions included numbness, yearning, disorganization and despair and reorganization

2.3.1. Numbness and shock

This is a stage where the sense of loss seems impossible to accept and not real. During this phase, Payne, Horn & Relf (1999) indicated that there is physical distress that can lead to somatic symptoms. If the person is grieving, like the spinal cord injury patient, do not progress through the numbness and shock stage, they will struggle to accept and to understand their emotions and to communicate them. Finally, they will shut down emotionally and not move on through the other grief phases.

Similarly, this phase represents the first few hours after an individual have been involved in a spinal cord injury; they are numb. They tend to have the feeling of disbelief and at the same time the emptiness. The full weight of losing some of his functionalities due to spinal cord injury have not yet been registered with him.

2.3.2. Yearning and searching

During this stage, the individual grieving is acutely aware of the void left in his or her life from the loss. Van and Kayes (2014) stated that the future these people imagined is no longer possible. For instance, in the case of the spinal cord injury patients, the future they imagine for instance being the best athlete, dancer, swimmer or any other activities that involved mobility is no longer a possibility. They try searching for the comfort from what they used to have from what they lost and also try filling the void of their absence.

The grieving individuals will continue identifying with the person who passed away or from they lost, constantly looking for the reminders of them and the ways of being close to them. Fr the spinal cord injury patients, their constant reminders could be watching their photos or videos of the past while doing what they loved.

Moreover, as the numbness wore off in the next few days, the spinal cord injury patient will be in agony. The grief will be coming in waves and typically yearning lasts between five and fourteen days after suffering the loss or the injury. The grieving individual will have feelings of panic, could not sleep and will also be unable to concentrate. Bowlby also indicated that a person in this phase will keep thinking that he felt ok, but it is always other people walking around or going about their businesses (Ribbens, 2006). Moreover, during the yearning stage, the bereaving spinal cord injury patients may experience anger and guilt and be irritable. The patient may feel guilty for not playing safely or not taking precaution to avoid his spinal cord injury. Similarly, they may also express their anger towards the doctors for not being able to save his spinal cord or being able to treat him fully to his recovery.

Parkes and Bowlby observed that if the grieving persons cannot progress through the yearning and searching phase, they will spend their whole life trying filling the void from their loss and remain preoccupied with what they lost or with the person thy lost.

2.3.3 Despair and disorganization

According to Bowlby (1969), during this phase, the grieving persons have accepted that everything has changed totally and will never go back to the way they imagine or the way it was. There are despair and hopelessness that comes with this phase as well as questioning and anger for the spinal cord injury patients in this phase, and they have accepted that everything has changed, and they will probably be confined to a wheelchair and life will not go the way they imagine or the way it was. The feeling of despair and hopelessness slowly creeps in as well as questioning and anger with their current condition. To them, life feels as though it will never make sense or improve again without the presence of what they lose or the person who passed away. The grieving person way also withdraw from the others

For the case of the spinal cord injury patients in this phase, as time passes, they will feel less intense pangs of yearning and guilt. The reality will sink that some of the functionalities of their spinal cord was good forever. They then become depressed and apathetic. This response, according to Bowlby may last even up to a year and more for some grieving people abo their loss or for losing their loved ones. Moreover, some people may lose in outside activities, work and friends and emotionally shut down (Stroebe, 2008).

According to Bowlby and Parkes, if the grieving individuals do not progress through the despair and disorganization phase, they will continue to be consumed by depression, anger and their attitude towards life will remain hopeless and negative.

2.3.4. Re-organization and recovery

The faith in life for the grieving persons who have reached this phase starts to be restored. They establish new patterns and goals of the day to day life. They start rebuilding slowly, and they come to realize that their life even after the loss can still be positive. Their trust is restored slowly. According to Cassidy & Shaver (1999), in this phase, the grief of the bereaving persons is neither fully resolved nor go away. However, Bowlby indicated that the loss shifts and recede to a hidden part of the brain, where it continues influencing the person but is not at the minds forefront.

For the spinal cord injury individuals in this phase, they will be able to compose themselves eventually. They will devote less energy to their attachment and their loss of spinal cord functionalities, and more energy to their other abilities and friends. The loss may still be hard dealing with from time to time, but with time, but they will be able to remember their former life and still move forward with their lives (Young & Dowling, 2012).

2.4 Erich Lindemann’s grief work

The work of grief was a term coined by Erich Lindemann back in the 1940s when conducting some studies on the grieving survivors of the tragedy of coconut grove. According to Lindemann (1979), many researchers and authors have cited his work on trauma as one of the vital early studies that revealed long-term impact of trauma and grief. Similarly, Lindemann later influenced other grief theorists like Kubler-Ross and Bowlby.

According to Lindemann (1944), the interest of Lineman was in understanding grief symptomology. Through his studies, he established some symptoms of grief that are common which included:

I. Somatic distress-

These included things like losing appetite, difficulty breathing, lack of motivation and exhaustion among others. Somatic distress can also be seen amongst the spinal cord patients, and these symptoms physically manifest themselves (Stroebe et al, 2001).

II. Preoccupation with the deceased images

According to Lindemann, these included fixating on particular images of the individual who just passed away. Sometimes these were difficult memories or images and sometimes they are positive memories or images. This could also include the grieving person continuing to talk or see the deceased person. For the spinal cord injury individuals showing this symptom, the individual will preoccupy himself or herself with memories or images of himself before when he or she was able to function well using his or her spinal cord. These memories can either be positive or negative (Neimeyer, 2011).

III. Guilt-

In his research, Lindemann also reported that his patients reported guilt often, fixating on any event whereby they believe that they should have done something or could have done something to prevent the death. For the spinal cord injury patients, the guilt may manifest in different scenarios. The patients will preoccupy himself or herself with an event which they believe they could have done something or could have done something to prevent their spinal cord injury. For instance, if the patient injured his or her spinal cord due to the vehicle over speeding, engaging in extreme sports or engaging in violent activities, they will regret doing so. Majorly, they will fixate and wish that they did not engage in these activities (Pearlman et al, 2014).

IV. Reactions that are hostile

Lindemann observed that that the next symptom was hostile reactions of the grieving persons towards others. He noted that despite the fact that when people are trying to be supportive and thoughtful, he is grieving individuals often feel hostile and irritable towards others (Payne, Horn & Relf, 1999).

Hostile reactions from the spinal cord injury patients towards others is also a symptom when they are grieving. These individuals will be harsh to their people even to the people who are supportive or taking care of them. They feel despair since they are immobilized, are in a sorry state and cannot do anything from their location

V. Loss of conduct pattern

Despite the fact that the loss of conduct pattern looks strange, it is something that most grieving individuals relate to easily. This is the experience that even the tasks and activities that are most basic become a chore. The grieving individuals in showing this symptom are restless often, and yet the activities do not look meaningful, and even the activities of every day to them needs much effort to finish (Buglass, 2010).

For the grieving spinal cord injury patients showing this sign, it can be as a result of the inability of them to do it. Similarly, it can be a manifestation of the symptom of loss of conduct pattern.

VI. Moreover, Lindemann noted the sixth and the reaction that is less common, whereby the deceased person’s traits would appear in the person bereaving. Lindemann provided numerous examples that range from adopting the hobbies and interest, walking like the individual or seeing resemblances in their appearance to the deceased. For this symptom is not common among the spinal cord injury patients but is sometimes evident in grieving persons who have lost their loved ones (Lindemann, 1979).

The most significant thing in the work of Lindemann was his evidence that grief has both physical and psychological impact. He indicated that these symptoms can start manifesting immediately, may be absent, be exaggerated or be delayed. Also significant to the theory by Lindemann was the idea that grief can take either a morbid or normal trajectory and lastly that professionals of mental health can assist in getting an individual back to the normal grief reaction trajectory.

By doing the grief work, Lindemann understood how individuals progress through grief and eventually reduce the grief symptoms. He explained that grief work for different people will take different times, but ultimately will need the same three tasks. According to Lindemann, grief work involved the following: Emancipation from bondage from the deceased, readjusting to the new environment whereby the deceased is absent, and Creation of new relationships (Lindemann, 1944).

2.4.1. Emancipation from bondage from the deceased

To begin with the emancipation from the bondage from the deceased, people do have attachments that are a string to the person they lost or anything that they lose. These connections are connected to the people negative reactions and incredible pain. Lindemann explained that people need to move on, that is to emancipate from the bondage, for people to proceed with the grief that is normal and continue and form new relationships. He further clarified that this is different that a person forgetting about the people they lost (Dell & Power, 2007).

For the spinal cord injury individuals, they have strong attachments to their spinal cord and their crucial functionalities that come with it. However, when a person loses the functionalities of the spinal cord due to injury which they have strong attachments, these connections are linked to their negative reactions and incredible pain. According to Lindemann, an individual need to emancipate from the bondage and this requires the spinal cord injury patient to move on for him or her to proceed with the normal grief and form new relationships. This implies that they should forget about what they loved doing when they were able to use their spinal cord, like walking or engaging in activities things and start forming new relationships due to their condition (Winokuer & Harris, 2012).

2.4.2. Readjusting to the new environment whereby the deceased is absent

In this phase, Landman indicated that it is also evident in other grief theories and is also straightforward. After an individual has lost someone, to them, the world becomes totally different, yet it is the same. The grieving person’s need to find a way of making sense of the world that their loved one is gone and is no longer part of them physically (Cleiren & Clairen, 1993).

For the spinal cord injury patients who have lost their spinal cord functionalities, during this phase, they need to readjust to their new environment whereby their spinal cord abilities are absent. These patients who have lost their spinal cord abilities, the world, is totally different, yet it is utterly the same. Therefore, they need to find ways of making sense to the world that their mobility is no longer possible. So they can readjust to using wheelchair, or living with a carer who will be taking care of their needs for the remaining part of their lives

2.4.3. Creation of new relationships

This is the last bit, where the grieving individuals need to form new relationships. According to Lindemann, by the grieving persons letting go of their attachments is an important part of creating new relationships.

For the spinal cord injury patients in this phase, they will create new relationships by being dependent on others for support or help, or adapt to using a wheel chair or having a carer at his or her disposal (Wilson, 2014).

2.5 Rando’s six “R” Model

Rando conceptualized the processes in her model that an individual must accomplish throughout the mourning phases. The processes in Rando’s six “R” Model are broken down into three phases of mourning. According to Wilson (2014), Rando suggested that the six “Rs” fall within the three mourning phases. It is of great importance to point out that Rando was careful in differentiating mourning from grief. She described grief as more of an involuntary reaction to an individual’s loss. On the other hand, Rando described mourning as an active, ongoing process of accommodation. The three mourning pass are the phase of avoidance, the phase of confrontation and the accommodation phase. During each of the phases, there is an “R” process that gets accomplished.

2.5.1. Avoidance Phase

1. Recognize the loss– this implies acknowledging and understanding death. This takes place in the avoidance phase. According to Rando, mourning that is normal will mean completing the six processes described above successfully. For Rando, when an individual recognizes the loss, it means understanding the loss cause as well as accepting the loss reality. For certain types of losses, Rando (1984) pointed out that the understanding can be difficult especially disenfranchised deaths, overdosed and suicides among others.

For the spinal cord injury patients experiencing this process, he or she has recognized his or her loss and what caused it. Moreover, they have accepted the reality of their loss. If their spinal cord injury was caused by accidents in a vehicle crash, extreme sports accidents or any other violent activity that resulted in their spinal cord injury, the patient under this process can recognize it and accept the reality that he or she has lost some the spinal cord functionalities.

2.5.2. Confrontation Phase

2. React to the separation– according to Rando (1986), this process involves experiencing the pain, identifying, and feeling, expressing and accepting reaction to the loss. It also includes identification and reaction to secondary losses. This process takes places in the confrontation phase

Rando (1984) elaborated that reacting to the loss implies that the that the individual is feeling, accepting, identifying and expressing reactions to his or her loss, but also expressing and identifying reactions to any other secondary losses related to the death or trauma. This could be the loss of the role (husband, mother, sibling or wife), loss of financial security, loss of faith in human nature, God among others. These secondary losses impact can often be underestimated or ignored. But, must be addressed as part of the process of reaction.

To the spinal cord injury patients reacting to loss, they will be feeling, identifying, accepting and expressing their reactions to their loss of spinal cord functionalities. Moreover, these patients will also be identifying and expressing their reactions to other associated secondary reactions with their trauma or spinal injury. The bedridden or immobile spinal cord injury patients will have lost their financial security, sometimes their faith in God and also their roles as wives, mother or husbands. Therefore, as a reaction process, all these factors should be addressed (Sanders, 1989).

3. Recollect and re-experience the relationship and the deceased- this needs reviewing and remembering realistically the deceased, as well as re-experiencing and reviving feelings. This also occurs in the confrontation phase.

Recollecting and re-experiencing the person who has passed away is the third “R”, is a significant step to incorporate memories into the present. This is because the memories will be a significant part of integrating the mourning individuals relationship with the person who dies into the present.In this step, an important point is recollecting, addressing honestly the good and bad memories and the relationship (Ribbens, 2006).

For the spinal cord injury patients recollecting and re-experiencing their loss will incorporate their memories into the present. These memories will become a significant part when they are integrating their relationship with what they lost into the present. The spinal cord injury patients should recollect and address with honesty the bad and good of their memories for proper mourning.

4. Relinquish old attachments to the old supportive world and the deceased- this takes place in the confrontational phase. This process according to Rando (1986) sounds unpleasant and harsh. This process’ reality is an acknowledgement that there exist certain things that a grieving individual will need to let go for him or her to move forward. Despite the fact that the process sounds like its severing abruptly, the actual process takes place over an extended period and allows a person to let go of things will taking their time to be comfortable with the idea that in the new world they will be okay without their loss or the deceased. Dell & Power (2007) asserted that it is of great importance to understand that this process is not letting everything go, but instead things that an individual must relinquish to continue going forward to the new world.

Similarly, the spinal cord injury patients in this process need also to relinquish their old attachments to the spinal cord functionalities they lost and their old assumptive world. The spinal cord injury patients need to acknowledge that for them to move forward, there are certain things in their life that they will need to let go. These things could include their old secondary roles at work or in the house, their jobs, and their sporting activities among others. This does not imply that they will need to let go everything they used to do, but just relinquishing things that are compulsory for them to continue moving forward with their recovery to a new better world (Stroebe, 2008).

2.5.3. Accommodation Phase

5. Readjust to move into the new world adaptively without forgetting the old world- this implies forming a new relationship with the deceased, adopting new ways of living and being in the world, and re-creating a new identity. This process takes place in the accommodation phase.

Readjusting as the fifth “R” according to Winokuer & Harris (2012) comes naturally after relinquishing the old attachments. This is the process where the grieving person has also moved to the third phase of accommodation. The grieving person after relinquishing the old attachments and embracing the new world with new ideas without their loss or the deceased establishes a new identity in the new world while still remembering and integrating the world before the loss or the death of the deceased. This is also an important time for the grieving person to find new ways in the new world of being comfortable and creating a new identity.

Similarly, for the spinal cord injury patients who are readjusting after relinquishing their old attachments, should be comfortable in the new world without the lost things due to their spinal cord injury. The grieving spinal cord injury patients readjusting should also establish a new identity in the world while still remembering and integrating their world before they lost their spinal cord functionalities and other secondary abilities. This also the time for them to find new ways of becoming comfortable in their new world and forming their new identity.

6. Reinvest- this implies putting the emotional energy into new goals, people among others. This takes place in the accommodation phase. This is the last process under Rando’s six “R” Model. A grieving person, like a spinal cord injury patient, who is in the process of reinvesting must invest emotional energy ultimately into new life experiences, goals and new people in the new world without what they lost or the deceased. Cleiren & Clairen (1993) pointed out that it is important to note that according to Rando, the phase of accommodation does not imply reinvesting in finding new things to replace the deceased. Instead, it implies creating space for new things in the new world while also marinating space for the different and new type of relationship with the deceased or what they lost. Rando in her Rando’s six “R” Model, wants grieving people to remember that the goals are to learn how to live with their losses and not finding someone time closure.

3.0 Conclusion

In conclusion, the paper discussed the typical stages of bereavement after sustaining a spinal cord injury. To understand the stages of bereavement, the paper applied different theories and models of grief and bereavement to apply them to a bereaving spinal cord injury patient. The bereavement and grief theories used in the paper included; Freud’s model of bereavement, Kubler-ross model-five stage grief, attachment model of bereavement, Erich Lindemann’s grief and finally Rando’s six “R” Model.

Freud’s model of bereavement was based on getting detached from the deceased person to overcome grief. On Kubler-ross model-five stage grief also referred to as the grief cycle also elaborates on its five phases of bereavement that apply to spinal cord injury patients; denial, anger, bargaining, depression, and acceptance.

Attachment model of bereavement by John Bowlby and Colin Murray Parkes gives a description to the four predominant reactions to the death of the persons loved. These are the four phases that were broken down by the natural adaptive grief response. These reactions included numbness, yearning, disorganization and despair and reorganization. On the other hand, Erich Lindemann’s grief which was based on some symptoms of grief that are common included somatic distress, preoccupation with the images of the deceased, guilt, hostile reactions, loss of conduct pattern and lastly the deceased person’s traits appearing in the person bereaving.

Finally, Rando’s six “R” Model is broken down into three phases of mourning. The three mourning pass are the phase of avoidance, the phase of confrontation and the accommodation phase. During each of the phases, there are an “R” process that gets accomplished which includes; recognizing the loss; reacting to the separation, recollecting and re-experiencing the relationship and the deceased; Relinquish old attachments to the old supportive world and the deceased; Readjusting to move into the new world adaptively without forgetting the old world; and finally Reinvesting.

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