Psychiatric Mental Health, part 7: Crises, Loss, and Grief

by Cathy Parkes July 26, 2021 Updated: September 05, 2021

You've probably heard of the five stages of grief, but in this article on crisis, loss, and grief, we'll also cover maturational, situational, and adventitious grief; actual vs. perceived loss, and complicated, anticipatory, and disenfranchised grief.

This series follows along with our Psychiatric Mental Health Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Crisis Management

A crisis is an overwhelming event that causes significant psychological stress. Crises management and crisis intervention are a key part of psychiatric mental health nursing. The types of crises we'll cover here include maturational, situational, and adventitious.

Maturational

A maturational crisis is a life-changing event that occurs as a normal part of the lifespan, but causes significant stress. Examples of maturational crises include marriage, having a baby, retirement, or sending a child off to college. These are all normal life events, but they can cause stress.

Situational

A situational crisis is an unexpected life event, like the loss of a job or the sudden death of a loved one.

Adventitious

An adventitious crisis is known as a crisis of disaster. It can include a natural disaster, such as a tornado, hurricane, or fire. It can include a national emergency, such as a terrorist attack, or it can include a violent crime, such as sexual assault.

Nursing care for a patient in crisis

When providing nursing care for a patient in crisis, your priority always is to provide for patient safety.

Beyond ensuring patient safety, you can assist the patient with anxiety reduction. You can assess the patient's support system (family and friends). You can also evaluate their coping skills and find out what coping mechanisms they have used in the past successfully. It's possible they can use those same coping mechanisms with the current crisis.

Loss

Loss is defined as having someone or something removed from ones' life in a way that causes a feeling of grief. Here, we'll discuss an actual loss vs. a perceived loss.

Actual loss

An "actual loss" is a loss that is recognized by others, such as the loss of a loved one, a job, or a limb. It may be helpful to think of an actual loss as a visible loss.

Perceived loss

A perceived loss is a loss that is not necessarily seen or felt by others. If an individual has loss of their mental acuity or a feeling of lost youth, those are perceived losses.

Grief & the five stages of grief

Grief is a normal response to loss. We'll explain the five stages of grief and some different types of grief.

Stages of grief

There are five stages of grief: denial, anger, bargaining, depression, and acceptance.

Denial

The first stage of grief is denial. Denial is rejection of reality. For example, a patient who does not accept their cancer diagnosis is in denial.

Anger

After denial comes the anger stage of grief. During the anger stage, a patient may have a short temper, lash out, or blame others for an injustice. The patient might have anger directed towards the provider, or a higher power (e.g., God).

Bargaining

Next up in grief is the bargaining stage. The bargaining stage of grief is when the patient negotiates in an attempt to get control over the situation. Again, the patient may attempt bargaining with the provider, or with a higher power.

For example, bargaining might look like a patient saying, "Dear God, if you heal her, I promise I'll go to church every day for the rest of my life."

Depression

The next stage of grief is depression. During the depression stage, a person might be sad, fatigued, or exhibiting anhedonia (inability to feel pleasure).

Acceptance

The last stage of grief in this model is acceptance. During the acceptance stage, a patient is able to acknowledge the loss or the impending loss. This does not mean the patient is happy about the loss they've experienced, but they accept the reality of the situation and acknowledge that loss.

Complicated grief

Complicated grief, which is also called prolonged grief disorder or pathological grief, is a type of grief that lasts for a long period of time. A patient experiencing complicated grief has intense, prolonged sorrow, for more than a year, that interferes with their daily functioning.

So, one year after a loss, if someone is not leaving their house, not bathing, not eating properly, or taking care of themselves, then that would be indicative of complicated grief.

Anticipatory grief

Anticipatory grief is grief in response to a known, impending loss. If a person is given a terminal diagnosis, then they and their family members would have anticipatory grief in anticipation of that loss.

Disenfranchised grief

Disenfranchised grief is a loss that is not publicly acknowledged. The lack of support received during disenfranchised grief can prolong emotional pain.

One example of disenfranchised grief is grief following a miscarriage. People may not share with their friends and family if they've had a miscarriage, but they will still be grieving the loss of their baby.

Other examples of situations that can lead to disenfranchised grief are dementia or addiction in a loved one, death of a patient, death of an unrecognized relationship (like an ex-partner, extramarital partner, absent parent, or in a same-sex relationship if the person isn't out and feels unsafe grieving the loss of their partner), or death of members of one's community.


Full Transcript

Hi. I'm Cathy with Level Up RN. In this video, we are going to talk about crisis management as well as loss and grief. And if you stick with me through the whole video, at the end, I'm going to give you guys a little knowledge check, a little quiz, make sure you've been listening and picking up on some of the key concepts that I'll be covering. Also, if you are new to the channel, or maybe you're not new to the channel, but haven't subscribed, be sure to subscribe to our channel. We'd love to have you.

All right. Let's first talk about crisis management.

A crisis is an overwhelming event that causes significant psychological stress. And there are three types of crises that we're going to talk about.

The first is a maturational crisis. So this is a life-changing event that occurs as a normal part of the lifespan but causes significant stress. So examples of this could be marriage, having a baby, retirement, sending your baby to college, which is something I'm getting ready to do. These are all normal life events, but they can cause stress.

And then we have a situational crisis. So this is an unexpected life event. So this could include loss of a job or the sudden death of a loved one. Then we have an adventitious crisis.

So an adventitious crisis can include a natural disaster, such as a tornado, hurricane, or fire. It can include a national emergency, such as a terrorist attack, or it can include a violent crime, such as sexual assault.

So in terms of nursing care, your priority always is to provide for patient safety. And then beyond that, you want to assist the patient with anxiety reduction. You want to assess the patient's support system, right, their family, their friends. And also, evaluate their coping skills and find out what coping mechanisms they have used in the past successfully so that perhaps they can use those same coping mechanisms with the current crisis.

All right. Let's now transition to talking about loss and grief.

So with loss, we have an actual loss and a perceived loss.

With an actual loss, this is a loss that is recognized by others, such as loss of a loved one.

Perceived loss is a loss that is not felt by others. So if an individual has loss of their mental acuity, that is not known to others, necessarily, but it is still a loss.

All right. Grief. Let's go through the five stages of grief.

The first is denial. So this is rejection of reality. So a patient who does not accept their cancer diagnosis, they are in denial at that point.

Then from denial, we go to anger. During this stage, an individual may have a short temper, and they may lash out and blame others for the injustice. So that can include the provider or a higher power.

Then we move to bargaining. This is where the patient is negotiating in an attempt to get control over the situation. So they may say, "Dear God, if you heal her, I promise I'll go to church every day for the rest of my life." That would be an example of bargaining.

Then from bargaining, we move to depression. So during this time, the individual is sad. They may be exhibiting fatigue.

And then, finally, we move to acceptance. So during the acceptance stage, the individual is able to acknowledge the loss or the impending loss. Doesn't mean they're happy about it, but they accept the reality of the situation and acknowledge that loss.

All right. Now that we've reviewed the five stages of grief, let's talk about some different types of grief.

So one type of grief is complicated grief, which can also be referred to as prolonged grief disorder or pathological grief. This is where an individual has intense, prolonged sorrow for more than a year that really interferes with their daily functioning. So a year after a loss, if someone is not leaving their house, not bathing, not eating properly, or taking care of themselves, then that would be indicative of complicated grief.

Then we have anticipatory grief. So this is in response to an impending loss. So if an individual is given a terminal diagnosis, then that individual and his or her family members would definitely have anticipatory grief in anticipation of that loss.

Then we have disenfranchised grief. So this is a loss that is not publicly acknowledged. So an example of this would be a miscarriage. Often, people don't share with all their friends and family if they've had a miscarriage, but obviously, that is still a loss, and they will be grieving the loss of their baby.

Okay. It's time for a quiz. So I've got three questions for you. First question: a hurricane is an example of what type of crisis? If you said adventitious crisis, you are right. Next question: name the five stages of grief. All right. Here they are: denial, anger, bargaining, depression, and acceptance. Last question: what kind of grief is characterized by intense sorrow that lasts more than a year and interferes with an individual's daily functioning? That would be complicated grief. Hope you did great on that. And I will see you in my next video, where we will talk about defense mechanisms. Take care.


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