The Psychological Impact on Families of Departed Patients with Infectious Diseases

Abstract

Looking back into history, infectious diseases played an important role in human history being responsible, in terms of pathologies, for more deaths than any other disease. Considering that infectious diseases have a high rate of transmissibility, with an acute debut and sometimes with a fast evolution to exitus, the impact of the news on families of the departed patient diagnosed with an infectious disease can come as a shock. Processing the unexpected death of a family member needs not only the implication of the physician but also the counseling of a specialized psychologist which can help the families through all stages of loss and grief.

1. Introduction

Mourning is the emotional response to loss. The mental suffering caused by mourning has emotional, physical, behavioral, social and spiritual consequences [1]. Suffering may manifest differently depending on each person’s personality, family values, culture and religious belief [2].

In medical practice, 2 types of mourning are often present which include the anticipatory mourning, occurring when a dear person is suffering from an incurable disease and the mourning associated with personal experience.

Mourning is influenced by age and gender and it is a known fact that women are more vulnerable to loss, due to the level of anxiety and insecurity of attachment ties. Also, the elderly are the most vulnerable in experiencing the mourning to the extent that it reminds them of an expected denouement. In association with age and gender, personality traits such as the level of emotional control and regulation, frustration resistance, traits of optimism and resilience, are important mediation factors of mourning [3].

Identifying the meaning of loss and finding a new meaning in life remains the main challenge for all mourning people. The coping mechanism of the person facing a loss is the recovery process that will allow the continuation of a normal life in the absence of the loved one [4].

2. Stages of processing a loss

Even if its course and manifestations are different, the researchers have shown that the processing of loss has several sequential and predictable stages:

• Shock and disbelief which appears immediately after a traumatic loss or event, one cannot believe that the event happened or even denies it.

• Sadness represents a healthy and normal feeling of being in a situation of loss. The feelings of inner emptiness, despair, desire for loneliness may also occur in situations of major loss. If there is no improvement from one day to the next, depression has settled in.

• Guilt - another common feeling is regret or guilt over things that have remained unspoken or unfulfilled and also can be associated with guilt over feelings of relief after dealing with a long and painful illness of the loved one.

• Anger/annoyance - in many cases, loss can seem unfair and make us feel angry or upset. For many people, the therapy for overcoming loss is an exercise in forgiveness or anger release.

• Fear - a significant loss can trigger feelings of anxiety, helplessness and insecurity and even lead to panic attacks.

• Physical symptoms - due to the intense levels of stress associated with psychological suffering caused by loss, our body also responds physically, not only emotionally by symptoms that may include fatigue, nausea, dizziness weight loss or gain, pain and insomnia [5, 6, 7].

All life problems are seen as social problems, and as with any other expressions of life, the suffering must be seen holistically (biopsychosocially) and in relation with the personality as a whole.

3. The role of the therapist

The therapist provides the emotional support needed to express, manage and respond to pain and supports the patient in mourning and establishes the defense mechanisms and strategies that the person uses to cope with the loss through psychological counseling, crisis intervention and supportive therapy. The active, empathetic and thoughtful engagement of the professionals coming in contact with persons living in grief leads to the adaptation of the way the subject constructs his reality and the meaning of loss, the first step towards a humanistic and efficient intervention [8].

Loss is a syndrome with psychological symptoms and somatic signs that may evolve normally to remission or abnormally to a mental disorder that must be addressed like any other mental disorder [9].

The researchers have shown that the loss processing has several sequential and predictable stages (Table 1):

Freud	Bowlby & Parkes	Kubler-Ross	Worden	Stroebe &Schut
The process of hyper cathexis (pain, thoughts and memories related to the missing person)	The phase characterized by shock, perplexity and denial that keeps the subject in a state of unreality	The denial phase - the individual does not accept that the loved one has died	The phase of accepting the reality of loss	The phase of loss of orientation that is given by the effort to overcome the loss, such as intrusive thoughts about the missing person, remembrance of the past, deep sadness
The decathexis process (relaxation of the emotional connection with the deceased person)	The phase characterized by deep grief towards the missing person and by waves of crying, pain and anxiety and sometimes by the feeling of the missing person’s presence	The rage/anger against oneself for not doing the right thing, the tendency to blame others.	The phase of grief and loss of regret	Orientation restoration phase which includes avoiding feelings of mourning by focusing on the future and solving secondary transition problems
The cathexis process (recovery of the emotional energy invested in the missing person)	Disorganization and detachment phase characterized by strong sadness and feeling of hopelessness	The negotiation phase - the attempt to negotiate in the imaginary or with a supernatural force the return of the lost person.	Phase of adaptation to the environment in which the deceased person no longer exists
	The reorganization phase, involving the missing relaxation and the return to the future	The sad phase - in which the subject is inhibited, withdrawn, disillusioned, hopeless.	Phase of emotional relocation of the missing and return to the current life
		The acceptance phase - the individual realizes and accepts the loss through contemplation, reflection, finding meaning in loss and continuation of life

Table 1.

Models of the stages of mourning.

• denial of loss;

• anger;

• bargaining;

• depression;

• acceptance [10, 11].

For the family of the deceased patients in hospitals, the shock of loss followed by potential depression of mourning is a reality that the psychologist and the attending physician face every day and try to prevent [12].

Challenges of loss in medical practice:

• anticipatory mourning which occurs when a dear person is suffering from an incurable disease;

• the mourning associated with personal experience.

There are 3 basic theories on mourning counseling - some might call them beliefs. The first one suggests the idea of mourning counseling offered to all individuals, especially to families where a parent or child has died. While this belief is understandable, the costs and other factors make impossible the offer to help on such a large scale. Moreover, it may not be necessary for everyone. The second belief is that some people will need help to overcome their guilt, but they will wait until they have difficulties, they will recognize their own need for help and will seek for assistance. This belief is perhaps more economical than the first, but it requires that individuals to go through some discomfort before help is offered. A third belief is based on a preventive approach in the form of an early intervention for avoiding an unresolved/complicated mourning reaction [13, 14, 15].

The role of the therapist can also be to introduce the person to the resources offered by the community (support groups, therapists, doctors). Also, is important to mention that mourning counseling can be done in the context of a group. This thing is not only very effective, but it can also be a way to provide emotional and social support during the interaction with people who are experiencing loss and adaptation to mourning. Mourning groups usually exist for more reasons which include emotional support or educational or social purposes. The groups formed for emotional support can continue with the same people for a period of time and embrace more social goals, even if the emotional support continues to be offered [16, 17].

4. Treatment

There are numerous efficient cognitive-behavioral protocols for treating depression

In case of complicated pain, the most effective treatment is Complicated Grief Treatment (CGT), a form of psychotherapy derived from cognitive-behavioral therapy and attachment theory, which is focused on addressing factors that impair adaptation: dysfunctional thoughts, maladaptive behaviors, inefficient emotional regulation strategies. Sessions include the idea of loss, healing, as well as elements of exposure to loss which finally leads to accepting the loss and its consequences by reviewing the relationship with the deceased person and the ability to imagine a future in which the possibility of happiness can be seen, despite the fact that the next person is missing [18]. Further research is needed to understand the role of attachment relationships in emotional and physiological regulation that seems to be deficient in persistent complicated mourning [19, 20, 21, 22, 23].

Anger can be a symptom of suffering. Families can be angry at doctors and nurses because they think they have not looked after the deceased well enough. Some are angry even on the deceased, considering that they had neglected their own health. Sometimes, the feeling of anger towards the missing person is associated with all the burdens that the deceased leave on the shoulders of the surviving partner.

Some people feel guilty because of the anger they experience. In other words, they feel condemned because of this anger. The family of patients may feel guilty because they have not offered better medical care, haven’t agreed to an operation, haven’t consulted a doctor earlier or didn’t choose the right hospital. Whatever the reasons are, most of this guilt is irrational and focuses on the circumstances of death [24, 25].

The particularities of death also influence the adaptation to grief and pain, as in the case of the sudden death of a child when mourning is prolonged by more than one year compared to the pain of the death of a sick person. In cases of a child’s death, there is always a feeling of guilt. Parents whose children died are highly vulnerable to feelings of guilt that focus on being unable to prevent the child’s suffering and death The role of a parent is to protect their child, to take care of their happiness and health, so whatever the circumstances are, mothers feel that they have failed. The death of an only child adds to the trauma of death the loss of the role, identity and social status of the parent [26].

There are different factors that are influencing parents grief and include a) the characteristics of the bereaved person (personality, age, physical and mental health), previous experiences of loss, social, economic, cultural, ethnic and religious background; b) the family typology and the relationship with the extended family; c) age and personality of the child at the time of death; circumstances in which the death occurred (sudden death, anticipated death) [27].

From a social point of view, the impact on the loss of a child is major not only for the parents but also for the grandparents. From our experience, children who are lost at a young age have young grandparents who also can become socially deprived due to their restraint from the social activities they used to participate in and to the inability to focus in a workplace with prolonged downtime. The professional activities also have a low yield, the subject being overwhelmed by memories, feelings of guilt, uselessness, with their somatization perceived as physical and mental asthenia with the impossibility of concentrating on professional and social duties. These can lead in extreme cases to the denial of social status, absenteeism in society and isolation, until the physical aspect of the person concerned is neglected, with the perception of uselessness of one’s own.

The final determinant that can give rise to complicated reactions of mourning is generated by social factors. Pain is a process and it is good to be experienced in a social context in which people can support and comfort each other. Lazare has found three social aspects that can inhibit or facilitate mourning. The first is when one cannot talk about loss socially, a second social factor that complicates mourning reactions occurs when the loss is socially denied (when the person and those around him act as if the loss never happened) and third social dimension that can cause complications is the absence of a network of social support, a support matrix formed by the people who have known the deceased [28].

The social impact is often smaller than in the case of the loss of a child, with a lower amplitude of the psychosocial phenomena mentioned above, because each of us considers this to be the natural course of life.

5. Conclusions

In conclusion, the infectious diseases physician and the clinical psychologist find the relationship with the caregivers and the family of the deceased patients difficult to manage. There are social consequences for the family that extend over a long period of time associated with decreased professional efficiency, absenteeism, lower productivity. This leads to emotional issues such as the tendency to blame, with the need for psychological and psychiatric intervention.

For the family of deceased patients in hospitals, mourning and depression are a reality that the psychologist and the attending physician face every day. The team of psychologists and medical doctors are facing cases of severe shock and depression in parents, varying with the age of the child and of the young adult, in cases with an acute or severe disease leading to death.

The psychologist and the physician are in close contact, so that the psychologist succeeds in rebalancing the psychoemotional state in an extremely difficult moment and in profiling the depression caused by mourning with the whole range of feelings of guilt, sadness and isolation.