Psychology of grief and loss. Grief is an emotional response to loss. Phases of Grief Approaching Death

The experience of grief is perhaps one of the most mysterious manifestations of spiritual life.

How miraculously will a person devastated by loss manage to be reborn and fill his world with meaning? How can he, confident that he has forever lost the joy and desire to live, be able to restore peace of mind, feel the colors and taste of life? How is suffering melted into wisdom?

All these are not rhetorical figures of admiration for the strength of the human spirit, but pressing questions, to know the specific answers to which it is necessary, if only because sooner or later we all have to, whether by professional or human duty, console and support grieving people.

Can psychology help in finding these answers? In domestic psychology - do not believe it! – there is not a single original work on the experience and psychotherapy of grief.

As far as Western research is concerned, hundreds of papers describe the smallest details of the branching tree of this topic - pathological grief and "good", "delayed" and "anticipatory", occupational psychotherapy techniques and mutual assistance of elderly widowers, grief from sudden infant death and the impact of videos about death on children in grief, etc., etc.

However, when behind all this variety of details you try to discern an explanation of the general meaning and direction of the processes of grief, then almost everywhere the familiar features of Z. Freud's scheme, given back in Sorrow and Melancholy, appear almost everywhere (See: Freud Z. Sadness and melancholia // Psychology of emotions Moscow, 1984, pp. 203-211).

It is unsophisticated: "the work of sadness" is to tear psychic energy from a beloved, but now lost object. Until the end of this work, "the object continues to exist mentally," and after its completion, the "I" becomes free from attachment and can direct the released energy to other objects.

"Out of sight - out of mind" - such, following the logic of the scheme, would be an ideal grief according to Freud. Freud's theory explains how people forget the departed, but it does not even raise the question of how they remember them. We can say that this is the theory of oblivion. Its essence remains unchanged in modern concepts.

Among the formulations of the main tasks of the work of grief, one can find such as "accepting the reality of loss", "feeling pain", "re-adjusting to reality", "reclaiming emotional energy and investing it in other relationships", but in vain to look for the task of remembering and remembering.

Namely, this task is the innermost essence of human grief. Grief is not just one of the feelings, it is a constitutive anthropological phenomenon: not a single most intelligent animal buries its fellows. To bury is, therefore, to be a man. But to bury is not to discard, but to hide and preserve.

And on the psychological level, the main acts of the mystery of grief are not the separation of energy from the lost object, but the arrangement of the image of this object for storage in memory. Human grief is not destructive (to forget, tear off, separate), but constructive, it is designed not to scatter, but to collect, not to destroy, but to create - to create memory.

Based on this, the main goal of this essay is to try to change the paradigm of "forgetting" to the paradigm of "remembering" and in this new perspective consider all the key phenomena of the grief process

The initial phase of grief is shock and numbness. "Can't be!" - this is the first reaction to the news of death. The characteristic state can last from a few seconds to several weeks, on average, by the 7-9th day, gradually changing to another picture.

Numbness is the most noticeable feature of this condition. The mourner is constrained, tense. His breathing is difficult, irregular, a frequent desire to take a deep breath leads to intermittent, convulsive (like steps) incomplete inspiration. Loss of appetite and sexual desire are common. Often occurring muscle weakness, inactivity are sometimes replaced by minutes of fussy activity.

A feeling of unreality of what is happening, mental numbness, insensitivity, deafness appears in the human mind. The perception of external reality is dulled, and then in the future there are often gaps in the memories of this period.

A. Tsvetaeva, a man of brilliant memory, could not restore the picture of her mother’s funeral: “I don’t remember how they carry, lower the coffin. How they throw clods of earth, fill up the grave, how the priest serves the memorial service. Something erased all this from memory ... Fatigue and drowsiness of the soul. After my mother's funeral in memory - a failure "(Tsvetaeva L. Memoirs. M., 1971. P. 248).

The first strong feeling that breaks through the veil of numbness and deceptive indifference is often anger. It is unexpected, incomprehensible to the person himself, he is afraid that he will not be able to contain it.

How to explain all these phenomena? Usually, the shock reaction complex is interpreted as a defensive denial of the fact or meaning of death, preventing the mourner from facing the loss in its entirety at once.

If this explanation were correct, consciousness, seeking to distract, turn away from what happened, would be completely absorbed in current external events, involved in the present, at least in those aspects of it that do not directly remind of the loss.

However, we see the exact opposite picture: a person is psychologically absent from the present, he does not hear, does not feel, does not turn on the present, it seems to pass him by, while he himself is somewhere in another space and time. We are not dealing with the denial of the fact that "he (the deceased) is not here", but with the denial of the fact that "I (the mourner) am here".

A tragic event that has not happened is not admitted into the present, and it itself does not allow the present into the past. This event, without becoming psychologically real at any moment, breaks the connection of times, divides life into unconnected "before" and "after". The shock leaves the person in this "before", where the deceased was still alive, was still nearby.

The psychological, subjective sense of reality, the sense of "here and now" gets stuck in this "before", the objective past, and the present with all its events passes by without being recognized by consciousness as its reality. If it were given to a person to clearly realize what is happening to him in this period of stupor, he could say to those who sympathize with him that the deceased is not with him: "I am not with you, I am there, more precisely, here, with him."

Such an interpretation makes clear the mechanism and meaning of the emergence of both derealization sensations and mental anesthesia: will terrible events subjectively occur; and post-shock amnesia: I can't remember things I didn't participate in; and loss of appetite and decreased libido, those vital forms of interest in the outside world; and anger.

Anger is a specific emotional reaction to an obstacle, an obstacle in satisfying a need. The whole of reality turns out to be such an obstacle to the unconscious desire of the soul to stay with the beloved: after all, any person, a phone call, household duties require concentration on oneself, make the soul turn away from the beloved, get out of the state of illusory connection with him even for a minute.

What theory supposedly infers from a multitude of facts, pathology sometimes visibly shows by one a prime example. P. Janet described a clinical case of a girl who took care of her sick mother for a long time, and after her death she fell into a painful state: she could not remember what had happened, she did not answer the doctors' questions, but only mechanically repeated movements in which one could see the reproduction of actions , which became familiar to her during the care of the dying.

The girl did not experience grief, because she lived completely in the past, where her mother was still alive. Only when this pathological reproduction of the past with the help of automatic movements (memory-habit, according to Jean) was replaced by the opportunity to arbitrarily recall and tell about the death of her mother (memory-story), the girl began to cry and felt the pain of loss.

This case allows us to call the psychological time of shock "the present in the past." Here the hedonistic principle of the avoidance of suffering reigns supreme over soul life. And from here the process of grief is yet to come long haul until a person can strengthen himself in the "present" and remember the past without pain.

The next step on this path - the search phase - is distinguished, according to S. Parkes, who singled it out, for an unrealistic desire to return the lost and a denial not so much of the fact of death as of the permanence of loss. It is difficult to indicate the time limits of this period, since it rather gradually replaces the previous phase of shock and then the phenomena characteristic of it occur for a long time in the subsequent phase of acute grief, but on average the peak of the search phase falls on the 5-12th day after the news of death.

At this time, it can be difficult for a person to keep his attention in the outside world, reality is, as it were, covered with a transparent muslin, a veil, through which the sensations of the presence of the deceased break through quite often: a knock on the door - a thought flashes: this is he; his voice - you turn around - strange faces; suddenly on the street: he is the one entering the telephone booth. Such visions, woven into the context of external impressions, are quite common and natural, but frightening, taking them as signs of impending madness.

Sometimes such an appearance of the deceased in the current present occurs in less abrupt forms. P., a 45-year-old man who lost his beloved brother and daughter during the Armenian earthquake, on the 29th day after the tragedy, telling me about his brother, spoke in the past tense with obvious signs of suffering, but when it came to his daughter, he smiled and with a gleam in his eyes he admired how well she studies (and not "studied"), how she is praised, what an assistant to her mother. In this case of double grief, the experience of one loss was already at the stage of acute grief, and the other was delayed at the stage of "search".

The existence of the deceased in the mind of the mourner differs in this period from that which pathologically acute cases of shock reveal to us: shock is unrealistic, search is unrealistic: there is one being - before death, in which the hedonistic principle reigns supreme over the soul, here - "as it were, a double being ("I live, as it were, on two planes," says the mourner), where, behind the fabric of reality, another existence is constantly felt latently, breaking through with islands of "meetings" with the deceased.

Hope, which constantly gives rise to faith in a miracle, coexists in a strange way with a realistic attitude, which habitually guides all the external behavior of the mourner. Weakened sensitivity to contradiction allows consciousness to live for some time according to two laws that do not interfere in each other's affairs - in relation to external reality according to the principle of reality, and in relation to loss - according to the principle of "pleasure".

They coexist on the same territory: in a series of realistic perceptions, thoughts, intentions (“I’ll call her now”), images of an objectively lost, but subjectively living being, become, become as if they are from this series, and for a second they manage to deceive the realistic installation, accepting them as "their own". These moments and this mechanism constitute the specifics of the "search" phase.

Then comes the third phase - acute grief, lasting up to 6-7 weeks from the moment of the tragic event. Otherwise, it is called a period of despair, suffering and disorganization and - not very accurately - a period of reactive depression.

Preserved, and at first may even intensify, various bodily reactions - difficult shortened breathing: asthenia: muscle weakness, loss of energy, a feeling of heaviness of any action; feeling of emptiness in the stomach, tightness in the chest, lump in the throat: increased sensitivity to odors; decreased or unusual increase in appetite, sexual dysfunction, sleep disturbances.

This is the period of greatest suffering, acute mental pain. There are many heavy, sometimes strange and frightening feelings and thoughts. These are feelings of emptiness and meaninglessness, despair, a feeling of abandonment, loneliness, anger, guilt, fear and anxiety, helplessness.

Typical is an extraordinary preoccupation with the image of the deceased (according to one patient, he remembered the deceased son up to 800 times a day) and his idealization - emphasizing extraordinary virtues, avoiding memories of bad features and deeds. Grief leaves its mark on relationships with others. Here there may be a loss of warmth, irritability, a desire to retire. Daily activities change.

It can be difficult for a person to concentrate on what he is doing, it is difficult to bring the matter to the end, and a complexly organized activity can become completely inaccessible for some time. Sometimes there is an unconscious identification with the deceased, manifested in involuntary imitation of his gait, gestures, facial expressions.

The loss of a loved one is the most difficult event that affects all aspects of life, all levels of the physical, mental and social existence of a person. Grief is unique, it depends on a one-of-a-kind relationship with him, on the specific circumstances of life and death, on the whole unique picture of mutual plans and hopes, insults and joys, deeds and memories.

And yet, behind all this variety of typical and unique feelings and states, one can try to isolate a specific set of processes that constitutes the core of acute grief. Only knowing it, one can hope to find the key to explaining the unusually variegated picture of the various manifestations of both normal and pathological grief.

Let us turn again to Z. Freud's attempt to explain the mechanisms of sadness. "... The beloved object no longer exists, and reality prompts the demand to take away all the libido associated with this object ... But its demand cannot be immediately fulfilled. It is carried out partially, with a great waste of time and energy, and before that the lost object continues to exist mentally.Each of the memories and expectations in which the libido was associated with the object is suspended, takes on an active force, and the release of the libido takes place on it.It is very difficult to point out and justify economically why this compromise work of demanding reality, carried out on all these separate memories and expectations, is accompanied by such exceptional mental pain "(Freud Z. Sadness and melancholy // Psychology of emotions. S. 205.).

So, Freud stopped before explaining the phenomenon of pain, and as for the most hypothetical mechanism of the work of sadness, he pointed not to the method of its implementation, but to the "material" on which the work is carried out - these are "memories and expectations" that "suspend and "acquire an increased active force".

Trusting Freud's intuition that it is here that the holy of holies of grief, it is here that the main sacrament of the work of sorrow is performed, it is worth peering carefully into the microstructure of one attack of acute grief.

This opportunity provides us with the subtlest observation of Anne Philip, the wife of the deceased French actor Gerard Philip: "The morning starts well. I have learned to lead double life. I think, I speak, I work, and at the same time I am completely absorbed in you. From time to time, your face appears in front of me, a little blurry, like in an out-of-focus photograph. And at such moments I lose my vigilance: my pain is quiet, like a well-trained horse, and I let go of the bridle. A moment and I'm trapped. Are you here. I hear your voice, feel your hand on my shoulder, or hear your footsteps at the door. I'm losing control of myself. I can only shrink inwardly and wait for it to pass. I stand in a daze, the thought rushes like a wrecked plane. It's not true, you're not here, you're there, in icy nothingness. What happened? What sound, what smell, what mysterious thought association brought you to me? I want to get rid of you. although I understand perfectly well that this is the most terrible thing, but at such a moment I do not have the strength to allow you to take possession of me. You or me The silence of the room cries out louder than the most desperate cry. Chaos in the head, the body is limp. I see us in our past, but where and when? My double separates from me and repeats everything that I did then "(Philip A. One moment. M., 1966. S. 26-27).

If we try to give an extremely brief interpretation of the internal logic of this act of acute grief, then we can say that the processes that make it up begin with an attempt to prevent the two currents flowing in the soul from touching - the life of the present and the past: they go through an involuntary obsession with the past: then through the struggle and pain of the voluntary separation from the image of a loved one, but ends with the "coordination of times" with the opportunity, standing on the shore of the present, to peer into the notes of the past, without slipping there, observing oneself there from the side and therefore no longer experiencing pain.

It is remarkable that the omitted fragments describe the processes already familiar to us from the previous phases of grief, which were dominant there, and now are included in the integral act as subordinate functional parts of this act. The fragment is a typical example of the “search” phase: the focus of arbitrary perception is kept on real deeds and things, but deep, still full of life the stream of the past introduces the face of a deceased person into the realm of ideas.

It is seen vaguely, but soon attention is involuntarily attracted to it, it becomes difficult to resist the temptation to look directly at the beloved face, and already, on the contrary, the external reality begins to double [note 1], and the consciousness is completely in the force field of the image of the departed, in a mentally full being with its own space and objects (“you are here”), sensations and feelings (“I hear”, “feel”).

The fragments represent the processes of the shock phase, but, of course, not in that pure form, when they are the only ones and determine the entire state of a person. To say and feel "I am losing power over myself" means to feel how my strength is weakening, but still - and this is the main thing - do not fall into absolute immersion, obsession with the past: this is a powerless reflection, there is still no "power over myself", there is not enough will to control oneself, but there are already forces to at least "inwardly shrink and wait", that is, to hold on to the edge of consciousness in the present and realize that "this will pass."

To "shrink" is to keep oneself from acting within an imaginary, but apparently so real, reality. If you do not "shrink", a condition may occur, like the girl P. Janet. The state of "numbness" is a desperate holding oneself here, with only muscles and thoughts, because feelings are there, for them there - here.

It is here, at this step of acute grief, that separation begins, separation from the image of the beloved, a shaky support in the "here and now" is being prepared, which will allow you to say at the next step: "you are not here, you are there ...".

It is at this point that an acute mental pain appears, before explaining which Freud stopped. Paradoxically, the pain is caused by the grieving person himself: phenomenologically, in a fit of acute grief, it is not the deceased who leaves us, but we ourselves leave him, break away from him or push him away from us.

And this self-made separation, this own departure, this expulsion of a loved one: "Go away, I want to get rid of you ..." and watching how his image really moves away, transforms and disappears, and causes, in fact, spiritual pain [note 2].

But here is what is most important in the performed act of acute grief: not the very fact of this painful separation, but its product. At this moment, not only does the separation, rupture and destruction of the old connection take place, as all modern theories believe, but a new connection is born. The pain of acute grief is not only the pain of decay, destruction and death, but also the pain of the birth of a new one. What exactly? Two new selves and a new connection between them, two new times, even worlds, and an agreement between them.

"I see us in the past..." - notes A. Philip. This is the new "me". The former could either be distracted from the loss - "think, speak, work", or be completely absorbed by "you". The new "I" is able to see not "you" when this vision is experienced as a vision in psychological time, which we called "present in the past", but to see "us in the past".

"Us" - therefore, his and himself, from the outside, so to speak, in the grammatically third person. "My double separates from me and repeats everything that I did then." The former "I" was divided into an observer and an acting double, into an author and a hero. At this moment, for the first time during the experience of loss, a piece of real memory of the deceased appears, of life with him as of the past.

This first, just born memory is still very similar to perception (“I see us”), but it already has the main thing - the separation and coordination of times (“I see us in the past”), when the “I” fully feels itself in present and pictures of the past are perceived precisely as pictures of what has already happened, marked with one or another date.

The former bifurcated being is united here by memory, the connection of times is restored, and pain disappears. It is not painful to observe a double acting in the past from the present [note 3].

It is no coincidence that we called the figures that appeared in the mind "author" and "hero". Here the birth of the primary aesthetic phenomenon really takes place, the appearance of the author and the hero, the ability of a person to look at the lived, already accomplished life with an aesthetic attitude.

This is an extremely important point in the productive experience of grief. Our perception of another person, especially a close one, with whom we have been connected by many life ties, is thoroughly permeated with pragmatic and ethical relations; his image is saturated with unfinished joint affairs, unfulfilled hopes, unfulfilled desires, unfulfilled plans, unforgiven insults, unfulfilled promises.

Many of them are already almost obsolete, others are in full swing, others have been postponed for an indefinite future, but all of them are not finished, all of them are like questions asked, waiting for some kind of answers, requiring some kind of action. Each of these relationships is charged with a goal, the final unattainability of which is now felt especially sharply and painfully.

The aesthetic attitude, on the other hand, is capable of seeing the world without decomposing it into ends and means, outside and without ends, without the need for my intervention. When I admire a sunset, I don’t want to change anything in it, I don’t compare it with what it should be, I don’t strive to achieve anything.

Therefore, when, in an act of acute grief, a person first manages to completely immerse himself in a part of his former life with the deceased, and then exit it, separating in himself the “hero” who remains in the past, and the “author”, who aesthetically observes the life of the hero from the present, then this particle turns out to be won back from pain, purpose, duty and time for memory.

In the phase of acute grief, the mourner discovers that thousands and thousands of little things are connected in his life with the deceased (“he bought this book”, “he liked this view from the window”, “we watched this movie together”) and each of them captivates his consciousness into "there-and-then", into the depths of the flow of the past, and he has to go through pain to return to the surface. The pain goes away if he manages to take out a grain of sand, a pebble, a shell of memory from the depths and examine them in the light of the present, in the here-and-now. The psychological time of immersion, "the present in the past," he needs to transform into the "past in the present."

In a period of acute grief, his experience becomes the leading activity of a person. Recall that the leading activity in psychology is the activity that occupies a dominant position in a person’s life and through which his personal development is carried out.

For example, a preschooler both works, helping his mother, and learns, memorizing letters, but not work and study, but play is his leading activity, in it and through it he can do more, learn better. She is his sphere personal growth.

For the mourner, grief during this period becomes the leading activity in both senses: it constitutes the main content of all his activity and becomes the sphere of development of his personality. Therefore, the phase of acute grief can be considered critical in relation to the further experience of grief, and sometimes it acquires special significance for the entire life path.

The fourth phase of grief is called the phase of "residual shocks and reorganization" (J. Teitelbaum). At this phase, life gets back on its track, sleep, appetite, professional activity are restored, the deceased ceases to be the main focus of life. The experience of grief is no longer a leading activity, it proceeds in the form of frequent at first, and then more and more rare separate shocks, such as occur after the main earthquake.

Such residual grief attacks can be as acute as in the previous phase, and subjectively perceived as even more acute against the background of normal existence. The reason for them most often are some dates, traditional events (" New Year first time without him", "spring first time without him", "birthday") or events Everyday life(“offended, there is no one to complain to”, “a letter was addressed to him”).

The fourth phase, as a rule, lasts for a year: during this time, almost all ordinary life events occur and begin to repeat themselves in the future. The death anniversary is the last date in this series. Perhaps it is no coincidence that most cultures and religions set aside one year for mourning.

During this period, the loss gradually enters into life. A person has to solve many new tasks related to material and social changes, and these practical tasks are intertwined with the experience itself. He very often compares his actions with the moral standards of the deceased, with his expectations, with "what he would say."

The mother believes that she has no right to take care of her appearance, as before, before the death of her daughter, since the deceased daughter cannot do the same. But gradually more and more memories appear, freed from pain, guilt, resentment, abandonment. Some of these memories become especially valuable, dear, they are sometimes woven into whole stories that are exchanged with relatives, friends, often included in the family "mythology".

In a word, the material of the image of the deceased released by acts of grief undergoes a kind of aesthetic processing here. In my attitude to the deceased, wrote M. M. Bakhtin, “aesthetic moments begin to prevail ... (compared to moral and practical ones): I have before me the whole of his life, freed from the moments of the temporal future, goals and obligations. The burial and the monument are followed by memory.

I have the whole life of another outside of myself, and here the aestheticization of his personality begins: fixing and completing it in an aesthetically significant image. From the emotional-volitional attitude of commemoration of the departed, the aesthetic categories of shaping the inner person (and the external) are essentially born, because only this attitude in relation to another has a value approach to the temporary and already completed whole of the external and inner life human...

Memory is the approach of the point of view of value completeness; in a certain sense, memory is hopeless, but only it can appreciate, in addition to purpose and meaning, an already completed, completely present life "(Bakhtin M.M. Aesthetics of verbal creativity. P. 94-95).

The normal experience of grief that we are describing enters its last phase, the “completion,” about a year later. Here, the mourner sometimes has to overcome some cultural barriers that make the act of completion difficult (for example, the notion that the duration of grief is a measure of our love for the deceased).

The meaning and task of the work of grief in this phase is to ensure that the image of the deceased takes its permanent place in the ongoing semantic whole of my life (it can, for example, become a symbol of kindness) and be fixed in the timeless, value dimension of being.

Let me conclude with an episode from psychotherapeutic practice. I once had to work with a young painter who lost his daughter during the Armenian earthquake. When our conversation was coming to an end, I asked him to close his eyes, imagine an easel with a white sheet of paper in front of him and wait until some image appeared on it.

The image of a house and a gravestone with a lit candle arose. Together we begin to complete the mental picture, and mountains appeared behind the house, blue sky and bright sun. I ask you to focus on the sun, to consider how its rays fall. And so, in the picture evoked by the imagination, one of the rays of the sun unites with the flame of a funeral candle: the symbol dead daughter connects with the symbol of eternity. Now we need to find a way to get rid of these images.

The frame in which the father mentally places the image serves as such a means. The frame is wooden. The living image finally becomes a picture of memory, and I ask my father to squeeze this imaginary picture with his hands, appropriate it, absorb it into himself and place it in his heart. The image of the dead daughter becomes a memory - the only way to reconcile the past with the present.

Psychological features of patients with incurable diseases.

The psychology of loss and death. Grief reaction.

Loneliness (sensory and social deprivation).

Dying and death (stages of the patient's reaction: denial, anger, deal, depression, acceptance).

Rules of conduct with a dying patient.

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Organization of hospice work.

Psychology of suicidal behavior. Stages of suicidal behavior.

1. Psychological characteristics of patients with incurable diseases. In the study of incurable diseases, great importance attached psychological characteristics patients with these diseases. As such diseases today are primarily cancer, AIDS, oncohematology, which are perceived by many people as processes that inevitably lead through withering and pain to death. The emotional burden experienced by dying patients is determined primarily by their personal characteristics, as well as thoughts of pain and possible slow and painful death. In the first place is the patient's fear of the rapid and inevitable end of life. Particularly pronounced fear may be due to the inevitability of risky surgical intervention.

The reactions of the individual to the disease at this stage can be different: the patient commits impulsive acts that are harmful to his own health, an anxious and suspicious attitude to what happened, throwing the patient from one doctor to another, then despair, then hope. And the overall success of treatment depends on how the patient treats his disease.

Among the mental manifestations, the leading ones are disorders classified as adaptive (psychogenic): depressive and mixed (anxious-depressive) reactions, behavioral disorders. However, in the diagnostic period, psychogenic reactions rarely reach the psychotic level. From this time on, the struggle of the individual with the impending formidable danger begins, and all forces are mobilized for the struggle - instinct, the affective sphere, restructuring intellectual activity, a changing attitude to the external and internal world.

The extended (stationary) period is characterized, in addition to psychogenic disorders, by the appearance of somatogenic changes in the psyche, with astheno-depressive manifestations in the first place. The active forces of the personality are used for a true or symbolic exit from the disease. Difficulties of a psychological order can be overcome thanks to the knowledge of the characteristics of the psychology of patients, which is based on faith in a successful outcome of the disease. And it must be supported by demonstrating examples of positive treatment results with complete recovery or long-term remission.

The mental state of the patient depends on the stage of the disease, the severity of intoxication and the tolerance of treatment methods. In some patients, there is an asthenic-dreary background of experiences, some lethargy is observed. Such patients are unable to endure even mild pain. Speech, appearance, posture, facial expressions become monotonous and monotonous. Despite some external detachment, these patients need a sympathetic attitude, because they are afraid to be alone with their gloomy thoughts. In patients with cancer intoxication against the background of cachexia, oneiroid states are possible: patients, lying in bed with their eyes closed, see moving images and scenes in front of them. The orientation is preserved. Some patients may develop anxiety and suspicion: they are treated incorrectly, drugs are confused, they are given harmful substances, experiments are carried out with them, neighbors say something unfriendly, hint at them, show them with a look. These disorders can be regarded as delusional ideas of persecution and attitude, which can be identified by careful questioning of patients and which can be partially corrected.

Psychoses in oncological patients are observed infrequently, manifested in the form of oneiric delirium, depression, paranoid outbreaks. The influence of the phenomenon of cancer intoxication on the mental state of patients can manifest itself in the form of specific cancer depressions. The inner world of patients becomes faded, the perception of time changes (it goes faster). The personality of the patient in the terminal stage remains intact, but intellectual intensity and purposefulness are falling. Speech changes due to exhaustion. The effects subside. The content of the mental world is reduced, criticism weakens, internal isolation grows, which resembles the state of patients with apathetic disorders. In a number of patients, the pre-mortem period is devoid of the experience of fear of death. The idea of ​​death in them is subjected to the so-called repression, “one’s own disease is alienated”, i.e. there is dissomatonosognosia, which is manifested by capriciousness, exactingness towards others, as well as quarrelsomeness, conflict.

2. Psychology of loss and death. Grief reaction. Grief is a specific syndrome with psychological and somatic symptoms. This syndrome may occur immediately after a crisis, it may be delayed, it may not manifest itself clearly, or, conversely, it may manifest itself in an overly emphasized form. Instead of a typical syndrome, distorted pictures may be observed, each of which represents some particular aspect of the grief syndrome.

Reactions of grief, grief and loss can cause the following reasons: 1) the loss of a loved one; 2) the loss of an object or position that had emotional significance, such as the loss of valuable property, deprivation of work, position in society; 3) loss associated with illness.

There are five pathognomic features for grief - physical suffering, preoccupation with the image of the deceased, guilt, hostile reactions and loss of behavior patterns.

The main thing in assessing a person’s condition is not so much the cause of the grief reaction, but the degree of significance of a particular loss for a given subject (for one, the death of a dog is a tragedy that can even cause a suicide attempt, and for another, grief, but fixable: “you can start another"). With a grief reaction, it is possible to form behavior that poses a threat to health and life, for example, alcohol abuse.

The duration of the grief reaction is obviously determined by how successfully the individual performs the work of grief, namely, he emerges from states of extreme dependence on the deceased, re-adapts to the environment in which the lost face is no longer there, and forms new relationships.

Stages of grief:

1. Numbness or protest. Characterized by severe malaise, fear and anger. Psychological shock can last for moments, days and months.

2. Longing and desire to return the lost person. The world appears empty and without meaning, but self-esteem does not suffer. The patient is preoccupied with thoughts of the lost person; periodically there is physical restlessness, crying and anger. This state lasts for several months or even years.

3. Disorganization and despair. Restlessness and performance of aimless actions. Increased anxiety, withdrawal, introversion and annoyance. Permanent memories of a departed person.

4. Rearrangement. The emergence of new experiences, objects and goals. Grief weakens and is replaced by memories dear to the heart.

Tactics of behavior with patients in a state of grief:

1. The patient should be encouraged to discuss his experiences, to allow him to simply talk about the lost object, to recall positive emotional episodes and past events.

2. Do not stop the patient when he starts to cry.

3. In the event that the patient has lost someone close, one should try to ensure the presence of a small group of people who knew the deceased (s), and ask them to talk about him (her) in the presence of the patient.

4. Frequent and short visits with the patient are preferable to long and infrequent visits.

5. Consideration should be given to the possibility that the patient may have a delayed grief reaction that manifests itself some time after the death of a loved one and is characterized by behavioral changes, anxiety, mood lability and substance abuse. These reactions may appear on the anniversary of death (called the anniversary reaction).

6. The reaction to expected grief occurs before the loss occurs and can reduce the intensity of the experience.

7. A patient whose close relative has committed suicide may refuse to talk about his feelings, fearing that this fact will somehow compromise him.

3. Loneliness (sensory and social deprivation). The state of loneliness is caused by a lack of external stimulation of a physical and social nature.

Based on the psychoanalytic concept, S.G. Korchagin (2001) identifies several types of the state of loneliness.

Self alienating loneliness. If the processes of identification with other people predominate in the mental life of a person, then there is an alienation of a person from himself, a loss of connection with himself, a loss of his own self, the impossibility of personal isolation, an almost complete loss of the ability of a person to reflect.

alienating loneliness. The consequence of the suppression of identification processes by processes of isolation is the alienation of the individual from other people, the norms and values ​​accepted in society, the loss of like-minded people, the loss of spiritually significant connections and contacts, the impossibility of truly close, spiritual communication, unity with another person. Such loneliness is often accompanied by agonizing enduring feelings of resentment, guilt, and shame. At the same time, the processes of reflection are activated, but often come down to self-accusation.

Loneliness can be absolute or relative(fighter pilots, astronauts, drivers of vehicles).

Signs of loneliness.

sensory deprivation - (from Latin sensus - feeling, sensation and deprivation - deprivation) - a prolonged, more or less complete deprivation of a person of visual, auditory, tactile or other sensations, mobility, communication, emotional experiences.

In another way, the term "deprivation" means the loss of something due to insufficient satisfaction of any important need, blocking the satisfaction of basic (vital) needs to the extent necessary and for a sufficiently long time. In the case when it comes to insufficient satisfaction of basic psychological needs, it is used as equivalent concepts of "mental deprivation", "mental starvation", "mental insufficiency", defining a state that is the basis or internal mental condition specific behavior (deprivation consequences).

Deprivation situation It is the inability to satisfy important psychological needs. Deprivation experience suggests that the individual has previously been subjected to a deprivation situation and that, as a result, he will enter into each new similar situation with a slightly modified, more sensitive or, on the contrary, more “hardened” mental structure.

has a negative impact on personality development. emotional deprivation. The socio-psychological consequences of deprivation include fear of people, which is replaced by numerous unstable relationships, in which an insatiable need for attention and love is manifested. Manifestations of feelings are characterized by poverty and often a clear tendency to acute affects and low resistance to stress.

It has been proven that with a deficit of sensory information of any order, a person actualizes the need for sensations and strong feelings, develops, in fact, sensory and / or emotional hunger. This leads to the activation of the processes of imagination, which in a certain way affect the figurative memory. Under these conditions, a person's ability to preserve and reproduce very vivid and detailed images of previously perceived objects or sensations begins to be realized as a protective (compensatory) mechanism. As the time spent in conditions of sensory deprivation increases, lethargy, depression, apathy begin to develop, which for a short time are replaced by euphoria, irritability. There are also memory disturbances, the rhythm of sleep and wakefulness, hypnotic and trance states, hallucinations of various forms develop. The more severe the conditions of sensory deprivation, the faster the thinking processes are disrupted, which manifests itself in the inability to focus on anything, to think about problems consistently.

Experimental evidence has also shown that sensory deprivation can induce a temporary psychosis in a person or cause temporary mental disturbances. With prolonged sensory deprivation, organic changes or the appearance of conditions for their occurrence are possible. Insufficient brain stimulation can lead, even indirectly, to degenerative changes in nerve cells.

It has been shown that under conditions of deprivation, disinhibition of the cortex will occur, which can usually appear in the form of hallucinations (not corresponding to reality, but perceived by consciousness), and in any form: tactile sensations (crawling, warm streams, etc.), visual ( light flashes, faces, people, etc.), sound (noises, music, voices), etc. However, the "contemplation" of a certain image, provided by the corresponding dominants in the cerebral cortex, can cause lateral inhibition of the cortex. Thus, there are two oppositely directed tendencies - to disinhibition of the cortex and to inhibition.

social deprivation. This phenomenon is due to the lack of the ability to communicate with other people or the ability to communicate only with a strictly limited contingent. In this case, a person cannot receive the usual socially significant information and realize sensory-emotional contacts with others. A person isolated from society can structure time in two ways: with the help of activity or fantasy. Communication with oneself, both as a specific mechanism for real control of one's own personality, and as a fantasy (communication "in memory" or "dreams on a given topic") is a way of filling time with activity. Different ways of filling time are play activities, and especially creativity.

In modern domestic psychology, loneliness refers to one of the types of "difficult" states. At the same time, there is also a subjectively positive type of the state of loneliness - solitude, which is a variant of the normal experience of loneliness, which is personally conditioned by the optimal ratio of the results of the processes of identification and isolation. This dynamic balance can be seen as one of the manifestations psychological stability individual to social influences. Solitude contributes to the growth of self-awareness, activates the processes of reflection and self-knowledge, is one of the ways of self-actualization and self-determination of a person in the world. As a peculiar form of "social hunger", by analogy with dosed physiological starvation, loneliness can be useful and even necessary for a person as a means of psychological restoration of his "self" and self-improvement.

4. Dying and death (stages of the patient's reaction: denial, anger, deal, depression, acceptance). Thanatology is a branch medical science dealing with the whole range of problems associated with death.

In the past, a person from childhood faced the death of relatives and loved ones, but now this is happening less and less. With more frequent deaths in hospitals, death is institutionalized. Until the age of six, a child has an idea of ​​the reversibility of death. A full understanding of its inevitability comes in the puberty period. Religious ideas about afterlife are now extremely rare. The cult of suffering, expressed in rituals and prayers (“Remember death!”), Turned thoughts about death, illness and suffering into an integral part of a person’s mental equipment. Religious institutions could provide people with psychological relief by forming in them certain "psychic antibodies" against the fear of illness and death. Therefore, a religious person more often (but not always) dies calmly, easily.

A modern healthy or temporarily ill person overcomes thoughts of death thanks to the mechanisms of psychological protection of the individual, which exist in the form of suppression and repression. With the problem of dying and death, a medical worker can meet in contact with very seriously and long-term suffering patients. At the same time, medical personnel are obliged to ensure the patient's right to a dignified death.

Elisabeth Kübler Ross, a pediatric psychiatrist in the Department of Psychopathology at the University of Chicago, studied the problem of death and dying in today's unbelieving person. She created her own scientific school and, together with her students, studied this problem. Elisabeth Kubler Ross stated that the mental state of a person with a fatal illness is unstable and goes through five stages, which can be observed in a different sequence (E. Kubler-Ross, 1969).

The first stage - denial stage and rejection tragic fact. It is expressed by disbelief in a real danger, the conviction that a mistake has occurred, the search for evidence that there is a way out of an unbearable situation, manifested by confusion, stupor, a feeling of explosion, deafness (“Not me”, “It can’t be”, “This is not cancer” ).

Second stage - protest stage. When the first shock passes, repeated studies confirm the presence of a fatal disease, a feeling of protest and indignation arises. “Why me?”, “Why others will live, but I have to die?” etc. As a rule, this stage is inevitable, it is very difficult for the patient and his relatives. During this period, the patient often turns to the doctor with a question about the time that he has left to live. As a rule, this stage is inevitable, it is very difficult for the patient and his relatives. During this period, the patient often turns to the doctor with a question about the time that he has left to live. As a rule, symptoms of reactive depression progress, and suicidal thoughts and actions are possible. At this stage, the patient needs the help of a qualified psychologist who knows logotherapy, the help of family members is very important. The resulting anger is determined by the recognition of danger and the search for the guilty, moaning, irritation, the desire to punish everyone around. One of the manifestations of this phase in AIDS patients are attempts to infect someone else.

Third stage - request for a delay (deal). During this period, there is an acceptance of the truth and what is happening, but "not now, just a little more." Many, even previously non-believing patients, turn their thoughts and requests to God. The beginnings of faith are coming. An attempt to negotiate with death is expressed in the search for ways to delay the end, active treatment. Patients may try to negotiate with doctors, friends, or God, and in exchange for recovery promise to do something, for example, give alms, go to church regularly.

The first three stages constitute the period of crisis.

Fourth stage - reactive depression, which, as a rule, is combined with feelings of guilt and resentment, pity and grief. The patient understands that he is dying. During this period, he mourns for his bad deeds, for the grief and evil caused to others. But he is already ready to accept death, he is calm, he has done away with earthly worries and has gone deep into himself.

Fifth stage - acceptance of one's own death (reconciliation). The person finds peace and tranquility. With the acceptance of the thought of imminent death, the patient loses interest in the environment, he is internally focused and absorbed in his thoughts, preparing for the inevitable. This stage indicates a restructuring in consciousness, a reassessment of physical and material truths for the sake of spiritual needs. The realization that death is inevitable and unavoidable for all. The methods of psychocorrection depend on the phase of experiences and the characteristics of the patient's personality, but all of them are aimed at a faster and painless achievement of the stage of reconciliation.

5. Rules of conduct with a dying patient . In a special approach that requires a doctor, a psychologist to solve very difficult psychological tasks needed by patients with incurable diseases.

1. The doctor, knowing that the patient's prospects are very sad, should inspire him with hope for recovery, or at least for a partial improvement in his condition. You should not take a rigid position, for example: "in such cases, I always inform the patient." Let the characteristics of the patient's personality determine your behavior in this situation. Determine what the patient already knows about the prognosis of his disease. Do not deprive the patient of hope and do not convince him if denial is his main defense mechanism, as long as he can receive and accept the necessary help. If the patient refuses to accept it as a result of denial of his illness, gently and gradually let him know that help is needed and will be provided to him. Reassure the patient that he will be taken care of regardless of his behavior.

2. You should spend some time with the patient after giving him information about the condition or diagnosis, after which he may experience a strong psychological shock. Encourage him to ask questions and give truthful answers.

3. It is advisable, if possible, to return to the patient a few hours after receiving information about his illness, in order to check his condition. If the patient has severe anxiety, then he should receive adequate psychological and psychopharmacological support, specialist advice. In the future, communication with a dying patient, practically devoid of meaning from a professional point of view, should not be interrupted, performing the function of psychological support for the patient. Sometimes medical workers, knowing that the patient is doomed, begin to avoid him, stop asking about his condition, make sure that he takes medication, and perform hygiene procedures. The dying person is alone. Communicating with a dying patient, it is important, without violating the usual ritual, to continue fulfilling the appointments, asking the patient about how he feels, noting every, even the most insignificant, signs of improvement in his condition, listening to the patient’s complaints, trying to facilitate his “care”, not leaving him alone with death . The fear of loneliness should be prevented and suppressed: the patient should not be left alone for a long time, carefully fulfill even the smallest of his requests, show sympathy and convince him that there is nothing to be ashamed of his fears; “Drive them inside” is useless, it’s better to speak out in front of someone.

4. It is necessary to give advice to the patient's family members regarding his illness. Encourage them to communicate with the patient more often and allow him to talk about his fears and worries. Family members not only have to deal with the loss loved one, but also to face the realization of the thought of one's own death, which can cause anxiety. Also, relatives and other relatives of the patient should be persuaded to leave the feeling of guilt (if it is inadequate), let the patient feel his value to family and friends, empathize with him, accept his forgiveness, ensure the fulfillment of last desires, accept the “last forgiveness”.

5. The pain and suffering of the patient should be relieved. Psychotherapeutic assurances about the need for patience must have limits, and the fear that the patient may become a drug addict is cruel and pointless.

6. When a patient dies, it is necessary to create conditions that take into account the interests of the surrounding patients, who are very sensitive to manifestations of professional deformation on the part of the staff. For example, at the time of the death of a neighbor in the ward, patients asked the nurse to somehow alleviate the suffering of a dying woman who had near-death dyspnea, to which she replied: “There is no need for this, she will die anyway.”

6. Ethical issues of euthanasia.Euthanasia – it is the deprivation of life of a patient at his will, it concerns terminally ill people and implies that the deprivation of life of such patients occurs with the help of medical workers.

Distinguish between passive and active euthanasia. Passive euthanasia (also called “delayed syringe method”) is the termination of “life-prolonging medical care”, which hastens the onset of death. This method is practiced in almost all countries, including Russia. Active euthanasia (“filled syringe”) is the administration of any drugs or other drugs to a dying person, or other actions that entail a quick death. Active euthanasia has three forms: 1) "mercy killing" (the doctor injects the patient with an overdose of pain medication); 2) "suicide assisted by a doctor" (a doctor helps a sick person to commit suicide); 3) actually active euthanasia (the patient himself, without the help of a doctor, turns on a special device that leads to a painless death).

Active euthanasia is punishable by law in most countries. In Russia, euthanasia is strictly prohibited and its accomplishment is a criminal offense. This should be known and remembered by everyone starting medical activities.

Euthanasia is opposed by representatives of almost all religious denominations.

Particularly debatable is the issue of refusing intensive care measures (droppers, dialyzers, mechanical ventilation), when there is absolutely no possibility of improving the patient's quality of life and suffering or "vegetative existence" is replaced by care and attention. Official documents providing for such events exist in the West. This testament living will- will to live) and DNR tactics (do not rehabilitate!). The issue is decided by a commission consisting of lawyers, doctors, priests, and members of the public.

Opponents of euthanasia, which include many specialists, primarily doctors, believe that modern civilization goes the way of justifying suicide. They insist on a position that says that more important than an individual's right to an easy death is his right to a decent, quality life in conditions of illness. One of the ways to ensure a decent life for the hopelessly ill is to create shelters, or hospices, where specialists work to alleviate the suffering of patients without killing them. Along with medical methods (reliable pain relief, symptomatic and restorative drugs), psychological and psychotherapeutic assistance to patients is widely used. The patient's appeal to the doctor with a request to speed up the end of life should be considered as a hidden call for salvation: after all, if a person really decided to die, he will not warn anyone about this and place this exorbitant responsibility on another. This behavior most likely indicates the presence of depression. It should be remembered that depressed patients tend to end their lives even when there is no real danger to their existence. Timely treatment of depression shows that, upon leaving the state of depression, patients express gratitude to the doctors who did not allow them to realize their desire for suicide. Often, pain and somatic symptoms contribute to the onset of depression, which must be fully overcome by doctors. It has been shown that the cessation of depression also contributes to an increase defensive forces organism and correlates with longer life expectancy in terminally ill patients.

7. Organization of work of hospices. HOSPICE is a medical and social institution for the provision of palliative care. Palliative care is the provision of medical, social, psychological, legal and spiritual support to terminally ill people and their loved ones. HOSPICE gives people the opportunity and hope to live without pain, fear and loneliness, to fully use the remaining time of life.

According to WHO, about 56 million people die in the world every year. Every week, 1,000,000 people die in the world, about one in 10 people die from cancer. More than 40 million people are infected with HIV/AIDS, and a growing number of people are living with other chronic fatal diseases and conditions. 90% of patients with advanced cancer and 70% of AIDS patients suffer from pain.

In Russia, more than 300,000 patients die of cancer a year, one patient dies every two minutes. More than 80% of them need palliative care. More than 200,000 patients suffer from chronic pain syndrome.

Care for incurable cancer patients and their families in HOSPICE creates a sense of security in this group of “outcasts”. The rights of a dying person, thanks to HOSPICE, are protected: the right to freedom to live without pain, without discomfort, respect for the individual; guarantee of fulfillment of the last will; support for hope even when the goal is comfort rather than cure, respect for dignity, privacy and spiritual hope; open and sensitive communication; attention to the quality of life; attention and care for those who are left behind.

HOSPICE patients are people of any age (from children to the elderly), different social status. Patients in HOSPICE are observed from several hours to several years.

The main principle of HOSPICE is free, affordable help for everyone!

Structurally, HOSPICE consists of a mobile service and a hospital. The basis of the work of HOSPICE is an outreach service, the activity of which is based on the principle of providing the maximum possible assistance directly at home: adequate, maximally complete pain relief, relief of painful symptoms, various manipulations and procedures (bandaging, pleural punctures, laparocentesis, epicystostomy, catheterization, etc.). ), training in the rules of caring for sick relatives and many others. In the same service, socio-psychological work is carried out by a psychologist and social workers who serve mainly lonely and “abandoned” patients.

In the HOSPICE hospital, complex therapy is carried out, the effect of which is aimed at alleviating all the painful symptoms that cause suffering to the patient. About half of the patients are hospitalized for medical and social reasons (there is no one to take care of them at home, they do not admit cancer patients to boarding schools).

There are many polemical observations about the specifics of working with the dying, about the qualities that hospice doctors should have. However, some of the most important principles are:

1. Death cannot be paid.

2. Death is a natural process that should neither be rushed nor slowed down.

3. Work with the dying should be individual, without ready-made recipes tested on the “majority”.

4. The time of the dying is special, and one approaching the bed of death should never be in a hurry.

5. Service, not submission, is at the heart of working with the dying.

8. Psychology of suicidal behavior. Stages of suicidal behavior. Suicide is a purely human act. The term "suicide" was first used in written sources, according to the Oxford Dictionary, in 1651 and is of Latin origin. Suicide is defined as intentional self-harm. Suicidal behavior is a person's auto-aggressive actions, consciously and deliberately aimed at depriving himself of life due to a collision with unbearable life circumstances, for psychopathological and psychological reasons.

Depending on the presence of a fatal outcome, a completed suicide is distinguished, which ended fatally, and an incomplete, or parasuicide, which in turn is subdivided, depending on the motivation, into a true and demonstratively blackmailing suicide attempt.

A suicide attempt without a fatal outcome often does not aim to end life, but symbolizes a “cry for help”, serves as a communicative act, is an appeal to others. Parasuicide is 10 times more common than completed suicide.

According to the form of committing, there are two types of suicide:

active - direct active auto-aggression;

hidden - passive, causing harm to the subject indirectly.

For example, in patients with chronic renal failure treated with permanent hemodialysis, one can observe both active (refusal of hemodialysis) and passive (ignoring the necessary medical care, gross violation of compliance, non-compliance water regime leading to the development of complications) a form of suicide.

Also distinguished:

1.presuicide. This stage includes:

passive suicidal thoughts - abstract ideas, fantasies of suicide;

suicidal ideation - contemplating a suicide plan;

suicidal intentions - joining the volitional component, preparing for suicide.

2. Suicidal act.

3.Post-suicidal period. The following types are distinguished:

critical, manipulative, analytical, suicidal-fixed type.

Common features of suicidal behavior include:

goals - finding a solution;

tasks - cessation of consciousness;

stimulus - unbearable mental pain;

emotions - helplessness, hopelessness;

attitudes towards suicide - ambivalence;

mental states - narrowing of the cognitive sphere;

communicative action - a message about your intention.

The behavioral expression of suicide is an unexpected, dramatic and inexplicable change in behavior, the so-called "terminal behavior". At the same time, the individual puts his affairs in order, distributes his property, often declares his sadness and despair.

The probability of committing suicide is determined by the ratio of three factors:

1. the intensity of suicidal impulses, for example, associated with the depth of depressive experiences;

2. anti-suicidal barrier - a psychological factor due to individual circumstances, for example, the need to complete a life's work, caring for an animal, having children or close friends;

3. influences that weaken the anti-suicidal barrier, such as loneliness, job loss, iatrogenic influences.

The post-suicidal state includes:

Middle post-suicide - the first week;

Early post-suicide - up to 1 month after a suicide attempt;

Late post-suicide - up to 5 months.

Socio-demographic aspects of suicide. According to researchers, suicide rates vary from country to country. Russia, Hungary, Germany, Austria, Denmark, China and Japan have very high level suicides: annually more than 20 people per 100 thousand of the population; on the other hand, Egypt, Mexico, Greece and Spain have a relatively low rate of less than 5 per 100,000. The United States and Canada occupy a middle position: in both countries this level is 12 people per 100 thousand of the population, in England it is about 9 people per 100 thousand.

Suicide rates for men and women also differ. Women are 3 times more likely than men to attempt suicide, yet the number of deaths in men (19 per 100 thousand) is three times higher than in women (5 per 100 thousand). The difference between these indicators lies in the methods used when committing suicide. In the United States, suicides with firearms account for almost 2/3 of the total number of suicides committed by men, while in women the share of similar suicides is 40%.

Marital status also influences suicidal tendencies. Married people, especially those with children, have the lowest suicide rate, single and widowed people have slightly higher suicide rates, and divorced people have the highest suicide rate.

When considering the relationship between religion and suicide, studies conducted in this direction suggest that the prevention of suicide is influenced not so much by formal affiliation to any religious denomination as by individual piety. Very devout people, regardless of their religion, are less likely to commit suicide. It seems that those people who are more reverent about the "miracle" of life are less likely to consider suicide or actually resort to self-destruction.

Concepts of suicide. psychodynamic point of view. Many theorists of the psychodynamic direction believe that suicide occurs due to depression and anger towards others, which a person directs at himself. This theory was first proposed by Wilhelm Stekel at a meeting in Vienna in 1910, when he stated that "he who wants to kill another person, or at least wants the death of another person, kills himself."

Freud and Abraham (1917) suggested that when people experience a real or symbolic loss of a loved one, they unconsciously incorporate that person into their own identity and feel for themselves what they felt for another person. For a short time, negative feelings towards a lost loved one are experienced as self-hatred. Anger towards a loved one can turn into intense anger towards oneself and finally develop into a major depression. Suicide is the ultimate expression of this self-hatred.

Sociological research data are consistent with this explanation of suicide. It has been found that the suicide rate in a nation drops during periods of war, when, one might explain, people are encouraged to direct the energy of self-destruction against the "enemy". Also, in a society with a high homicide rate, the suicide rate is quite low, and vice versa.

However, while hostility is an important part of suicide according to this theory, some researchers find that other emotional states are more common than anger.

Sociocultural point of view. AT late XIX century sociologist Emile Durkheim developed a general theory of suicidal behavior, according to which the likelihood of suicide is determined by how attached a person is to social groups such as family, religious institutions and society. The stronger the person's ties to these groups, the lower the likelihood of suicide. Durkheim defined several categories of suicide:

selfish suicide suicide, which is committed by people who are not at all or almost controlled by society, people who do not care about social rules or norms. How more number such people living in society, the higher the suicide rate;

altruistic suicide - suicide, which is committed by people who deliberately sacrifice their lives for the public good (soldiers who threw themselves on grenades to save others);

anomie suicide- suicide committed by people whose social environment does not provide them with stability and does not form in them a sense of belonging.

biological point of view. Researchers studying parenting have found higher rates of suicide among parents and close relatives of suicides than in families whose members did not attempt suicide. Based on such data, the researchers suggested that genetic, and therefore biological, factors are at work in these cases.

Assistance to suicides and prevention of suicides. Therapy for people with suicidal tendencies falls into two broad categories: post-suicide therapy and suicide prevention.

The goal of post-suicide therapy is to support people, help them reach a non-suicidal state of consciousness, and show them more effective methods fight stress. Various types of therapy are used, including medication, psychodynamic, cognitive, group and family therapy.

Also, after a suicide attempt, most victims require long-term and serious treatment for associated serious injuries. Psychotherapy and the use of drugs should be started after the correction of physical health. The patient may stay in the hospital for the duration of treatment, or live at home and only come to the hospital for therapy.

In 1955, the first suicide prevention program was launched in Los Angeles in the USA, which found wide support and application in many countries of the world. Currently, these programs offer crisis intervention: they try to help suicidal people assess their situation more objectively, teach them to make smarter decisions, act constructively, and work through their crisis. The centers hosting these programs provide information about their hotlines and always accept those who come without an appointment.

Key steps in a suicide prevention program:

Establish a positive relationship between the contact person and the consultant;

Understand the nature of this crisis state and then help the person to understand it just as clearly and constructively;

Assess the person's potential for suicide: determine the degree of stress, relevant personality characteristics, how detailed the suicide plan is, the severity of the symptoms, and the caller's coping options;

Assessment and mobilization of the caller's capabilities (his strengths, help from relatives and friends);

Formulation of the plan (development of a joint way out of the crisis, an alternative to the act of suicide).

If callers are already committing suicide during the phone call, the counselor is faced with the task of locating and providing emergency medical assistance.

USED ​​BOOKS:

1. Asmolov A.G., Marilova T.V. The role of changing the social position in the restructuring of the motivational and semantic sphere in cancer patients // Journal of Neurology and Psychiatry. S.S.Korsakov. 1985. No. 12. S. 1846-1851.

2. Zeigarnik B.V., Bratus B.S. Essays on the psychology of abnormal personality development. M.: Publishing House of Moscow. un-ta, 1980. 160s.

3. Kvasenko A.V., Zubarev Yu.G. Psychology of the patient. L .: Medicine, 1980. S. 1 - 180.

4. Clinical psychology / Ed. M. Perret, W. Baumann. - 2nd ed. - St. Petersburg: Peter, 2003. - 1312 p.

5. Clinical psychology: Textbook / Ed. B.D. Karvasarsky. - St. Petersburg: Peter, 2002. - 960 p.

6. Psychology of health / Ed. G.S. Nikiforova. - St. Petersburg: Peter. 2003. - 607 p.

7. Reikovsky Ya. Experimental psychology of emotions. M.: Progress, 1979. S.ZO 1-352.

8. Hardy I. Doctor, sister, patient. Psychology of work with the patient. / Ed. M.V. Korkina. - Publishing House of the Hungarian Academy of Sciences. Budapest, 1981. - 286 p.

The reaction of loss to the death of a loved one can be manifested by an emotional shock with numbness and "petrification" or anxiety, crying, sleep disturbance, appetite, narrowing of consciousness on psycho-traumatic experiences, constant memories of the deceased, emotional longing, etc. With such symptoms, patients often, in connection with the death of loved ones, turn to psychiatrists and psychotherapists.

The reaction to the loss of a significant object is specific mental process developing according to its own laws. This period of life, accompanied by mourning, special attributes and rituals, has a very important task - the adaptation of the subject who has suffered a loss to a “new” life, life without a deceased person.

To date, there are no theories of grief (loss, losses) that adequately explain how people cope with losses, why they experience changing degrees and types of distress in different ways, how and after what time they adapt to life without significant dead people.

There are several classifications of grief reactions. Researchers distinguish from 3 to 12 stages or stages. These classifications assumed that the bereaved person moves from stage to stage. However, some experts criticize this approach. They believe that the main difficulty in using these classifications lies in the lack of clear boundaries between the stages, but recurrent recurrences of the disease state, when the patient returns to the already past, seemingly successfully lived stage.

Another feature of the manifestation of grief, which makes it difficult to use stage classifications and diagnose the current state, is its individual and variable nature. In addition, in certain cases, some stages are absent or are poorly expressed, and then they cannot be tracked and / or taken into consideration. Therefore, some authors prefer to focus not on stages and stages, but on the tasks that must be completed by a person experiencing loss during the normal course of grief.

Thus, the majority of modern specialists identify diverse variants of the course and changeability of grief experiences, which differ significantly in intensity and duration among cultural groups and among different people.

It is important for a psychiatrist (psychotherapist) in his practice to distinguish the adaptive variant of coping with a tragic situation (uncomplicated grief) from the maladaptive variant (complicated grief).

Subjective experiences of loss are individually different for each person, and therefore the clinical manifestations can be extremely variable. However, the psychiatrist (psychotherapist) needs to form an opinion on whether a person's grief develops adaptively or not in order to decide on an intervention. A clinician who does not represent the range of grief symptoms runs the risk of interfering with the normal process and possibly upsetting it.

Knowing the boundaries of uncomplicated, adaptive grief can help the practitioner recognize complicated grief and/or depression following the death of a loved one.

Although uncomplicated grief is determined to some extent by temporal criteria and the depth of experiences, they are not decisive. The criteria for diagnosing uncomplicated grief are:

1. The presence of state dynamics. Grief is not a state, but a process. A “frozen”, unchanging state should inspire fear.

2. Periodic distraction from the painful reality of death.

3. The emergence of positive feelings during the first 6 months after the death of a loved one.

4. Transition from acute to integrated grief. Shear M.K. and Mulhare E. distinguish two forms of grief. The first is acute grief that occurs immediately after death. It is manifested by severe sadness, crying, unusual dysphoric emotions, preoccupation with thoughts and memories of a departed person, impaired neurovegetative functions, difficulty concentrating, and a relative lack of interest in other people and activity in everyday life.

During the transition from acute to integrated grief, the intensity of psychopathological disorders decreases and the person who has experienced the loss finds a way to return to full life. The loss is integrated into autobiographical memory, thoughts and memories of the deceased no longer absorb all attention and do not disable. Unlike acute grief, integrated grief does not constantly occupy one's thoughts or interfere with other activities. However, there may be periods when acute grief re-actualizes. This often happens during significant events such as holidays, birthdays, anniversaries, but especially on "round" dates associated with the death of a loved one.

5. The ability of the bereaved subject not only to recognize the death of a loved one and part with him, but also to search for new and constructive ways to continue the relationship with the deceased. Faced with the dilemma of balancing inner and outer realities, mourners gradually learn to see their loved one again in their lives as dead.

The researchers found that the presence of the above criteria is a sign of resilience for bereaved people and is associated with good long-term outcomes for them.

Complicated grief, sometimes referred to in relation to intractable or traumatic grief, is a common term for a syndrome of prolonged (extended) and intense grief, which is associated with a significant deterioration in work, health, social functioning.

Complicated grief is a syndrome that occurs in about 40% of bereaved people, which is associated with an inability to move from acute to integrated grief.

In complicated grief, the symptoms overlap with those of normal, uncomplicated grief and are often overlooked. They are perceived as "normal" with the erroneous assumption that the time strong character and the natural support system will correct the situation and free the grieving from mental suffering. Although uncomplicated grief can be extremely painful and devastating, it is usually tolerable and does not require specific treatment. At the same time, complicated grief and various mental disorders associated with it can be maladaptive and severely disabling, affecting the functioning and quality of life of the patient, leading to severe somatic diseases or suicide. Such conditions require specific psychotherapeutic and psychiatric intervention.

People with complicated grief are characterized by specific psychological attitudes associated with difficulties in accepting the death of a loved one. They perceive joy for themselves as something unacceptable and shameful, they believe that their life is also over and that the severe pain that they endure will never disappear. These people do not want the grief to end, because they feel that this is all that is left for them from the relationship with their loved ones. Some of them idealize the deceased or try to self-identify with him, adopting some of his character traits and even symptoms of the disease.

Subjects with complicated grief are sometimes noted to be over-involved in activities related to the deceased on the one hand, and excessive avoidance of other activities. Often these people feel alienated from others, including those previously close to them.

© S.V. Umansky, 2012
© Published with the kind permission of the author
2. Psychology of loss and death. Grief reaction. Grief is a specific syndrome with psychological and somatic symptoms. This syndrome may occur immediately after a crisis, it may be delayed, it may not manifest itself clearly, or, conversely, it may manifest itself in an overly emphasized form. Instead of a typical syndrome, distorted pictures may be observed, each of which represents some particular aspect of the grief syndrome.

Reactions of grief, grief and loss can cause the following reasons: 1) the loss of a loved one; 2) the loss of an object or position that had emotional significance, such as the loss of valuable property, deprivation of work, position in society; 3) loss associated with illness.

There are five pathognomic features for grief - physical suffering, preoccupation with the image of the deceased, guilt, hostile reactions and loss of behavior patterns.

The main thing in assessing a person’s condition is not so much the cause of the grief reaction, but the degree of significance of a particular loss for a given subject (for one, the death of a dog is a tragedy that can even cause a suicide attempt, and for another, grief, but fixable: “you can start another"). With a grief reaction, it is possible to form behavior that poses a threat to health and life, for example, alcohol abuse.

The duration of the grief reaction is obviously determined by how successfully the individual performs the work of grief, namely, he emerges from states of extreme dependence on the deceased, re-adapts to the environment in which the lost face is no longer there, and forms new relationships.

Stages of grief:

1. 
   Numbness or protest. Characterized by severe malaise, fear and anger. Psychological shock can last for moments, days and months.
2. 
   Longing and desire to return the lost person. The world appears empty and without meaning, but self-esteem does not suffer. The patient is preoccupied with thoughts of the lost person; periodically there is physical restlessness, crying and anger. This state lasts for several months or even years.
3. 
   Disorganization and despair. Restlessness and performance of aimless actions. Increased anxiety, withdrawal, introversion and annoyance. Permanent memories of a departed person.
4. 
   rearrangement. The emergence of new experiences, objects and goals. Grief weakens and is replaced by memories dear to the heart.

Tactics of behavior with patients in a state of grief:

1. 
   The patient should be encouraged to discuss his experiences, to allow him to simply talk about the lost object, to recall positive emotional episodes and past events.
2. 
   Do not stop the patient when he starts to cry.
3. 
   In the event that the patient has lost someone close, efforts should be made to ensure the presence of a small group of people who knew the deceased and ask them to talk about him (her) in the presence of the patient.
4. 
   Frequent and short visits with the patient are preferable to long and infrequent visits.
5. 
   Consideration should be given to the possibility that the patient may have a delayed grief reaction that manifests itself some time after the death of a loved one and is characterized by behavioral changes, anxiety, mood lability and substance abuse. These reactions may appear on the anniversary of death (called the anniversary reaction).
6. 
   The reaction to anticipated grief occurs before the loss occurs and can lessen the intensity of the experience.
7. 
   A patient whose close relative has committed suicide may refuse to talk about his feelings for fear that this fact will somehow compromise him.

3. Loneliness (sensory and social deprivation). The state of loneliness is caused by a lack of external stimulation of a physical and social nature.

Based on the psychoanalytic concept, S.G. Korchagin (2001) identifies several types of the state of loneliness.

Self alienating loneliness. If the processes of identification with other people predominate in the mental life of a person, then there is an alienation of a person from himself, a loss of connection with himself, a loss of his own self, the impossibility of personal isolation, an almost complete loss of the ability of a person to reflect.

alienating loneliness. The consequence of the suppression of identification processes by processes of isolation is the alienation of the individual from other people, the norms and values ​​accepted in society, the loss of like-minded people, the loss of spiritually significant connections and contacts, the impossibility of truly close, spiritual communication, unity with another person. Such loneliness is often accompanied by agonizing enduring feelings of resentment, guilt, and shame. At the same time, the processes of reflection are activated, but often come down to self-accusation.

Loneliness can be absolute or relative(fighter pilots, astronauts, drivers of vehicles).

Signs of loneliness.

sensory deprivation - (from Latin sensus - feeling, sensation and deprivation - deprivation) - a prolonged, more or less complete deprivation of a person of visual, auditory, tactile or other sensations, mobility, communication, emotional experiences.

In another way, the term "deprivation" means the loss of something due to insufficient satisfaction of any important need, blocking the satisfaction of basic (vital) needs to the extent necessary and for a sufficiently long time. In the case when it comes to insufficient satisfaction of basic psychological needs, it is used as equivalent concepts of "mental deprivation", "mental starvation", "mental insufficiency", defining a state that is the basis or internal mental condition of a specific behavior (deprivation consequences) .

Deprivation situation It is the inability to satisfy important psychological needs. Deprivation experience suggests that the individual has previously been subjected to a deprivation situation and that, as a result, he will enter into each new similar situation with a slightly modified, more sensitive or, on the contrary, more “hardened” mental structure.

has a negative impact on personality development. emotional deprivation. The socio-psychological consequences of deprivation include fear of people, which is replaced by numerous unstable relationships, in which an insatiable need for attention and love is manifested. Manifestations of feelings are characterized by poverty and often a clear tendency to acute affects and low resistance to stress.

It has been proven that with a deficit of sensory information of any order, a person actualizes the need for sensations and strong experiences, develops, in fact, sensory and / or emotional hunger. This leads to the activation of the processes of imagination, which in a certain way affect the figurative memory. Under these conditions, a person's ability to preserve and reproduce very vivid and detailed images of previously perceived objects or sensations begins to be realized as a protective (compensatory) mechanism. As the time spent in conditions of sensory deprivation increases, lethargy, depression, apathy begin to develop, which for a short time are replaced by euphoria, irritability. There are also memory disturbances, the rhythm of sleep and wakefulness, hypnotic and trance states, hallucinations of various forms develop. The more severe the conditions of sensory deprivation, the faster the thinking processes are disrupted, which manifests itself in the inability to focus on anything, to think about problems consistently.

Experimental evidence has also shown that sensory deprivation can induce a temporary psychosis in a person or cause temporary mental disturbances. With prolonged sensory deprivation, organic changes or the appearance of conditions for their occurrence are possible. Insufficient brain stimulation can lead, even indirectly, to degenerative changes in nerve cells.

It has been shown that under conditions of deprivation, disinhibition of the cortex will occur, which can usually appear in the form of hallucinations (not corresponding to reality, but perceived by consciousness), and in any form: tactile sensations (crawling, warm streams, etc.), visual ( light flashes, faces, people, etc.), sound (noises, music, voices), etc. However, the "contemplation" of a certain image, provided by the corresponding dominants in the cerebral cortex, can cause lateral inhibition of the cortex. Thus, there are two oppositely directed tendencies - to disinhibition of the cortex and to inhibition.

social deprivation. This phenomenon is due to the lack of the ability to communicate with other people or the ability to communicate only with a strictly limited contingent. In this case, a person cannot receive the usual socially significant information and realize sensory-emotional contacts with others. A person isolated from society can structure time in two ways: with the help of activity or fantasy. Communication with oneself, both as a specific mechanism for real control of one's own personality, and as a fantasy (communication "in memory" or "dreams on a given topic") is a way of filling time with activity. Different ways of filling time are play activities, and especially creativity.

In modern domestic psychology, loneliness refers to one of the types of "difficult" states. At the same time, there is also a subjectively positive type of the state of loneliness - solitude, which is a variant of the normal experience of loneliness, which is personally conditioned by the optimal ratio of the results of the processes of identification and isolation. This dynamic balance can be considered as one of the manifestations of the psychological resistance of the individual to the influences of society. Solitude contributes to the growth of self-awareness, activates the processes of reflection and self-knowledge, is one of the ways of self-actualization and self-determination of a person in the world. As a peculiar form of "social hunger", by analogy with dosed physiological starvation, loneliness can be useful and even necessary for a person as a means of psychological restoration of his "self" and self-improvement.

4. Dying and death (stages of the patient's reaction: denial, anger, deal, depression, acceptance). Thanatology is a branch of medical science that deals with the whole range of problems associated with death.

In the past, a person from childhood faced the death of relatives and loved ones, but now this is happening less and less. With more frequent deaths in hospitals, death is institutionalized. Until the age of six, a child has an idea of ​​the reversibility of death. A full understanding of its inevitability comes in the puberty period. Religious ideas about the afterlife are now extremely rare. The cult of suffering, expressed in rituals and prayers (“Remember death!”), Turned thoughts about death, illness and suffering into an integral part of a person’s mental equipment. Religious institutions could provide people with psychological relief by forming in them certain "psychic antibodies" against the fear of illness and death. Therefore, a religious person more often (but not always) dies calmly, easily.

A modern healthy or temporarily ill person overcomes thoughts of death thanks to the mechanisms of psychological protection of the individual, which exist in the form of suppression and repression. With the problem of dying and death, a medical worker can meet in contact with very seriously and long-term suffering patients. At the same time, medical personnel are obliged to ensure the patient's right to a dignified death.

Elisabeth Kübler Ross, a pediatric psychiatrist in the Department of Psychopathology at the University of Chicago, studied the problem of death and dying in today's unbelieving person. She created her own scientific school and, together with her students, studied this problem. Elisabeth Kubler Ross stated that the mental state of a person with a fatal illness is unstable and goes through five stages, which can be observed in a different sequence (E. Kubler-Ross, 1969).

The first stage - denial stage and rejection of the tragic fact. It is expressed by disbelief in a real danger, the conviction that a mistake has occurred, the search for evidence that there is a way out of an unbearable situation, manifested by confusion, stupor, a feeling of explosion, deafness (“Not me”, “It can’t be”, “This is not cancer” ).

Second stage - protest stage. When the first shock passes, repeated studies confirm the presence of a fatal disease, a feeling of protest and indignation arises. “Why me?”, “Why others will live, but I have to die?” etc. As a rule, this stage is inevitable, it is very difficult for the patient and his relatives. During this period, the patient often turns to the doctor with a question about the time that he has left to live. As a rule, this stage is inevitable, it is very difficult for the patient and his relatives. During this period, the patient often turns to the doctor with a question about the time that he has left to live. As a rule, symptoms of reactive depression progress, and suicidal thoughts and actions are possible. At this stage, the patient needs the help of a qualified psychologist who knows logotherapy, the help of family members is very important. Embittered determined by the recognition of danger and the search for the guilty, moaning, irritation, the desire to punish everyone around. One of the manifestations of this phase in AIDS patients are attempts to infect someone else.

Third stage - request for a delay (deal). During this period, there is an acceptance of the truth and what is happening, but "not now, just a little more." Many, even previously non-believing patients, turn their thoughts and requests to God. The beginnings of faith are coming. An attempt to negotiate with death is expressed in the search for ways to delay the end, active treatment. Patients may try to negotiate with doctors, friends, or God, and in exchange for recovery promise to do something, for example, give alms, go to church regularly.

The first three stages constitute the period of crisis.

Fourth stage - reactive depression, which, as a rule, is combined with feelings of guilt and resentment, pity and grief. The patient understands that he is dying. During this period, he mourns for his bad deeds, for the grief and evil caused to others. But he is already ready to accept death, he is calm, he has done away with earthly worries and has gone deep into himself.

Fifth stage - acceptance of one's own death (reconciliation). The person finds peace and tranquility. With the acceptance of the thought of imminent death, the patient loses interest in the environment, he is internally focused and absorbed in his thoughts, preparing for the inevitable. This stage indicates a restructuring in consciousness, a reassessment of physical and material truths for the sake of spiritual needs. The realization that death is inevitable and unavoidable for all. The methods of psychocorrection depend on the phase of experiences and the characteristics of the patient's personality, but all of them are aimed at a faster and painless achievement of the stage of reconciliation.

5. Rules of conduct with a dying patient. Patients with incurable diseases need a special approach that requires a doctor, a psychologist to solve very difficult psychological problems.

1. The doctor, knowing that the patient's prospects are very sad, should inspire him with hope for recovery, or at least for a partial improvement in his condition. You should not take a rigid position, for example: "in such cases, I always inform the patient." Let the characteristics of the patient's personality determine your behavior in this situation. Determine what the patient already knows about the prognosis of his disease. Do not deprive the patient of hope and do not convince him if denial is his main defense mechanism, as long as he can receive and accept the necessary help. If the patient refuses to accept it as a result of denial of his illness, gently and gradually let him know that help is needed and will be provided to him. Reassure the patient that he will be taken care of regardless of his behavior.

2. You should spend some time with the patient after giving him information about the condition or diagnosis, after which he may experience a strong psychological shock. Encourage him to ask questions and give truthful answers.

3. It is advisable, if possible, to return to the patient a few hours after receiving information about his illness, in order to check his condition. If the patient has severe anxiety, then he should receive adequate psychological and psychopharmacological support, specialist advice. In the future, communication with a dying patient, practically devoid of meaning from a professional point of view, should not be interrupted, performing the function of psychological support for the patient. Sometimes medical workers, knowing that the patient is doomed, begin to avoid him, stop asking about his condition, make sure that he takes medication, and perform hygiene procedures. The dying person is alone. Communicating with a dying patient, it is important, without violating the usual ritual, to continue fulfilling the appointments, asking the patient about how he feels, noting every, even the most insignificant, signs of improvement in his condition, listening to the patient’s complaints, trying to facilitate his “care”, not leaving him alone with death . The fear of loneliness should be prevented and suppressed: the patient should not be left alone for a long time, carefully fulfill even the smallest of his requests, show sympathy and convince him that there is nothing to be ashamed of his fears; “Drive them inside” is useless, it’s better to speak out in front of someone.

4. It is necessary to give advice to the patient's family members regarding his illness. Encourage them to communicate with the patient more often and allow him to talk about his fears and worries. Family members will not only have to cope with the loss of a loved one, but also face the realization of the thought of their own death, which can cause anxiety. Also, relatives and other relatives of the patient should be persuaded to leave the feeling of guilt (if it is inadequate), let the patient feel his value to family and friends, empathize with him, accept his forgiveness, ensure the fulfillment of last desires, accept the “last forgiveness”.

5. The pain and suffering of the patient should be relieved. Psychotherapeutic assurances about the need for patience must have limits, and the fear that the patient may become a drug addict is cruel and pointless.

6. When a patient dies, it is necessary to create conditions that take into account the interests of the surrounding patients, who are very sensitive to manifestations of professional deformation on the part of the staff. For example, at the time of the death of a neighbor in the ward, patients asked the nurse to somehow alleviate the suffering of a dying woman who had near-death dyspnea, to which she replied: “There is no need for this, she will die anyway.”