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Towards A More Grief Literate Society

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Towards A More Grief Literate Society

Ensuring members of society are grief literate is the first step towards providing adequate support to the grieving.

The sudden loss of Mr Ong’s beloved wife, whom he called his “right-hand man” just four months after her cancer diagnosis, hit him hard. Life with its daily activities, from attending medical appointments to going to the hawker centre, became meaningless for him. Despite the support of his children, he was reluctant to burden them. He eventually retreated inward.

The grieving process was not easy, but slowly, Mr Ong was encouraged by Singapore General Hospital Principal Medical Social Worker Ann Chow to open up about the complex emotions that he was going through. In his own ways, Mr Ong learnt to live with his wife’s absence and honoured her memories through quiet moments spent sitting on her favourite chair at home and re-watching old videos he had taken with her

Ms Chow has dedicated time to equipping herself with grief literacy skills through courses and professional development. “Grief is a complex and multifaceted experience that requires empathy and active listening,” she says. “Our relationships with our loved ones who have passed on can still continue, even though they are no longer physically here. ” 

Medical Antgropologist, Dr Mary Ellen Macdonald in a 2020 journal article has asserted that we live in grief-denying societies, where people feel they are not permitted to grieve and face socially awkward and maladapted responses to grief. 

 For instance, the bereaved often report that friends, colleagues, and health professionals “disappear” or offer insensitive comments and platitudes because they do not know how to be supportive. People also avoid the grieving person because they are at a loss for words and actions, which adds to the grief. 

Moreover, mental health professionals typically only located in clinical and institutional forms of care such as palliative care or health and social services, usually provide bereavement care.

The Compassionate Communities movement is seeking to change that. As more mainstream media outlets shine light on the various grieving experiences of those around us, there is growing recognition that this responsibility to care for the grieving has to go beyond the clinical institutions. 

 In Singapore, there has been a momentous shift from a grief-denying society to one that is more grief-literate.


RECOGNISING GRIEF

Before diving into grief literacy, let’s better understand grief. Grief is an embodied response to loss. 

“While grief is typically associated with the event of death, we usually start experiencing grief during the end-of-life process through the many losses that one encounters along the way, such as loss of independence, loss of mobility, loss of privacy, loss of physical functions, loss of mental capacity, and loss of identity,” said Tay Jia Ying, an end-of-life doula and founder of Happy Ever After, a service that connects with and supports individuals in end-of-life planning.

Some people may also experience anticipatory grief and are already grieving now for a future loss (page 24). “As we journey with them, we will start to unpack and support people through these losses as they experience them, before the final death event,” she explained. 

Grief is multidimensional in that it affects all of life’s domains: physical, emotional, behavioural, social, financial, and spiritual. Furthermore, grief may not always be death-related; It may come from a relationship breakdown, family estrangement, or intergenerational grief and trauma.

Grief literacy is a relatively new concept that was born in 2018 out of a working group on death, dying and bereavement that met in Canada, referring to the capacity to access, process, and use knowledge regarding the experience of loss. The capacity is multidimensional, comprising the knowledge to facilitate understanding and reflection, skills to enable action, and values to inspire compassion and care.


TOWARDS A GRIEF-LITERATE SOCIETY

What would a grief-literate society look like? 

This ideal society would have members who can recognise and acknowledge grief from non-death losses, accept differences in the ways people grieve, understand variations in grief responses and practices across cultures, and feel comfortable talking about losses instead of avoiding the subject or showing discomfort. Schools will include grief education as part of the curriculum from an early age.

Healthcare professionals and scholars on grief say there is now greater awareness and space for grief than before. 

The 2023 National Strategy for Palliative Care Report recommends to “strengthen death and grief literacy in Singapore through the provision of more accessible information and conversation platforms, for the general public and healthcare professionals to obtain death and grief-related information”. Despite the encouraging progress, there is more work to do in this area.


NAVIGATING GRIEF LITERACY

“Death is still a taboo topic and is still a less-accepted thing to talk about, though that is slowly changing,” said Dr Paul Victor Patinadan, Assistant Professor of Psychology at the Nanyang Technological University, Singapore (NTU), who has certification in thanatology, which is a scientific study of death and the losses that result. “There is still very much a culture of silence. After the funeral ends, people feel that they are expected to move on with their lives quickly,” he said. 

It’s also weighed down by plenty of cultural baggage. “In an Asian society, there are many cultural norms and traditions to observe. For example, people may view inviting a grieving person to a wedding or festive occasion as inauspicious, but this is actually when the grieving individual needs the most interaction,” he said. 

“There is often the misconception that grieving should only last for a year, but the reality is that grief has no timeline,” said Dr Paul. In his experience, he has seen clients who have grieved for 20 years. Prolonged grief disorder is something less talked about too, as pointed out by Dr Paul. It is an intense and persistent grief that can be debilitating to daily life. 

Dr Paul Patinadan at the “Live Well. Leave Well” Festival, 2023

Another experience of grief is STUG, a sudden temporary upsurge of grief which hits one out of nowhere, and can have devastating and paralysing impact. Dr Paul shares that this is both common and normal.

In fact, many experts, including Associate Professor of Psychology, Mary-Frances O’Connor,have been rethinking the validity of the five stages of grief model. It was initially intended to describe the experiences of terminally ill patients facing their own death. However, there is a lack of sound empirical evidence to support the model for bereavement-related grief, said Mr Ng Yong Hao, a registered social worker currently completing his PhD at the University of Hong Kong, studying the social processes of pre-death grief among caregivers of persons with dementia.


People do not always follow the five stages of grief linearly, but some believe they must. Such beliefs can be unhelpful in the grieving process, Mr Ng said.

People experience grief in various ways and each individual has their own unique approach to living with loss and grief, even within a family. “Some individuals may prefer talking to someone about their grief, but others may dislike talking and instead choose other ways to cope with it, such as engaging in physical activities,” he explained.

Other types of grief expressions can also occur, such as somatic ones, where grief is manifested in a physical manner. For instance, Mr Ng knows of bereaved individuals who would experience pain in the same parts of the body as the deceased as a way of being connected to the deceased. “Feeling that kind of pain is relatively uncommon but not unheard of. Regardless, one should always go for a medical examination to ascertain if the physical experiences are symptoms of underlying medical issues,” he said.

“We often hear variations of ‘Oh, it has been so long, I thought you should have moved on’,which suggests that grief has got to end sometimes, but it doesn’t,” he said.

Mr Ng Yong Hao (right) nd fellow panel speakers at the Asia Pacific Social Work Conference

Disenfranchised grief is another type of grief that goes unacknowledged or invalidated by society, such as the loss of a pet, perinatal losses, elective abortions, the loss of a body part, the loss of a personality from dementia, the death of someone who is not blood-related, such as a close friend, and even grief over climate challenge

 While people have largely looked at grief on an individual level or between patient and caregiver, a person’s social environment heavily influences one’s pre-death grieving process, he said. 

If caregivers observe healthcare workers care for and interact with a family member with dementia with respect, they may feel less guilt and grief over having to place the family member in institutional care. Conversely, if the healthcare workers treat the family member as just another warm body to care for, it may aggravate the caregivers’ guilt and grief.

In another case, Mr Ng has seen how a young person with terminal illness grieved over a terrible breakup, but received unsupportive remarks from his friends and family as they disapproved of the relationship. It can be challenging to counsel the person through this grief, he said.


SUPPORT FOR GRIEVING INDIVIDUALS

In a grief-literate society, the community is able to approach the grieving person with empathy, respect and gentleness, said Dr Paul. “People should avoid cliches such as ‘He’s in a better place now’ and ‘Time heals all wounds’… It makes the grief seem insignificant and doesn’t acknowledge it,” he explained. 


 Friends and colleagues can acknowledge that grief is ongoing, provide tangible offers of help, and give the grieving person the space to decline, which can be important as they struggle with even the smallest tasks, said Dr Paul. 

For parents, it may be instinctive to shield their children from difficult topics, but they can also learn to normalise healthy conversations about death, such as a plant or pet dying. 

Dr Paul recalled how his mother had shared with him the news of his grandfather’s death with great sensitivity and grace, which left a deep impression on him. Humour is another way to break the tension, according to Dr Paul — to “recognise our own mortality and laugh at it. 


EFFORTS ON THE GROUND

To normalise conversations around grief, Dr Paul, with ARCH (Action Research for Community Health) Lab NTU and TaiTaiChef, has organised a series of “Table to Console” events for the public from 2022-2024. Participants explored their grief through food, and cooked two dishes to celebrate the lives of their deceased loved ones, including chendol, char kway teow, brownies, fruit tarts, and kueh.

NTU Chancellor President Tharman and Dr Paul
at “The Table to Console” event

Mr Ng and his colleagues have also embarked on a major project to develop a grief literacy inventory, which seeks to establish the most essential attitudes, values, knowledge and skills we should possess. Since last year, they have been collecting ideas from grief experts around the world, including Australia, Germany, Hong Kong, Malaysia, Singapore, the United Kingdom, and the United States.

“Grief literacy is an important concept. More efforts are required to get the public acquainted with loss and grief issues, and to develop more grief-literate communities in Singapore. The first step is awareness,” he said.

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