univers ity of the cumberlands department of education u c presented by dr. susan r. rose march 2,...

Universityof the

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Department of Education

UC

Presented by Dr. Susan R. RoseMarch 2, 2011

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Introductions

Your name Your title and your school/organization Educational Goals What brought you to this session? To the

conference? Something of interest about yourself that you

haven’t already mentioned Favorite vacation Hobbies Foreign languages

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Purpose of GriefPurpose of Grief…

this is not a process which can be rushed. I

t is about integrating the changed circumstances into the survivor’s ongoing life.

While I thought I was learning how to live, I was learning how to die. - Leonardo da Vinci Life is measured not by its length, but by its depth. – Mary Fisher

Related Quotes & Thoughts

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Grief knits two hearts in closer bonds than happiness ever can;

and common sufferings are far

stronger links than common joys.- Alphonse de Lamartine

(French writer, poet, and politician, 1790-1869)

School Counseling Program

Level 1: Defining the Loss Experiences That Generate Grief Reactions

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The Experience of LossThe Experience of LossB

ereavement: The objective event of loss Disrupts survivor’s life “Shorn off or torn up” / “Being robbed” A normal event in human experience

Grief: The Reaction to Loss

Thoughts (mental distress) Feelings (emotions) Physical responses Behavioral responses Spiritual responses

Mourning

Process by which a bereaved person integrates a loss into his or her ongoing life

Determined partly by social and cultural norms for expressing grief

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Basic Facts about Loss and GriefBasic Facts about Loss and GriefE

very year, two million people die in the U. S. If each of these deaths affects just five people, at least ten million people are

affected each year.

Chronic illnesses such as cancer, heart disease, and diabetes account for two of every three deaths. These illnesses create many losses before death is anticipated.

Accidents are the leading cause of death children under age eighteen. Accidents are also the cause of many disabling injuries, creating loss of mobility, fine motor skills, and cognitive functions.

In 1999, the most recent year for which statistics are published by the U.S. Dept. of Health and Human Services, 568,000 children were removed from their biological families to live in foster care. These children, their biological and foster parents, siblings, teachers, and counselors/social workers are all affected by loss and grief.


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Basic Facts about Loss and Grief cont.Basic Facts about Loss and Grief cont.According to predictions based on the U.S. census,

approximately 43% of marriages in the U.S. will end in divorce. Some parents and children who experience divorce

consider adjusting to the losses associated with it to be as challenging as the losses associated with death.

The tragic events of September 11, 2001 immediately affected people all over the world. Traumatic losses associated with these terrorist attacks,

along with other tragedies such as the Columbine High School shootings, have an impact on individuals and communities far beyond what can currently be understood.


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If you’re wondering what you should gain from this If you’re wondering what you should gain from this workshop, you should ask yourself:workshop, you should ask yourself:

How comfortable and confident am I in my own ability to deal with grief and loss?

How well do I understand the impact of death on people of different ages, genders, cultures and spiritual orientations?

How familiar am I with other life events and losses that can cause grief reactions?

Am I confident that I can identify when an individual or family is expressing normal grief or when their grief may be complicated?

How prepared am I to respond effectively to those around me who are grieving?

Do I know how to acknowledge grief and make a referral to an appropriate resource when necessary?


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More Insight into the Purpose of this WorkshopMore Insight into the Purpose of this Workshop


The KeeperThe Keeperhttp://www.counselingtoday.com/FreeStuff.html

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Symbolic (Psychological) Loss Symbolic (Psychological) Loss Divorce/The end of a relationship without one of

the partners dyingFoster care placementChildren leaving home for independent living (The

“empty nest”)Unemployment or Job demotionChanges in health statusMoving, Selling a childhood home, etc.Parents whose children have been diagnosed with

a disabling medical or mental conditionMoving parents into a nursing homeLoss of independenceMiscarriage/InfertilityDeath of a pet


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Loss and Grief in Different ContextsLoss and Grief in Different ContextsC

risis Counseling We can’t “cure” grief, but we can offer help and care.

Trauma Therapy/Counseling

Becoming attuned to grief issues helps identify and assist with loss and grief associated with these problems.

Unacknowledged Grief – For example:

Losing a parent symbolically due to substance abuse Refugees fleeing their homeland Empty Nest (High School Counseling) Loss of Health


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Loss and Grief in Different Contexts cont.Loss and Grief in Different Contexts cont.

The “Tough” Kid

14-year-old girl place in therapeutic home for adolescents Mother died in a car accident when she was a toddler Father was incarcerated at the time, so she and her sister

were moved from family member to family member as well as to foster homes where she was sexually and physically abused.

Frequent expression of anger and poor behavior resulted in residential placement, outside of the city in which she has spent her childhood and separate from her sister.

What do you think happened next?


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Small Group Exercise (3 – 4 members)Small Group Exercise (3 – 4 members)Divide a sheet of paper into two columns. In the

first column, write down the types of losses, both actual and symbolic, that students are likely to experience.

In the second column, write the emotions someone experiencing each loss is likely to experience.

Discuss your thoughts about how you might observe these losses and the feelings related to them. (For example, a school counselor leading a group for children whose parents are divorcing might observe academic problems with some of the children.)


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Share out in Large GroupShare out in Large Group

Although the world is full of suffering,

it is full also of the overcoming of

it. -

Helen Keller


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Everything that happens to you is your teacher. The secret is to sit at the feet of your own life and be taught by it.

- Polly B. Berends

(Author & Editor

of Children’s book)


Level 2: Self-PreparationLevel 2: Self-Preparation - Preparing Yourself - Preparing Yourself to Help Others Encountering Loss and Griefto Help Others Encountering Loss and Grief

What is of greatest importance in a person’s life is not just the nature and extent of his or her experiences but what has been learned from them.

-Norman Cousins

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Reviewing Our Own Experiences and Attitudes Reviewing Our Own Experiences and Attitudes Related to GriefRelated to GriefExperiences with death or loss significantly influence the way we

react to the losses of other, both consciously and unconsciously.

Take a few moments now to think about the following questions. What was your earliest experience with death or loss? How old were you

when it occurred? Where were you when you learned of the loss? Who did it involve?

What were the physical, emotional, and cognitive reactions you were aware of in yourself following the loss?

How did the people around you respond to the loss? How did they respond to your reactions?

How did your cultural and/or spiritual background influence your responses?

What about the loss makes you feel vulnerable now? Based on what you have learned since, what do you think can help you to

cope more easily with death or loss now and in the future? How do you think your own feelings and reactions to loss may impact

your work with others who are experiencing loss or trauma?


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Assessing and Enhancing Readiness to Address Grief Assessing and Enhancing Readiness to Address Grief in Our Workin Our WorkHow do we know if we are ready to help others with

their grief? Self-Assessment/Self-Awareness

Working with individuals and families facing loss inevitably brings up emotions and memories for every professional.

Establishing competence in providing care to those

who are grieving. Support clients in their expression of emotional needs Actively listen Refer to support groups, peer support programs, and

professional experts Ask open-ended questions such as, “How are you doing?”


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Supervision, Consultation, and Collaboration with Supervision, Consultation, and Collaboration with other Professionalsother ProfessionalsEspecially important when exposure to distress of

others is prolonged, frequent, or intense. Vicarious/Secondary trauma: a common reaction in

professionals who work closely with individuals or groups who directly experienced trauma. Supervisors, peers and consultants can help us to recognize when

our own reactions may be distressed.

Interdisciplinary/Multidisciplinary Team Counselors Teachers Attendance Specialists/Clerks Disciplinary Staff Administrative Personnel


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Questions, Comments,

Concerns

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Factors that influence a child’s a child’ cognitive, Factors that influence a child’s a child’ cognitive, emotional, and behavioral reactions to death: emotional, and behavioral reactions to death:

Chronological age

Earlier experiences with death

Reactions of adults and other children around them

Child’s own unique personality and coping style


Childhood

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Infants Infants Key developmental issues for infants are dependency and attachment. Developmental Factors

Dependence on caregivers for all basic needs Limited object constancy – the understanding that person or object exists, even if not physically

present. Limited ability to verbalize. Few coping strategies to regulate tension.

Understanding of death Do not recognize Experience feelings of loss in reaction to separation that are part of developing an awareness

of deathR

eactions to loss Emotional: Sluggish, quiet, unresponsive to a smile or a coo; may also cry and appear

inconsolable Physical: Weight loss, less active, sleep less

What can help? Maintaining normal routines of care giving and familiar surroundings Providing a consistent caregiver who can give frequent and lengthy periods of love and

attention, including holding and hugging Providing consistent, gentle, physical and verbal reassurance and comfort Expressing confidence in the child and the world


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Ages 2 – 3 (Toddlers)Ages 2 – 3 (Toddlers) Like infants, key developmental issues for toddlers are dependency and

attachment. Great variation in cognitive and emotional development

Developmental Factors Ambivalence about independence Increasing comprehension and articulation of language Learning by mimicking and following the examples of others

Understanding of death Generally cannot cognitively understand death Cannot differentiate absence for a short time from a long time Can sense loss of change but often cannot verbally explain or discuss it

Reactions to loss Emotional: Express discomfort or insecurity through frequent crying or protest; Express

distress or sadness through withdrawal, loss of interest in usual activities, and changes in eating and sleeping patterns.

Physical: May show regression through clinging or screaming when a caregiver tries to leave; May express distress through regression, often giving up previously acquired skills such as speaking clearly, toileting, and self-soothing at bedtime

What can help? Same as infant + Providing simple, understandable verbal explanations for changes Naming feelings expressed by the child and those the child observes being expressed by

others, such as, “Daddy feels sad; that is why he is crying.”


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Ages 3 - 6Ages 3 - 6 Children at this stage are still thinking concretely and may perceive death

as a kind of sleep Concept of death may involve magical thinking

Developmental Factors Developing a fuller mastery of language Learning to read Expressing feelings through art and play Acquiring social skills through interactions and observing others

Understanding of death Cannot quite comprehend the difference between life and death

Reactions to loss Emotional: May be very anxious that something could happen to them or someone else upon

whom they are dependent; May exhibit searching behaviors Physical: May have trouble eating, sleeping, and controlling bladder and bowel functions

What can help? Explaining death in simple and direct terms, including only as much detail as the child is able to

understand. Answering a child’s questions honestly and directly, making sure that the child understands the

explanations provided. Reassuring children about their own security and explaining that they will continue to be loved

and cared for (They often worry that their surviving parent or caregiver will go away) Encouraging master of age appropriate skills while allowing for regression Expressing confidence in the child and the world.


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Ages 6 – 9 Ages 6 – 9 Children in this age are commonly curious about death and may ask

questions about what happens to one’s body when a person dies. Children beginning in this age benefit from being invited to contribute to

memorial ceremonies or activities. Developmental Factors

Relationships with peers and adults are important Striving for mastery of information and tasks Superego and a sense of responsibility are developing Cognitively, they are still thinking concretely.

Understanding of death Children’s questions often indicate their efforts to understand death fully.

Reactions to loss Can become afraid of going to school or have difficulty concentrating, may behave aggressively,

become overly concerned about their own health, or withdraw from others. W

hat can help? Discussions of death that include proper words, such as ‘died” and ‘death” Providing opportunities for children to ask questions freely and to express their feelings directly

or through creative activities Providing reassurances that the child’s thoughts, feelings, and behavior did not cause death Reading aloud stories or books that deal with death and allowing the child to share their reactions

or questions Inviting children to share memories and participate in ceremonies or remembrance activities


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The SandpiperThe Sandpiper


http://www.counselingtoday.com/FreeStuff.html

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What is What is your Joy?your Joy?


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Ages 9 – 12 Ages 9 – 12 Child is developing an increasing grasp of abstract concepts

By the time a child is 12, death is seen as final and something that happens to everyone

Developmental Factors Interest in and capacity to understand biological processes Heightened sensitivity to others’ emotions Increased awareness of vulnerability Regressive and impulsive behaviors indicate stress

Understanding of death Death is usually known to be unavoidable and is not seen as punishment

Reactions to loss Greater risk for symptoms of depression, withdrawal, anxiety, conduct problems, changes in

school performance, and low self-esteem Capable of empathy

What can help? Talking about death can help children learn effective ways to cope with loss Providing an opportunity to explore and discuss spiritual and cultural beliefs related to loss Providing physical outlets for strong emotions Encouraging expression of feelings through different media including art, music, dance, and

writing. Letting children know they are not alone and that others experience loss and the feelings related

to it. Modeling direct and constructive expression of feelings naturally associated with loss such as

anger and sadness.


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AdolescenceAdolescence Adolescents may view death in the family as making them appear

different from their peers May perceive death has placed greater demands on their own development

Developmental Factors Searching for identity Peer relationships are very important Exposure to maladaptive responses to stress Abstract thinking

Understanding of death Adolescents comprehend that death is permanent, irreversible, and affects everyone.

Reactions to loss At risk for exposure to maladaptive coping strategies; May also be at risk for parentification

What can help? Talking openly about death, indicating that the subject is not off-limits Verbal or written explanations that tears, sadness, anger, guilt, and confusion are all part of

normal grief Providing opportunities for adolescents to hear from and talk with peers who have also

experience loss Inviting the adolescent to help plan or participate in memorial or remembrance activities in the

way that feels most comfortable to them Connecting adolescents to peers who have similar experiences to reduce isolation Encouraging journal writing or using other methods to express thoughts and feelings Constructing memorials, memory books, boxes, or quilts, or providing other tangible ways to

memorialize significant relationships


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Young AdulthoodYoung Adulthood Multiple demands of life may deter ability to devote time and

energy to grief. Developmental Factors

Expected to be self-sufficient (economically, if not emotionally) Developing career and life plans Expanding their range of roles and coping strategies

Understanding of death Fully comprehend and are also capable of comprehending the complex range of

responses of different people to different types of lossesR

eactions to loss Vulnerable to the emergence of anxiety, depression, and other disorders that

stress related to loss can exacerbate W

hat can help? Acknowledge the multiple impacts of loss and the normalcy of grief reactions Encouraging individuals to take time to attend to their own feelings as well as

those of others Acknowledging or providing opportunities for expression and discussion of

conflicting feelings Promoting social connections through peer support and group activities Referring young adults to credible Internet sources for information and peer

supportSchool Counseling Program

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Middle AdulthoodMiddle Adulthood “Sandwich” generation Developmental Factors

Re-examination, renewal, and /or reintegration of identity Multiple roles and responsibilities Long-established patterns may be difficult to change Increased vulnerability to physical disorders

Reactions to loss “Pile-up” of losses Maladaptive patterns may make the process of grieving complicated

What can help? Empathic listening and support Release time from work or school to meet family obligations and process

grief Bereavement support groups Tangible expressions of support or caring Pastoral care or connection with a religious or spiritual community Identification of risk factors and offering intervention for complicated grief Opportunities for respite and renewal Opportunities to assist others


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Late AdulthoodLate Adulthood Textbooks define this as 65 and older Developmental Factors

Poor health or disabling medical conditions may have significant impact as biological aging progresses

Serenity and wisdom may be sought Changes in identity related to work and family occur Adaptation to changes in information processing and memory is required to

maintain maximum functioningR

eactions to loss Multiple losses require continuing adaptation; May be difficult to differentiate

between grief and depressionW

hat can help? Acknowledgement of symbolic losses as well as losses through death Maintaining or augmenting social supports Provision of income supports or economic assistance, when needed Identifying new activities, roles, and relationships to augment or replace those

that have been lost Conducting informal and formal life review, with emphasis on strengths and

contributions


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Conducting informal and formal life review, with emphasis on strengths and contributions

A Life Well-Lived



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Advanced AgeAdvanced AgeTextbooks define this as 80 and older Developmental Factors

Vulnerability to social isolation, disabling medical conditions, and memory loss

Adaptation to multiple losses, both symbolic and through deaths

Change in sense of time A sense of consummation and conclusion in life

Reactions to loss Anticipate own death; Reminiscence is common and

often brings a positive sense of closure and fulfillment


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Advanced Age cont.Advanced Age cont.W

hat can help? Reminiscence through sharing of memories, with

individuals and groups “Make memories, Little Buddy, because when you get older,

that’s all you’ll have.”

Thank You for Your Time , http://www.counselingtoday.com/FreeStuff.html


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Advanced Age – What can help? cont.Advanced Age – What can help? cont.W

hat can help? Reminiscence through sharing of memories, with

individuals and groups Providing concrete supports to allow expenditures of time

and energy on satisfying activities and relationship (helping with household maintenance or bill paying)

Acknowledging losses as well as strengths and coping capacities

Encouraging completion of advance directives Providing opportunities to open discuss ideas, values,

feelings, and fear related to dying and death Just Be There


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Just Be ThereJust Be There



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Questions, Comments,

Concerns

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Level 4: Normal and Complicated

Grief Reactions


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And can it be that in a And can it be that in a world so full and busy world so full and busy the loss of one creature the loss of one creature

makes a void in any makes a void in any heart so wide and deep heart so wide and deep

that nothing but the that nothing but the width and depth of width and depth of

eternity can fill it up! eternity can fill it up!

- Charles Dickens- Charles Dickens


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Theories That Inform Our Understanding of GriefTheories That Inform Our Understanding of GriefS

igmund Freud’s Mourning and Melancholia (1917) Every human infant develops attachments to significant people (whom he

referred to as “objects”) through the process of Cathexis. Cathexis: process of attaching emotionally Decathexis: process of letting go of an attachment as an adaptive response

to loss of a significant “object”

John Bowlby elaborated on Freud’s ideas (1973)

Proposed that attachment behavior helps infants establish an maintain a sense of security throughout their life.

According to Bowlby’s theory, grief reaction of the bereaved to the loss of a significant other is a similar process. Bereaved must cease investing their emotional energy (referred to as libido in

both Freud and Bowlby) in the deceased in order to reinvest it in other relatioship

Both believed that with the passage of time grieving individuals could achieve decathexis

Failure to do this results in depression


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Theories That Inform Our Understanding of Grief Theories That Inform Our Understanding of Grief Eric Lindemann became interested in grief

reactions after a major tragedy in Boston, the Coconut Grove nightclub fire, took the lives of 492 people in November 1942.

Lindeman studied the grieving survivors and found common reactions of: Physical or Bodily Distress Preoccupations with the image of the person who had died Anger or hostility Guilt Impaired functioning in work or family roles

He also identified task that grievers completed that resulted in a diminishment of these symptoms. Acknowledging the reality of the death Adjusting to life without the deceased person Forming new relationships


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Theories That Inform Our Understanding of Grief Theories That Inform Our Understanding of Grief Elizabeth Kubler-Ross, a physician who worked with

dying patients, made major contributions to our understanding of Anticipatory Grief.

Pioneering Publications in the 1960’s and 1970’s described her stage model1. Denial and Isolation2. Bargaining3. Anger4. Sadness/Depression5. Acceptance

Parkes (1998) identified related stages in the grieving process

Shock or numbness Yearning and pining (anger & guilt) Disorganisation Beginning to pull life back together


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More recently, grief counselors Therese Rando and William Worden have expanded on earlier theories

Worden (2005) concentrates on tasks of grieving that have to be worked through (‘grief work’) if resolution of grief is to take place:

To accept the reality of the loss To work through or experience the pain of grief To adjust to a changed environment in which the deceased is

missing To emotionally relocate the deceased and move on with life and

capacity to love others. Rando’s 6 R’s/ The Tasks of Mourning

Recognize the loss React to the separation Recollect the deceased and the relationship Relinquish old attachments to the deceased Readjust adaptively into a new world without forgetting the old Reinvest

Theories That Inform Our Understanding of Grief Theories That Inform Our Understanding of Grief

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Common Reactions in Normal GriefCommon Reactions in Normal GriefH

ighly variable and individualistic Grief reactions vary across a wide spectrum according to:

Cultural Backgrounds Social Support Networks Gender Socioeconomic Status Psychological Health Circumstances of Loss

Complex, evolving process

Multiple dimensions

Signs of grief may appear immediately after the death or may be delayed or even absent

No predetermined timetable for “completion”

Most often, the social and emotional support provided by family and friends is enough


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Normal Grieving BehaviorsNormal Grieving Behaviors Thoughts (Mental Distress) Confusion, inability to concentrate or remember details, disbelief,

anxiety; Sense of disorganization; Depression; Sensory responses undependable and erratic; and auditory or visual experiences that mimic hallucinations – such as seeing an image of the deceased person or hearing their voice – are not uncommon following a loss

Feelings (Emotions) Sadness, Longing, Loneliness, Sorrow and Anguish, Guilt, Frustration at

being unable to control events, Anger and outrage at injustice of the loss, Anxiety, Fatigue, Helplessness, Numbness, Shock, and even Relief

Physical (Somatic) Sensations Tightness in the chest or throat, choking, shortness of breath; Lack of

energy; Feeling of emptiness in the abdomen and stomach; Frequent sighing; Sleep disruptions (e.g., insomnia); Changes in appetite; Chills, tremors, hyperactivity

Behavioral Responses Crying; Searching for the deceased; Incessant talk about the

deceased and circumstances of death; Avoidance of talk about the deceased; Restlessness, irritability, hostility


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Expressions of MourningExpressions of MourningT

he bereaved are “different” for a timeA

bstaining from social occasionsV

isual Symbols Black armbands National flag at half-mast Seclusion Cutting long hair short (Native Americans)

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The Course of Grief The Course of Grief (Summarizing Normal Grief) (Summarizing Normal Grief)

Initial phase: Shock, numbness, disbelief, denial

Middle phase: Anxiety, despair, volatile emotions, yearning for deceased, feelings of abandonment

Last phase: Sense of resolution, reintegration, and transformation; turmoil subsides; balance regained

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Complicated GriefComplicated Grief Complicated Grief/Complicated Mourning: difficulty coping with

loss; prolonged distress long after the loss has occurred.

Failure to complete the tasks of grief/mourning results in several types of complicated mourning: Delayed grief: when a loss is insufficiently mourned Masked grief: when grief is absent immediately after a loss but

appears later in the form of a medical or psychiatric problem Exaggerated grief: when a normal grief reaction, such as

depressed mood or anxiousness, goes beyond normal grief to a clinical level of depression or anxiety

Chronic grief: when the mourner is stuck, sometimes for many years, in the grief process

Anomic grief: where there is an absence of standards or guidance on how to grieve. The person does not know what to do, doesn’t know how to deal with the loss, change in circumstances.

Forbidden grief: when others deny the person has suffered any loss.

Time-limited grief: the idea is that you should get back to normal, especially emotional normality, as soon as possible.


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Who is at risk for complicated grief?Who is at risk for complicated grief? Perceived lack of social support

Examples: Suicide, older adults who have already sustained the loss of many members of their primary support network, Children placed in foster care

High Profile Losses Lack of privacy; frequent inquiries about and exposure to the details of the

loss make it difficult to obtain respite Multiple Stressors

Reduced income or unexpected financial debt Loss of important roles Loss of a job or health insurance

Disenfranchised loss: losses accompanied by stigma resulting in loss of support or acknowledgment for grieving survivors

Examples: Execution of a prisoner, loss associated with AIDS, death of a drunk driver, suicide

Unique losses that produce intense grief reactions for a long time Examples: Loss of a child, Parents whose children have been removed by CPS or

how have relinquished the role of parent through adoption Sudden, unanticipated loss (especially when traumatic, violent,

mutilating, or random) Bereaved’s perception that the death was preventable Death from overly lengthy illness Relationship that was markedly angry, ambivalent, or dependent Mental health problems or unaccommodated losses


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Danger of “Medicalizing” GriefDanger of “Medicalizing” GriefBecause circumstances and personalities differ, what

is a pathological response for one mourner may be an appropriate response for another mourner

Many of the criteria suggested for making a diagnosis of traumatic grief appear virtually indistinguishable from the signs of normal grief

Label of “dysfunctionality” may be applied to normal expressions of grief and mourning.

No direct cause-effect link established between bereavement and onset of disease.

Higher incidence of some chronic diseases in recently bereaved individuals Mortality/Morbidity of Grief: Studies Reported...

Diminished immune response has been found among widowers during first months following bereavement

Death rate during first year of bereavement nearly seven times that of general population (small community in Wales)

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Variables Influencing GriefVariables Influencing GriefS

urvivor’s model of the world Personality Cultural context and social roles Perceived relationship with the deceased Values and beliefs

Mode of death

Anticipated Sudden Suicide Homicide Disaster

Multiple losses and bereavement burnout

Social support and disenfranchised grief

Unfinished business

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Interventions for Normal and Complicated GriefInterventions for Normal and Complicated GriefWhy and how can a referral to a mental

health professional or grief therapist help?

According to the DSM-IV, bereavement is considered to be complicated by a major depressive episode if the normal depressive symptoms are accompanied by: Morbid preoccupation with worthlessness, suicidal

ideation Marked functional impairment or psychomotor

retardation of prolonged duration


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Interventions for Normal and Complicated GriefInterventions for Normal and Complicated GriefP

reventive Interventions Anticipatory grieving Education Emotional support

Monitoring, with social support

Support groups

Face-to-face Online Telephone (Skype, etc.)


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Interventions for Normal and Complicated GriefInterventions for Normal and Complicated Grief

Maintaining Bonds

Rather than severing ties with the deceased, the bereaved person incorporates the loss of a loved one into his or her ongoing life

Maintain “inner representation” of the deceased Bonds sustained through memories and linking

objects The “ties that bind” are maintained by “threads of

connectedness”

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Interventions for Normal and Complicated Grief cont.Interventions for Normal and Complicated Grief cont.B

rief supportive or bereavement counseling

Grief therapy

Individual Couples Family Therapy

Psychiatric referral and use of psychotropic medication

Innovative Interventions

Daylong workshops Annual memorial workshops held at hospitals or hospices Retreat programs/Camp Programs Bibliotherapy Using music in counseling


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Exercise: Identifying Signs of Normal and Complicated GriefExercise: Identifying Signs of Normal and Complicated Grief

Think of someone you know who has experienced a loss. Using the normal emotions of grief as a checklist, note whether the person showed signs of sadness, anger or guilt that are a part of normal grief. Describe your observations

Discuss whether you saw signs of complicated grief. Describe the type of complicated grief the individual evidenced and the interventions that may have been helpful to them to complete the tasks of grieving.


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Only people who avoid love avoid grief. The point is to learn from it and remain vulnerable to love. - John Brantner


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We must accept We must accept finite finite

disappointment, disappointment, but never lose but never lose infinite hope.infinite hope.

- Martin Luther King, Jr.- Martin Luther King, Jr.


Cultural and Spiritual Influences

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Grief and LossGrief and LossGrief and loss can be said to be part of every

human life although the meaning of this experience and responses to it are unique.

Each of us will grieve in our own unique way for the unique loss that we have suffered. There is no right or wrong way to grieve.

Each person’s unique feelings of grief and loss will be influenced by the culture and society in which they live.

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Influence of Culture in Coping with Loss and GriefInfluence of Culture in Coping with Loss and Grief

Culture: the integrated pattern of human that includes thoughts, communications, actions, beliefs, values, and institutions of a racial, ethnic, religious, or social group. Often referred to as the totality of ways that are passed down from one generation

to another (NASW, 2005)Cultural Sensitivity: an awareness of, and appreciation

for, the differences in values, beliefs, and norms of people from different cultural and spiritual backgrounds.

Cultural Competence: professionals practice of cultural sensitivity as well as the ability to engage and interact effectively with people from diverse cultural backgrounds.


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Lack of Awareness of different cultural Lack of Awareness of different cultural groups’ responses can lead us to:groups’ responses can lead us to:

Misinterpret an individual’s or family’s reactions

Fail to offer support or assistance that might be perceived as helpful

Offend the grieving person(s) and create a barrier to their receiving care and support


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Group vs. the IndividualGroup vs. the IndividualKnowledge of a particular group does not

necessarily equip someone to adequately understand in individual, who may not subscribe to the beliefs or norms of the group.

Differing Spiritual Practices within the group Differing Norms based on:

Socioeconomic Status Multiple Group Memberships Individual Ideology


Sharing Stories of Differing Cultural Experiences

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Gender and GriefGender and GriefIn American culture, men are taught not to

show emotions such as sadness, loneliness, or depression.

Causes some men to be unable to cope with the feelings they are experiencing.

They may not have health outlets to express their emotions


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The Transmission of Cultural MessagesThe Transmission of Cultural MessagesF

amily communication or interactionM

ass Media Vicarious Experiences

Makes us all “Instantaneous” survivors

Contributes to “Grief Denying” culture

Famous are front page news, while the average Joe or Jill isburied in death notices deep in “Section G”


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The Transmission of Cultural MessagesThe Transmission of Cultural MessagesC

ulture of Poverty and Violence “Waking up and living another day, facing an endless

accumulation of losses” Area where much work is needed

Let’s Brainstorm


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Influence of Spirituality in Coping with Loss and GriefInfluence of Spirituality in Coping with Loss and Grief

Spirituality: that which gives meaning to one’s life and draws one to transcend oneself

Expressions of Spirituality Prayer Meditation Interactions with others or nature Relationship with God or a higher power

Religion: communal or institutional expression or practice of faith.


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Assessing importance of Spirituality in Assessing importance of Spirituality in People’s LivesPeople’s Lives

Pulchalski (1999) developed a user tool:

F: Faith or beliefs I: Importance and influence C: Community A: Address


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ExerciseExercise1.Of the stories that we discussed earlier or other

experiences that you have had, discuss the funeral rituals or mourning behavior you have observed.

2.What aspects of these rituals are similar to the practices of your own cultural or religious groups?

3.What aspects are different?

4.Of the rituals, practices or behaviors you have observed in your own life, which ones do you feel would be particularly helpful for those who have experienced a loss?


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While we are mourning the loss of our friend, others are rejoicing to meet him behind the veil.

~John Taylor


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One of the most One of the most beautiful beautiful

compensations of compensations of this life is that no this life is that no man can sincerely man can sincerely try to help another try to help another

without helping without helping himself. himself.

- - Ralph Waldo EmersonRalph Waldo Emerson


Level 6: Counseling the Individual - What Can We Do To Help?

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GriefGrief“

No one ever told me that grief felt so like fear. I am not afraid, but the sensation is like being afraid. The same fluttering, the same restlessness, yawning. I keep on swallowing. At other times it feels like being mildly drunk, or concussed. There is a sort of invisible blanket between the world and me. I find it hard to take in what anyone says. Or perhaps, hard to want to take it in; it is so uninteresting. Yet I want the others to be about me. I dread the moments when the house is empty. If only they would talk to one another and not to me” C.S. Lewis, A Grief Observed

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Misconceptions of GriefMisconceptions of Grief1. Time heals all wounds.

2. People find it too painful to talk about their loss.

3. Crying indicates that someone is not coping well.

4. The grieving process should last about one year.

5. Quickly putting grieving behind will speed the process of healing.


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Empathic CommunicationEmpathic Communication

Active Listening

S= Sit up straight L= Lean forward A= Activate your thinking N= Note key ideas (Verbal following) T= Track the talker (Appropriate eye contact)

Communication Facilitation

Reflection of feeling Paraphrasing Use of minimal encouragers Use of open-ended questions Therapeutic silence


(Attentive body language)

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Empathic CommunicationEmpathic CommunicationA

void: Saying “I know how you feel” or “I understand.” Talking about your own losses (me-too-ism) Parroting or repeating the speaker’s exact words. Try,

instead to respond to the actual content expressed. Thinking about or planning your own responses instead

of listening to what is being said. Giving unsolicited advice. Breaking silences too quickly or filling in before the

speaker has finished speaking. Challenging the other person’s perception of their

situation or feelings.


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Utilizing Information and ResourcesUtilizing Information and ResourcesIdentify key experts in your own community and

obtain their contact informationInternet National Organizations

Compassionate Friends: support organization for parents who have lost a child

COPS (Concerns of Police Survivors): organization assisting survivors of police who die in the line of duty

The Dougy Center: National Center for Grieving Children and Families

Cancer Care KET: Kentucky Educational Television

Examples: Before It’s Too Late – Preventing Teen Suicide, http: www.ket.org/health/before-its-too-late.htm ; The Forgetting - A Portrait of Alzheimers, http://www.ket.org/forgetting/

PBS: Public Broadcasting System


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Collaborating with OthersCollaborating with OthersC

ore functions related to goal attainment: Completing a thorough assessment Contributing to the development of a comprehensive

educational/treatment plan Participating as a member of the interdisciplinary

team Implementing the components of the

educational/treatment plan Evaluating progress Advocating


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Functions of Team MembersFunctions of Team MembersC

ounselors contribute an understanding of: Compassion Fatigue: the reactions that professional

caregivers sometimes experience in the process of helping others with grief, loss, and trauma.

Secondary trauma/Vicarious trauma: trauma that professional caregivers can experience through listening to the details of trauma that others have experienced.

Counselors help other professionals cope effectively with the demands of their work.

Expressing feelings to others who can listen empathetically and provide support

Using stress management techniques Making sure there is a balance in our lives


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Books About Death, Loss, Illness, and Hope Books About Death, Loss, Illness, and Hope for Children and their Caregiversfor Children and their Caregivers


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Songs about GriefSongs about Grief

http://www.recover-from-grief.com/songs-about-grief.html

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Visual Art & GriefVisual Art & GriefM

aterials Paper: Letter, Legal, Butcher, Bulletin Board, etc. Colorful Copy Paper Construction Paper Ribbon Yarn Glue Sticks and/or Tape Coloring Pencils and/or Crayons Pencils and/Pens (Depending on age) Any other Art supplies you have on hand

Beads, glitter, sequins, etc.

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Grief BoxGrief BoxY

our Grief Box for Counseling Books CD’s with songs Visual Art supplies

Student’s Grief Box

Decorated Cardboard Box (Shoe Box, Shirt Box, etc.) Hand-made frames (Child can place pictures later) Quotes, Phrases, Scripture verses, etc. Journal (Notebook tied together with ribbon will suffice) Any other memories

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Questions , Comments,

Concerns

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As the sun As the sun illuminates the illuminates the moon and stars moon and stars

so let us so let us illuminate each illuminate each

other.other. - Master Lui- Master Lui


Level 7: When Organizations and Communities Grieve

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Counselors can make a significant difference Counselors can make a significant difference through a variety of helpful responses:through a variety of helpful responses:Practicing empathic communication (Chapter 6)Referring a client to a support group, a

bereavement counselor, or another community provider (Chapter 4)

Attending a funeral or planning a memorial service can serve as an expression of support

Offering to be present with those who are grieving

Taking a Leadership Role


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Establishing a Bereavement Protocol: Establishing a Bereavement Protocol: Interdisciplinary CollaborationInterdisciplinary Collaboration1. Communicate the news to all the members of

the school community who knew the deceased.2. Provide concrete ways for people to express

their caring and concern. 3. Acknowledge the loss in meetings and classes.4. Obtain consultation or support for staff who are

providing grief counseling to others, if needed.


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Creating Remembrances and MemorialsCreating Remembrances and MemorialsMemorial cookbook for an avid cookMemorial Walk accompanied by a

“Concrete” MemorialHonorary Trees/BushesDonate organs as a “living” tributeFoundations to collect $ to find a cure for a

disease that took the loved one Scholarships or Memorial fundsMemorial Events

Basketball Games, Dances, etc.


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Never doubt that a

small group of thoughtful, committed

citizens can change the world. Indeed, it is the only that ever

has.

- Margaret Mead


Discuss the Charles Schulz Philosophy


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Concerns

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Look well into Look well into thyself. There is a thyself. There is a source of strength source of strength which will always which will always

spring up if thou will spring up if thou will always look there. always look there.

- Marcus Aurelius Antoninus- Marcus Aurelius Antoninus


Level 8: Self-Care – Sustaining Hope, Helpfulness, and Competence in Working with Grief

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Continuing EducationContinuing Education

You have taken the first step in taking care of yourself. You are here!


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Self-Care StrategiesSelf-Care StrategiesA

void compassion fatigue Take regular time off

Vacation Mental health days

Creative Expressions Art Music Dance

Peer Support Debriefing Supervisor who can balance employee’s need for empathy

and protection with the need to feel competent and to continue work


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Informal Self-Care StrategiesInformal Self-Care Strategies

Spend more time with family and friends Enjoy evenings full of laughter, ice cream and

good times Exercise regularly Write a journal Eat healthy food Take a bubble bath Take time for appreciating or creating art Watch a sunset Read for leisure Gardening Yoga (active relaxation)


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Informal Self-Care StrategiesInformal Self-Care Strategies Hug someone Listen to music (singing along with the radio

in the car works wonders) Watch movies (Save the heavy dramas for

when life isn’t already full of dramas) Go for a walk Dance Get a good night’s sleep Eat one piece of chocolate Reduce clutter/Get more organized so that

the details of everyday life don’t add to stress

Take a weekend retreat or a day trip Take a vacation


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Informal Self-Care StrategiesInformal Self-Care StrategiesListen to soft music in combination with deep

breathing exercisesListen to a guided imagery tapeMeditateTake at least 1 – 2 hours every week to do

something you want to doGet a massageBegin the day with gratitude and continue

to practice it throughout the dayPractice mindfulnessPray

Enjoy the Ride: http://www.lshs64.com/enjoytheride.html


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Professional Support SystemsProfessional Support SystemsS

eeking help for ourselves Warning signs that trigger that we need to seek help:

Use of maladaptive strategies Overworking Avoiding others Using substances Shutting down our emotions

Options for Self-Care Same organizations and resources we provide to clients Same methods of individual or group counseling we use with

clients Trusted supervisor or colleague can help with referral Effective models of Professional Development Retreats for Professionals coping with grief


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One Last ThingOne Last Thing

We need to take a proactive role in preventing burnout and managing stress related to professional caregiving.

Philosophy for Old Age http://www.authorstream.com/Presentation/aS

Guest40411-347103-philosophyforoldage-entertainment-ppt-powerpoint/


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ExerciseExerciseAsk yourself the following questions:

1. Why am I drawn to the work I do?2. What feelings are you aware of as you think about

more in-depth work with others experiencing grief?3. What plans do you have to sustain yourself in your

work with grieving clients in the future? What strategies and methods to you plan to use personally to prevent burn-out and compassion and fatigue, and to maintain a balance in your personal and professional life?


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There are things that we don't want to happen but have to accept, things we don't want to know but have to learn, and people we can't live without but have to let go.

~Author Unknown


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Concerns

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CURRENT, UPDATED BIBLIOGRAPHY

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Albom, Mitch. (2002). Tuesdays with Morrie: An old man, a young man, and life’s greatest lesson. New York, NY: Random House.

Allen, J. (2002). Using literature to help troubled teenagers cope with end-of-life issues. Westport, Conn.: Greenwood Press.

Barnes, G.E. and Prosen, H. (1985). Parent death and depression. Journal of Abnormal Psychology, 94, 64-69.

Becvar, D. (2001). In the presence of grief. New York, NY: Guildford.

Bendikson, R. and Fulton, R. (1975). Childhood bereavement and later behavioral disorders. Psychiatric Annals, 16, 276-280.

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Irish, D.P., Lundquist, K.F., and Nelson, V.J. (1993). Ethnic variations in Dying, Death and Grief. Washington, DC: Taylor and Francis.

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univers ity of the cumberlands department of education u c presented by dr. susan r. rose march 2,...

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