Bereavement

1. Bereavement

2. Sadness Anger Guilt & self-reproach Anxiety Loneliness Fatigue Helplessness Shock Yearning Emancipation Relief Numbness Feelings

3. All the above represent normal grief feelings and there is nothing pathological about any one of them. • However, feelings that exist for abnormally long periods of time and at excessive intensity may portend a complicated grief reaction.

4. Physical Sensations • Hollowness in the stomach • Tightness in the chest • Tightness in the throat • Oversensitivity to noise • A sense of depersonalization • Breathlessness, feeling short of breath • Weakness in the muscles • Lack of energy • Dry mouth

5. Cognitions • Disbelief • Confusion • Preoccupation • Sense of presence • Hallucinations

6. Sleep disturbance Appetite disturbances Absent-minded behavior Social withdrawal Dreams of the deceased Avoiding reminders of the deceased Searching & calling out Sighing Restless overactivity Crying Visiting places or carrying objects that remind the survivor of the deceased Treasuring objects that belonged to the deceased Behaviors

7. Grieving Reactions over time • Annual incidence of bereavement in the population: 5 – 9 % * • Byrne and Raphael (1994): • 76.5% of bereaved elderly mean had intrusive memories of their spouses at 13 months; • 49% reported feelings of distress; • 43% were preoccupied with mental images of their spouse; • 41% were still yearning for their spouses, and • 25% had looked for their spouse in familiar places.

8. Depression • Overall about 20% of bereaved individuals will develop a psychiatric disorder, primarily depression *

9. Predictors of Poor Bereavement Outcome * • Perception of poor social support • Prior psychiatric history • High initial distress with depressive symptoms • Unanticipated death • Other significant life stresses and losses • Prior high dependency on the deceased who provided key support • Death of a child

10. Janoff-Bulman (1992) • 3 basic assumptions: beliefs about ourselves, external world, and the relationship between the two. • The world is benevolent, meaningful. The self is worthy. • Meaningfulness found in predictable life patterns or expected life roles. • The world is benevolent when one feels in control; the “story-book” world. • Crisis, such as loss, invalidates certain assumptive structures and challenges individuals to affirm or reconstruct a personal world of meaning (Neimeyer, 1997). Rebuilding an assumptive world after trauma as both an emotional and cognitive process or reestablishing equilibrium.

11. Dual-Process view of bereavement • Stroebe and Schut (1999): grief work is seen as a loss-oriented process that alternates with restoration-oriented processes (e.g. denial, suppression and distraction). • “Loss orientation”: engages in intensive “grief work”, experiencing, exploring and expressing the range of feelings associated with loss in an attempt to grasp its significance for his of her life. • “Restoration orientation”: the griever focuses on the many external adjustments required by the loss, concentrating on work and home responsibilities, establishing and maintaining relationships, while “tuning out” the waves of acute grief that may come again. • Some degree of avoidance of the reality of loss may be both helpful and common, and will be experienced throughout the adjustment process, rather than confined solely to its initial process.

12. The Four Tasks of Mourning Worden, 1991

13. (1) To Accept the Reality of the Loss • Vs. not believing through some type of denial • Searching behavior • Mummification • Distortion • Deny meaning of the loss: • Minimize significance • Selective forgetting • Deny that death is irreversible • Spiritualism: chronic hope for reunion • Involves emotional acceptance • Funeral

14. (2) To Work Through to the Pain of Grief • Necessary to acknowledge and work through this pain, otherwise symptoms • Vs.: Not to feel • Idealize the dead • Avoid reminders • Use alcohol or drug

15. (3) To Adjust to an Environment in Which the Deceased is Missing • Vs. Not adapting to the loss by promoting their own helplessness, or by withdrawing from the world • Adjust to the loss of roles played by the deceased • Adjust to own sense of self • Lowered self-esteem • Sense of the world: new beliefs may be adopted or old ones modified to reflect the fragility of life and the limits of control

16. (4) To Emotionally Relocate the Deceased and Move on With Life • Vs. holding on to past attachments • “A survivor’s readiness to enter new relationships depends not on “giving up” the dead spouse but on finding a suitable place for the spouse in the psychological life of the bereaved – a place that is important but that leaves room for others.” (Shuchter & Zisook, 1996) • Some people find loss so painful that hey make a pact with themselves never to love again.

17. Identifying the At-Risk Bereaved

18. Diagnosing Complicated Grief • The person cannot speak of the deceased without experiencing intense and fresh grief. • Some relatively minor event triggers off an intense grief reaction. • Themes of loss come up in a clinical interview. • Unwilling to move material possessions belonging to the deceased.

19. Complicated Grief (Cont’d) • Developed physical symptoms like those the deceased experienced before death. • Radical changes in their lifestyle following a death. • Long history of subclinical depression: persistent guilt and lowered self-esteem, severe hopelessness, self blame.

20. Complicated Grief (Cont’d) • A compulsion to imitate the dead person. • Self-destructive impulses. • Unaccountable sadness occurring at a certain time each year. • Phobia about illness or about death is often related to the specific illness that took the deceased.

21. Complicated Grief (Cont’d) • Real delay in grief reactions. • Severely out of touch with feelings. • Intense anger. • Social withdrawal. • Loss of interest or planning for future. • Substance abuse.

22. Counseling Principles Principle One: Help the survivor actualize the loss Principle Two: Help the survivor to identify and express feeling Principle Three: Assist Living Without the Deceased Principle Four: Facilitate Emotional Relocation of the Deceased

23. Counseling Principles Principle Five: Provide time to grieve Principle Six: Interpret “normal” behavior Principle Seven: Allow for individual differences Principle Eight: Provide continuing support Principle Nine: Examine defense & coping styles Principle Ten: Identify pathology and refer

24. Useful Techniques • Evocative language • Use of symbols • Writing • Drawing • Role playing • Cognitive restructuring • Memory book • Directed imagery

25. Neimeyer (2000) • Death as an event can validate or invalidate the constructions on the basis of which we live, or it may stand as a novel experience for which we have no constructions. • Grief is a personal process, one that is idiosyncratic, intimate, and inextricable from our sense of who we are. • Grieving is something we do, not something that is done to us. (experience of grieving itself may be rich in choice) • Grieving is the act of affirming or reconstructing a personal world of meaning that has been challenged by loss. (assimilate loss into pre-existing frameworks of meaning, ultimately reasserting the viability of the belief system that previously sustained us, or we can accommodate our life narative to correspond more closely to what we perceive as a changed reality. • Feelings have functions, and should be understood as signals of the state of our meaning making efforts in the wake of challenges to the adequacy of our constructions. (Denial, depression, anxiety, guilt, hostility, threat). • We construct and reconstruct our identities as survivors of loss in negotiation with others. • Neimeyer (2000). Lessons of Loss p. 98-97

26. Position of not knowing, rather than imposition of “expert” knowledge. • Grieving is an active process, a period of accelerated decision-making. Encourages caregivers to assist bereaved individual in identifying conscious and unconscious choices they confront, and then helping them sift through their options and make difficult decisions. • Neimeyer (2000). Lessons of Loss p.111-2

27. “Mourning never ends. Only as time goes on, it erupts less frequently.” - Widow in her 60s

28. Thank you.