Published on December 22, 2008
Loss and Bereavement : Loss and Bereavement McGill School of Social Work Presented by Estelle Hopmeyer Slide 2: 2 Loss and Bereavement All humans grieve a loss to one degree or another – death and non-death loss are grieved Useful definitions: for death loss Grief: is the experience of one who has lost a loved one to death Mourning: is the process that one goes through in adapting to the loss of the person Bereavement: defines the loss to which the person is trying to adapt Disenfranchised Grief : 3 Disenfranchised Grief The loss is not openly acknowledged, publicly mourned or socially supported (Kenneth Doka) Societies have sets of grieving rules: who, when, where, how, how long and for whom people grieve This defines ‘legitimate’ right to mourn – generally familial These grieving rules may not correspond to the nature of the attachments, sense of loss or feelings of survivors Disenfranchised Grief (cont’d) : 4 Disenfranchised Grief (cont’d) Relationship not recognized e.g. divorce, non-kin, gay partner Loss not recognized – perinatal loss, abortion, pets, foster care Griever not recognized – very young or old, intellectually disabled Paradox – the very nature of disenfranchised grief which complicates grief is that it removes or minimizes social support Psychosocial Loss : 5 Psychosocial Loss Psychological death: Person ceases to be aware of self – does not know who s(he) is or does not know that s(he) is Loss of identity - person still alive but personality is markedly different Social death – person is still alive but maybe socially dead – e.g. comatose, severe brain injury or severe mental illness Does not create space for emotional detachment but may increase time and energy for caregivers Need to adjust to life with the “new person”; Need to recognize losses Western Grief and Mourning : 6 Western Grief and Mourning Freud in 1917 proposed that people whose loved ones died needed to work through the loss with the final outcome being to detach emotionally from the deceased. Lindemann in 1944 perpetuated the notion that healthy resolution of grief involved confronting the reality of the loss and severing the emotional bonds with the deceased allowing for the building of new relationships. Kubler-Ross (1969) stages of death and dying derived from dying patients and not survivors – linear. Worden (1982, 2002) task model of bereavement. Four tasks that could be revisited, not linear. Western Grief and Mourning (cont’d) : 7 Western Grief and Mourning (cont’d) Walsh and McGoldrick (1995) Family bereavement relational aspects of mourning sharing the grief family involvement in mourning rituals expression of feelings open communication Goal to maintain a sense of family cohesion while being flexible enough to adapt to family loss Western Grief and Mourning (cont’d) : 8 Western Grief and Mourning (cont’d) Rando, T (1985-1986) Introduced the idea that one could remain emotionally connected to the deceased loved one but that the relationship changed – e.g. holding positive memories Relationships survivors have with the deceased are unique for each individual e.g. sense of presence, connection through special items Bereavement can be a catalyst for increased coping skills and personal growth – e.g. psychospiritual transformation – meaning making from the death Reactions to Grief and Bereavement : 9 Reactions to Grief and Bereavement There is no right or wrong way to grieve. Here are some reactions that people have felt after a death loss Feelings: Sadness, anger, guilt, anxiety, loneliness, fatigue, helplessness, shock, yearning, relief, numbness, feeling cut off from the rest of the world, irritability Physical Sensations: Shallowness in the stomach Tightness in throat or chest Oversensitivity to noise Shortness of breath Weakening in the muscles Lack of energy or exhaustion Dry mouth Getting sick more often than usual due to the stress of experiencing the loss Cognitions: Reaction to Grief : 10 Cognitions: Reaction to Grief Disbelief Confusion Preoccupation with the deceased Sense of presence of the deceased Hallucinations Inability to concentrate and/or remember things Behaviours : 11 Behaviours Changes in sleep patterns (inability to sleep, sleeping all the time, difficulty sleeping) Appetite disturbances – weight loss or gain Absent minded behaviour Social withdrawal Dreams of deceased Avoiding reminders of the deceased Searching and calling out Restless over-activity Crying Visiting places or carrying objects that remind the survivor of the deceased Treasuring objects that belonged to the deceased Behaviours (cont’d) : 12 Behaviours (cont’d) Taking on some of the characteristics of the person who died (adopting mannerisms) Lack of motivation Fearful of being alone or with people Use of drugs or alcohol Turning to or away from religious beliefs Tasks of Mourning –William Worden : 13 Tasks of Mourning –William Worden Accept the reality of the loss Work through the pain of grief Adjust to the environment where the deceased is missing Emotionally relocate the deceased and move on with life Health Care Professional needs to: Help actualize the loss Help to identify and experience feelings Assist in living without the deceased Help find meaning and emotional relocation Mediators of Mourning –William Worden : 14 Mediators of Mourning –William Worden Who the person was Nature of the attachment Mode of death: NASH: Natural, Accidental, Suicidal, Homicidal Proximity, suddeness/expectedness, violent/traumatic, multiple losses, preventable, ambiguous, stigmatized Historical antecedents, loss history, intergenerational Personality variables Age and gender, coping styles, e.g. strengths, assumptive world beliefs Social variables – social support, roles, religious resources etc. Concurrent stresses Three Phases of Bereavement (Therese Rando) : 15 Three Phases of Bereavement (Therese Rando) Avoidance Phase Psyche is in shock, numbness, denial, disbelief. Need to know. Intellectual but not emotional response Confrontation Phase Grief experienced intensely. “angry sadness” Panic, anger, guilt, depression, despair, relief Preoccupation with the deceased Worry about being crazy Re-establishment Phase Beginning emotional and social reentry Guilt (betraying the deceased) Six “R” Processes of Mourning (T.Rando) : 16 Six “R” Processes of Mourning (T.Rando) Recognize the loss. Acknowledge and understand the death React to the separation Experience the pain – give expression to psychological reactions to the loss. Identify and mourn secondary losses Recollect and re-experience the deceased and the relationship. Review and remember realistically – re-experience the feelings Relinquish the old attachments to the deceased and the old assumptive world Readjust to move adaptively to the new world without forgetting the old. Revise assumptive world. Develop a new relationship with the deceased. Adopt new ways of being in the world. Form a new identity Reinvest in new relationships. Invest in other people and things Complicated Mourning (T. Rando) : 17 Complicated Mourning (T. Rando) Complicated mourning is present whenever there is some compromise, distortion, or failure of one or more of the processes or stages of mourning. The amount of time since the death needs to be considered. The mourner may be stuck in the phases of bereavement, feeling pain years after. (no movement). In addition the mourning may be absent, delayed or inhibited. Experiences which could lead to complicated mourning Death from a lengthy illness Sudden, unexpected death (especially traumatic or violent) Death the mourner perceives as preventable No verbal ability to express grief Secrecy or non-involvement in rituals when a parent or significant person dies Multiple losses and death Mourner’s lack of social support Sudden DeathSuicide, Accident, Heart Attack : 18 Sudden DeathSuicide, Accident, Heart Attack Preparation (anticipatory grief) is missing Shock, unreality, feelings of guilt responsibility – what if and if only –sense it could have been prevented Heart attack: He didn’t look good, he was tired. I should have insisted he see his doctor Suicide: I should have understood her message, the extent of her pain. I should have been able to prevent her death Sense of helplessness, assault on sense of control Loss of sense of security in the world Sudden Death (cont’d) : 19 Sudden Death (cont’d) No chance to say good-bye – unfinished business Lack of time to bring relationship to a close Wish to turn the clock back – to say we loved them, ask for forgiveness or to forgive etc. Survivors need to understand – to make sense – Need to tell the story often to find some meaning in the death – To understand they may never really know the “why” in the case of a suicide and to forgive themselves. The Mourning Process (William Worden) : 20 The Mourning Process (William Worden) Mediators of Mourning Person who died Nature of attachment Circumstances of death Personality mediators Historical mediators Social mediators Concurrent changes Tasks of Mourning To Accept reality To experience pain To adjust to environment without loved one - external adjustments - internal adjustments -spiritual adjustments To relocate and memorialize loved one Practice – Helping the Bereaved with death and Non-death Loss : 21 Practice – Helping the Bereaved with death and Non-death Loss Begin with understanding and respect – understand that much of the emotions, feelings expressed are normal and a necessary part of the grieving process – understand this loss in terms of the mediators of grieving and loss history Listen – understand the depth of the distress and at times sense of hopelessness and powerlessness. Be open to hearing negative emotions such as anger and guilt – know clients are doing the best they can Practice – Helping the Bereaved with death and Non-death Loss (cont’d) : 22 Practice – Helping the Bereaved with death and Non-death Loss (cont’d) Stay with the sadness – learn to be comfortable with the pain that can challenge professionals own resources – understand how the pain impacts on you Know and use a conceptual framework (Rando, Worden) so as not to be overwhelmed and to not pathologize normal feelings and behaviours. Be culturally appropriate Practice – Helping the Bereaved with death and Non-death Loss (Cont’d) : 23 Practice – Helping the Bereaved with death and Non-death Loss (Cont’d) Adopt a teaching as well as support role. Teach new skills and coping strategies Knowledge is control for clients – encourage use of rituals and symbols Be respectful of the time needed by clients as they work through the tasks and search for meaning Attend to your “self-care” needs. You need to be supported in this work – e.g. supervision, recognition of the impact on the professional Mental Illness as a form of Non-Bereavement loss : 24 Mental Illness as a form of Non-Bereavement loss Difficult to clearly identify losses as person is still alive Psychosocial losses – In severe mental illness the person “that was” might seem like a ‘bizarre’ stranger living in the house For parents they grieve for the child “that was” about the present life they live which may be painful and joyless and for the future – the hopes and dreams for their child and for themselves. Normal life transition are drastically transformed Interventions with Non-Bereavement Loss Mental Illness : 25 Interventions with Non-Bereavement Loss Mental Illness Assist in dealing with Emotional Issues Related to Loss. ? Can be difficult to share emotions, particularly negative emotions – social sanctions, disloyalty, unfeeling, need to explore guilt ? Need to assure that feelings are normal ? Suggest writing letters to sufferers, speaking an apology, addressing an empty chair ? Explore alternative coping strategies that allow for legitimacy of response and a lack of viable alternatives e.g. hospitalization ? Deal with fear and anxiety about the future – about other family members ? Address anger and crises in faith Interventions with Non-Bereavement Loss Mental Illness (cont’d) : 26 Interventions with Non-Bereavement Loss Mental Illness (cont’d) Secondary Losses maybe profound – deal with them ? Review how life has changed ? What secondary losses are most significant ? What can be regained and modified Explore nature of support system ? Respite care ? Surprises – positive and negative ? Other social system options – (ask for help) Interventions with Non-Bereavement Loss Mental Illness (cont’d) : 27 Interventions with Non-Bereavement Loss Mental Illness (cont’d) Help plan realistically for the future – “one day at a time” – realistic hopes. Planning does increase sense of control Develop rituals for recognizing changes – need some sense of closure Know a person can survive though things will never be the same – Giving up hope for a cure maybe a turning point (Mona Wasow) – Cyclical nature of illness can make this especially difficult as there can be chronic sorrow and recycled grief
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