Grief & Bereavement: A Practical Approach

Grief & Bereavement:

A Practical Approach

Ian Anderson Continuing Education

Ian Anderson Continuing Education Ian Anderson Continuing Education

Ian Anderson Continuing Education

Program in End

Program in EndProgram in End

Program in End-

--

-of

ofof

of-

--

-Life Care

Life CareLife Care

Life Care

Module Objectives

!

1. Define grief & bereavement.

!

2. Describe some of the models of grief.

!

3. Describe factors influencing grief.

!

4. Describe complicated grief.

!

5. Describe a practical approach in the

management of grief.

Introduction to Grief

!

Grief is a normal phenomenon common to

all of us.

!

As we go through life, we experience a

wide variety of losses for which we grieve.

!

It is not possible to go through life without

suffering losses.

Introduction to Grief

!

Grief is the response to any loss and is therefore a

common human experience.

!

a common but often unrecognized part of life cycle

changes.

!

often seen as interfering with life, rather than being

intrinsic to life. Subsequently

!

We do not mentor our children concerning this

aspect of life.

!

we tend to protect them, not only from death, but

often also from the little losses that happen

throughout our lives

Introduction to Grief

!

A terminal illness or indeed any chronic

illness is replete with successive losses and

consequent grief.

!

Losing your own life i.e. dying is

associated with grief.

!

Losing a loved-one is also associated with

grief. Who feels the grief – all ages, all

persons and often care providers.

Introduction to Grief

!

Grief starts with the symptoms of illness

and the diagnosis of any illness.

!

Good end-of-life care has incorporated the

concept of good grief (i.e. a healthy

expression of our life force) as part of a

good death.

Grief is:

!

a life experience to be lived.

!

a mystery to be entered.

!

a stimulus for compassion and kindness.

!

a reminder of who and what we have loved.

!

a longing for relatedness.

Definitions

!

GRIEF

is the process of psychological, social &

somatic reactions to the perception of loss.

!

MOURNING

is the cultural response to grief.

!

BEREAVEMENT

is the state of having

suffered a loss.

!

GRIEF WORK

is the work of dealing with

grief, requiring the expenditure of physical and

emotional energy.

Grief Models

!

No one accepted model.

!

Grieving is:

!

active

!

healing

!

skillful

!

transformative

!

connective

!

social

Background Issues and Factors in Grief:

Compounding of Losses

!

A single loss will precipitate other losses.

!

e.g. the physical loss of a breast through a

mastectomy for breast cancer will cause

losses in the areas of body image, sexuality,

role, good health and independence.

Background Issues and Factors in Grief:

Characteristics of the Bereaved

!

Inconclusive evidence that men do more

poorly than women but there are

differences in the way grief may be

handled.

!

There are more consequences in children

especially if grief is not managed well.

Background Issues and Factors in Grief:

Characteristics of the Bereaved

!

Older persons in general may have less

intense & fewer reactions but this depends

somewhat on the relationship to the

deceased.

!

Often overlooked is the intense grief

subsequent to the loss of adult children.

Background Issues and Factors in Grief:

Characteristics of the Bereaved

!

Poor physical health may limit the ability

to expend the necessary physical and

psychic energy to integrate grief into our

lives.

!

The use of drugs such as psychotropic

agents.

Background Issues and Factors in Grief:

Characteristics of the Bereaved

!

A previous history of psychiatric problems

or addictions like alcoholism.

!

There are few conclusive studies about the

influence of personality variables and the

course and outcomes of grief.

Background Issues and Factors in Grief:

Characteristics of the Bereaved

!

Patterns of coping.

!

Past or current experiences with grief.

!

Current other psychological or social

problems or crises.

!

Culture, ethnicity & religion.

Background Issues and Factors in Grief:

Characteristics of the Bereaved

!

There is a unique nature to each

relationship.

!

The role that deceased had in family e.g the

power authority in the family.

!

The amount of unfinished business in the

relationship.

!

Dysfunctional families will react in their

usual patterns – they will be dysfunctional!

Background Issues and Factors in Grief:

The Nature of the Death

!

There are no studies indicating significant

differences between acute vs. chronic

deaths as far as outcomes are concerned but

many of studies have not been done in

populations receiving good palliative care.

!

Violent deaths such as those secondary to

crime or accidental deaths.

!

Suicidal death.

Background Issues and Factors in Grief:

Characteristics of the Deceased

!

The age of the deceased particularly if

young will affect the course and outcomes

of grief.

!

The type of person the deceased was.

!

The timeliness (e.g. at retirement, around

the time of an important event such as the

birth of a grandchild, a marriage of a child,

etc.) may influence the course and outcome

of grief.

Background Issues and Factors in Grief:

The Adequacy of Social Support

!

Persons lacking or withdrawing from

support may have worse outcomes.

!

Remarriage or other close or intimate

relationships protect.

!

Culture.

Background Issues and Factors in Grief:

Gender Issues

!

Men may have different coping styles than

women:

!

To remain silent.

!

To engage in solitary mourning or “secret”

grief.

!

To take physical or legal action.

!

To become immersed in activity.

!

To exhibit addictive behaviour.

Background Issues and Factors in Grief:

Children & Grief

!

Children of all ages grieve & grief is

particular to age groups.

!

Children should not be protected from

grief, funerals or issues of death & dying.

!

They need to be educated in terms they can

understand.

!

Parents must be involved in the education.

Background Issues and Factors in Grief:

Children & Grief

!

Children cope with grief according to their

developmental stage & may re-visit a

grieving situation as they reach new

developmental stages.

!

for example, a death witnessed as a toddler

can resurface & need to be addressed again in

a 7-year-old.

Psychological Phases of Normal

Grief

!

Need to be interpreted not necessarily as

sequential but more likely concurrent

processes through much of the grief

experiences that change and remit over

time until healing occurs.

Psychological Phases of Normal Grief:

Acute or Self Protective Phase

!

Initial shock, denial and disbelief.

!

May feel dissociated from the world around them

!

If family well prepared, there may not be the

same amount of shock or avoidance.

!

Sometimes initially see an intellectualized

acceptance without an emotional component as

an initial denial of the loss, rather than a

necessary self protective mechanism.

Psychological Phases of Normal

Grief: Confrontation:

!

Most intense experience of grief.

!

Emotional extremes common.

!

an emotional “roller coaster”.

!

Rapid and large swings in emotion often

cause fear & more anxiety.

Psychological Phases of Normal

Grief: Confrontation:

!

Anger is a common component including

anger that may be directed towards

physicians and other health care team

members.

Psychological Phases of Normal

Grief: Confrontation:

!

Guilt, inwardly directed anger, confronts

the bereaved with questions of :

!

“What if I had….?”, “Did I do enough?”,

“What did I do wrong?” “What did I do to

deserve this?”

!

Guilt around so- called survivor guilt.

!

“Why wasn’t it me?”

Psychological Phases of Normal

Grief: Confrontation:

!

Sadness & despair.

!

Inability to concentrate or process

information.

!

Preoccupation with the deceased.

!

Over time the extreme emotional swings

lessen.

!

Intermittent denial may also occur.

Psychological Phases of Normal

Grief: Confrontation

!

Social manifestations of this phase include:

!

Restlessness & inability to sit still.

!

Lack of ability to initiate & maintain

organized patterns of activity.

!

Difficulty completing or concentrating on

tasks at work.

!

Withdrawal from the very people who may be

able to help.

Psychological Phases of Normal

Grief: Confrontation

!

Physiological or somatic manifestations of

grief are common:

!

Often these complaints bring the bereaved

into physicians’ offices.

!

The elderly bereaved are a group

vulnerable to illness and physical

symptoms must be addressed appropriately.

Psychological Phases of Normal

Grief: Confrontation

!

Spiritual issues:

!

The basic search for meaning and value in

life, i.e. “who am I?”

!

The feeling of abandonment & anger.

!

Fear of the unknown.

!

Finding a secular framework to face the

unknown – the mystery of death.

Psychological Phases of Normal

Grief: Reestablishment:

!

Grief gradually softens to an “acceptance”

of the reality of the loss.

!

Gradual decline in symptoms as grief

becomes integrated into life.

!

Grief is compartmentalized but periods of

grief may arise at specific times such as

holidays, birthdays, etc.

Complicated Grief

1.

Delayed or absent grief.

2.

Conflicted grief.

3.

Chronic grief.

4.

Psychiatric disturbances associated with

grief.

5.

Physical illness associated with grief.

The Four Tasks of Mourning

(Worden)

!

To accept the reality of the loss.

!

To experience the pain of grief.

!

To adjust to an environment in which the

deceased is missing.

!

To withdraw emotional energy and reinvest

it in other relationships.

Grief Counseling Goals

!

To increase the reality of the loss.

!

To help the bereaved deal with both experienced

& latent affect.

!

To help the bereaved overcome impediments to

readjustment.

!

To encourage the bereaved to make a healthy

emotional withdrawal from the deceased &

reinvest energy into other relationships

Management: Basic Issues

1.

Begin grief counseling if possible while

the patient is still alive.

2.

The family is the unit of care.

3.

Grief is a normative process and requires

much listening and often not a lot of

intervention on the part of the counselor.

Management: Basic Issues

4.

Allow sufficient time to grieve.

!

Most people resolve to a level of functioning around

one year.

!

Some individuals and families will accomplish the

tasks of grieving in two years.

!

Advocate for sufficient time off from work for the

bereaved especially in the first few weeks of

bereavement.

!

Discuss the fact that grief spikes continue for life

through events, holidays and “anniversary” reactions.

Management : Basic Issues

5.

Emphasize the role of the funeral and of

memorial service.

!

Encourage families to bring children to these rites.

!

Consider having memorial services in hospitals,

agencies and palliative care programs for bereaved

families and for staff.

6. Medications, particularly tranquillizers and

antidepressants are usually not needed for any

sustained period of time.

Management: Basic Issues

7. Contact the bereaved at regular intervals.

! Definitely monitor any families with high risk

for grief problems.

8. Identify concurrent problems that may

interfere with normal grief.

Management: Basic Issues

9. Use resource books that have been written

on grief to help the bereaved.

10. Monitor children at school for grief

problems manifesting as school problems.

11. Investigate to see what types of

bereavement programs exist in your

community.

Nature of Grief Work

a) Family (friendship) orientated:

!

The ability to accept loss is at the heart of all

skills in healthy family relation.

b) Relational:

!

Opportunities for resolution, forgiveness,

gratitude.

Nature of Grief Work

c) Intergenerational:

!

How we want to be remembered.

!

Legacy work e.g. what are we leaving behind as a

legacy.

!

Healthy and effective parenting model.

!

Mentorship re: coping skills with children.

!

Decreasing fear in future generations.

!

Teaching children.

!

Learning from children.

!

People die, relationships don’t.

Nature of Grief Work

d) Psycho educative:

!

Anxiety about the unknown.

!

What changes to expect.

!

Forewarned is forearmed.

!

Physical & emotional.

!

Changing family dynamics/roles.

Nature of Grief Work

e) Harm reductive/preventative:

!

Identifying destructive coping mechanisms.

i.e. alcohol/drug use.

f) Community oriented:

!

Looking at the larger social interaction e.g. in

school or workplace.

g) Active:

!

What we need to do in order to integrate how

we are changed?

Nature of Grief Work

h) Narrative:

!

Richly descriptive in elucidating personal

meaning – ‘Tell me what it is you see death

or this loss as?”

i) Supportive:

!

Facilitating the safe containment of emotional

space.

Nature of Grief Work

j) Intrapsychic:

!

Facilitating connection to our own deeper

wisdom and ability to heal ourselves.

k) Spiritually supportive:

!

We are dealing with the unknown, with life’s

mysteries.

Summary

!

Grieving is the active way by which we

incorporate grief into our lives and discover how

we are changed by it.

!

It is open ended and is continually transformed as

we go through life and experience further losses.

As caregivers we need to be self-aware.

!

If we cannot bear our own grief, it will be hard to

work in the presence of another person’s grief.