BereavementBereavement

Feelings

Sadness Anger Guilt & self-reproach Anxiety Loneliness Fatigue

Helplessness Shock Yearning Emancipation Relief Numbness

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.

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

Cognitions

Disbelief Confusion Preoccupation Sense of presence Hallucinations

Behaviors

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

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.

Depression

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

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

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 rol

es. The world is benevolent when one feels in control; the “story-book”

world. Crisis, such as loss, invalidates certain assumptive structures and chal

lenges 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.

Dual-Process view of bereavement Stroebe and Schut (1999): grief work is seen as a loss-oriented p

rocess 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.

The Four Tasks of MourningThe Four Tasks of Mourning

Worden, 1991

(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

(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

(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

(4) To Emotionally Relocate the Deceased and Move on With Life

Vs. holding on to past attachments “A survivor’s readiness to enter new relations

hips 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.

Identifying the At-Risk BereavedIdentifying the At-Risk Bereaved

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.

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.

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.

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.

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

Counseling Principles

Principle Five: Provide time to grievePrinciple Six: Interpret “normal” behavior Principle Seven: Allow for individual

differencesPrinciple Eight: Provide continuing supportPrinciple Nine: Examine defense & coping

stylesPrinciple Ten: Identify pathology and refer

Useful Techniques

1. Evocative language

2. Use of symbols

3. Writing

4. Drawing

5. Role playing

6. Cognitive restructuring

7. Memory book

8. Directed imagery

Neimeyer (2000) Death as an event can validate or invalidate the constructions on the basis of which we li

ve, 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 s

ense of who we are. Grieving is something we do, not something that is done to us. (experience of grieving it

self may be rich in choice) Grieving is the act of affirming or reconstructing a personal world of meaning that has be

en 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

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

““Mourning never Mourning never ends. Only as time ends. Only as time goes on, it erupts goes on, it erupts less frequently.”less frequently.”

- Widow in her 60s

Thank you.Thank you.