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Thinking about Losses and Grief Differently
Universal phenomena
Is challenging and distressing
But it can be transformational, and most of us overtime develop skills and attitudes that assimilate our losses in our lives in a functional manner
Psychotherapy and Psychotherapist’s
Often miss or fail to identify the presence of loss and grief – unless of course the intake tells us the person is coming for bereavement counselling
However, grieving a death of a loved one – is similar to other losses and may invoke similar responses
Loss Responses: Non-Death and Death
We experience:
Sadness, we confront and avoid painful emotions, we attempt to reorganize our world, we struggle with connection and disconnection
Our new losses trigger material from our old world (attachment theory) we year to return to these preloss circumstances
We try to make sense of losses, or make meaning, we are paralyzed, we are transformed, and struggle to integrate losses into our lives
Loss and Grief Terminology
Bereavement: period of sorrow following the death of a significant other
Loss: real or perceived deprivation of something deemed meaningful (death or non-death related)
Grief: an emotion generated by an experience of loss characterized by sorrow and/or distress, and the personal and interpersonal experience of loss.
Coping: Time limited reaction in which an event is endured or momentarily managed with coping skills
Loss Adaptation: Process of adjusting to loss/grief (active process of modification, revision, reorganization, and assimilation over time
Changing Ideas
Not linear - there is not necessarily a characteristic set of processes that each griever experiences or phases he / she must pass through
Not abnormal – don’t necessarily need to detach/sever from object we are grieving over
Grief doesn’t necessarily end
We are not passive victims over our grieving
We must assume personal, social, familial, historical, and culture, influences our grieving and healing – but not necessarily get caught by them
Grief is an individual phenomena!
Let’s Chat about these Cases
Kito
Elena
Jane
Billy
What loss and grief loss requires the counselor to do:
a. Prioritize uniqueness of our clients and their experiences within the context of their lives
b. Recognize normality of grief, empower clients to be actively involved in their adaptation to loss, support clients without attempting to cure or fix them
c. Respect clients as experts on themselves
Let’s talk about the last one…Humphrey Chapter 9 pgs. 213 – 219
Three Roles
Witness
Facilitator
Collaborator
The Witness
To observe, to listen, to hear, to remember, and to understand at the deepest level the powerful narratives of loss and grief
We bear witness
Thus as a witness we:
1. Listen more than we talk
2. Employ respectful silence
3. Fully attend (see what is here)
4. Exhibit comfort
5. Allow grief (don’t fix even when clients request rescue)
6. No judgment
Facilitator Role
Provide a framework conducive to functional loss adaptation
Focus and structure
Typical questions and framework
How can I be of help? How is the session going thus far? Where should we be spending our time?
We facilitate the clients work, but we don’t do the work for them!
Facilitator Medicine:
1 Encourage recognition and use clients strengths, resources and abilities
2 Respect the natural ebb and flow of the grieving journey, including periods of disorder, impasse, resistance, and confusion as part of the loss adaptation process
3 Consult with clients regularly as to direction of therapy, and usefulness of various techniques / activities
4 Assist clients where they are - not where the counselor wants them to be
Collaborator Role
1. Collaborative counselors are more interested in client perspectives than they are in preconceived notions about grief based on expertness of others
2. Neither directive nor nondirective
3. Fellow explorer
4. Help clients educate themselves about themselves and their world past, present, future
Collaborator Medicine:
1. Respect clients as narrators of their own stories
2. Encourage and attitude of exploration and discovery
3. Rely and what and how questions to encourage reflection and ownership
4. Encourage divergent thinking (ideas)
5. Promote client resiliency
Key Technique in Working With Loss, Grief, and Bereaved Clients
Master the Art of Silence
Respectful silence is bearing witness
Silence punctuates moments, prompts reflection, provides support, deepens process, and is healing
We are creating a space for coping, holding, adapting
We do not solve grief
We do not rescue grief
Video Emersion: Practicing The Three Roles
Listening To and Listening For Loss and Grief
Listen to this song…?
What do you think is going on?
Let’s not Get Ahead of ourselves?
Why do we grieve?
Love somebody?
What is love?
Why Loss / Grief Clients
Some clients specifically come for counseling due to loss and as a result of
Bereavement
Divorce
Separation
Loss of livelihood
Because they believe they are not adjusting well
Why Loss / Grief Clients (cont.)
However, most loss and grief experiences appear far more often in therapy not as the presenting problem, but as an underlying cause or contributing factor to client troubles.
As we explore client anger often we reveal core losses that have never been addressed or were adequately grieved for.
Refer to text pg. 19
Primary and Secondary Losses
Primary Loss: significant loss event such as death
Secondary Loss: come about as a result of a primary loss
Secondary Losses
Acts a dominoes: and can arise as a chain of events from primary loss
Death of spouse brings about loss of companionship, financial security, sexual intimacy, family role, social status
Job loss: self-esteem, identity, financial security, sense of future
Childhood sexual abuse: loss innocence, trust, sense of control, etc.
Mental illness: loss of control over emotions, thoughts, family role, loss of occupation
The question to ask then or to understand in facilitating adaptation to loss that we must ask our clients?
WHAT HAVE YOU LOST?
Primary Loss = Relationship
Questions we need to know:
Ambiguous Loss (AL)
Two types
① Physically absent / psychologically present (e.g. kidnapping, people missing from natural disaster, divorce situations, baby put up for adoption, etc.)
② Physically present / psychologically absent:person is emotionally and cognitively missing (Alzheimer’s, traumatic brain injury, addictions)
The uncertainty characteristics of (AL) can bring about long term dysfunctional coping often contributing to complications in the grieving process
Stigmatized Losses
Losses that reveal transgressions of societal norms or go against norms, mores, and folkways
These include losses related to HIV/AIDS, suicide, violence (e.g., homicide, genocide, domestic violence, homelessness, sexual abuse, addictions, to name a few)
Stigma attached to the loss, should they be allowed to grief? Family hides “the secret”
These sufferers usually experience and have a difficult time getting over guilt, shame, blame and their support networks can often be limited
Disenfranchised Grief
Cultural losses
Historical oppression Racism Residential school Immigration
Psychosocial Factors: Facing Our Loss
Now that we have seen that grief and loss are unique to the sufferer and that different losses bring with them different obstacles to adaptation let’s look at psychosocial factors that impact grief and healing.
Adaptive strategies
Affective (emotional response / regulation)
Cognitive (analysis, reframing, distraction or avoidance
Behavioral (problem solving, activity, behavioral distraction)
Spiritual (prayer, meditation, rituals)
Adaptive Strategies
Can be used both positively and negatively
Everyone has their own combination of adaptive strategies based on personality and life experience
The idea is for the counselor and client to use which ones that are most helpful
30
Attachment Theory
Definition of Attachment:
An enduring emotional tie to a special person, characterized by a tendency to seek and maintain closeness, especially during times of stress.
Healthy and unhealthy attachments can predict duration and intensity of bereavement
Disrupted Meaning Structures
Basic truths about the world = assumptive world
Loss can shatter our assumptive world
I don’t know who I am anymore “shakes us to our foundations”
An important job of the grief counselor is to help clients deal with disruption of their pre-loss meaning structures
Meaning Reconstruction 3 Phases
① Sense or meaning making
Begins with exploring the “why”
And maybe ends with “letting go of the why”
Moreover, the counselor’s aim here is to examine the meaning structures that once made one’s world comprehensible, then renewing, redefining, or revising them to so as to restore balance
Benefit Finding: Phase 2
Learning to find personal growth in loss
We may find a greater faith
Transform our identity
Develop competence or independence
Its not above moving on – its about thriving in the aftermath of a reality we can’t change
Identity Change
Process of reorganizing and rebuilding a sense of self fragmented by loss
Help client revise one’s self narrative in a way that maintains continuity of a person while also incorporating altered aspects of the self
We are always becoming
Video Emersion: Shattered Assumptive Word
Video II: Disrupted Meaning Structures
Other Psychosocial factors
Personal history of Loss and Separation
Developmental considerations
Women’s / Womanist development
Racial Identity development
Homosexual Identity development
Faith Development
Social Support
The better the quality of the grievers support network, the more functional is her or his loss adaptation
Sometimes our notions of who will support us does not happen or our initial grief reactions, or deficits in our interpersonally functioning limit our reaching out to others.
The latter support mechanisms and tendency’s need to be explored by counselors
Uncomplicated and Complicated Grief
Uncomplicated grieving
Self-limiting
Common symptoms gradually diminish (e.g. sadness, yearning, confusion, numbing, and loneliness)
There is an increasing acceptance of the reality of death
Steady integration of loss
Grief is seen as normal
Easing of symptoms can be observed 6 months to a year following the death
Complicated Bereavement Grief (Prigerson et al. 1995)
Used to denote specific symptoms and level of distress due to a death (distinguishing primary disorder)
Grief is prolonged
Grief symptoms intensify rather than diminish
Disability of death lingers, and loss is not observed to have been integrated
Toward Diagnosis: Four Proposed Criterions
A. Symptoms must last for 6 months
B. Symptoms cause marked dysfunction in social, occupations or other important domains
C. Yearning, pining, longing for deceased must be experienced at least daily over past month to a distressing or disruptive degree
D. 4 symptoms of 8 must be experienced in the past month as extreme
These are:
① Trouble accepting death
② Inability to trust others since the death
③ Excessive bitterness about the death
④ Feeling uneasy about moving on with one’s life
⑤ Feeling emotionally numb/detached from others since death
⑥ Feeling life is meaningless without the deceased
⑦ Feeling the future holds no meaning without the deceased
⑧ Feeling agitated, jumpy, or on edge since the death
Let’s talk about pathologizing grief
Contemporary Models of Loss Adaptation
Martin and Doka’s Adaptive Grieving Styles
Dual Process Model of Coping
Adaptive Grieving Model
Model focuses on:
A. Specific patterns of grieving that is natural to the person, and
A. The preferred cognitive, behavioral, affective, and spiritual strategies an individual uses to manage our innate response to loss
Continuum: 3 Basic Grieving Styles
A Closer Look at The: Intuitive and Instrumental…
Adaptive Grieving Styles
Our style can shift along the continuum, but for the most part is generally consistent across time
The model’s grieving styles reflect and respect innate differences among individuals that result from personality, culture, familial, developmental, and social influences
Preferred Coping Strategies
Affective
Cognitive
Behavioral
Spiritual
Any adaptive strategy may be used by an individual person, but there appears to be a clear preference for each grieving style
Thus, an instrumental griever and intuitive griever may employ the same strategy, but it’s use will be put in action for different means
Sharing a story for an intuitive is done to express emotion and connect on emotional level with others, whereas an instrumental tells a story to to gather info, organize a response, or solve problems
Affective Strategies
Strategies at Work: Some Details
Strategies that work at the beginning may not work during later adaptation
Your strategy of adaptation may clash with spouse, siblings, and family, causing deterioration in overall support
What if your counselor has a different innate adaptive strategy?
Counselors must what to make sure clients are utilizing their primary adaptive strategies
It’s good to have secondary strategies, but the secondary strategies may be ineffectively applied
Counselor’s job to root this out
Strategies at Work: Some Details
Dissonant Responses
Common for grievers to initially use secondary strategy and go against their natural style of grieving
This can further complicate grief
The discrepancy is resolved when the client/individual moves into innate response or in counseling when we fetter out clients primary strategy
Reasons for dissonant responses include: personality, gender role socialization, type and intensity of grief, image management, substance abuse, etc.
What are we seeing here?
Intuitive is going against her / his nature
Dissonance typically occurs when the intuitive attempts to limit their internal experience
Dissonance response intuitive (cont.).
They begin to use behavioral and CBT strategies: such as
Avoid people who would otherwise elicit a emotional response, rationalize / intellectualize experience,
Use alcohol / drugs to suppress emotion, overuse physical exercise to deny reality of loss, focus on everyone but themselves
This type of strategy can lead to physical / emotional exhaustion, psychosomatic illness, estrangement from others, complications may also from risky behaviors
Dissonance Response: More Instrumental Griever
What are we seeing Here?
Instrumental griever is in dissonance because they believe they should be feeling (believe there is something wrong with themselves)
They are self critical and blame themselves
Distance themselves from others because they believe they are cold, uncaring, and insensitive
May conjure up feelings or loosen inhibitions (drink / rather than numb) to feel
Provoke violence to feel
Martin and Doka report that instrumental grievers may come to therapy for the problems created by the dissonance not the dissonance itself
Counseling Implications?