Working with Bereavement across the Life Cycle

Arlene Vetere

drarlenevetere@hotmail.com

The Plan

• Introductions – why are we interested in this work? Expected/unexpected resonances

• Hopes for this session?

• Theory: Kubler Ross, Worden, Murray Parkes, Neimeyer, attachment

• Disability and families

• Children and families

• Intervention and Protective Factors

• Traumatic bereavement – sudden death

Dynamic Systems

“Many of the most intense emotions arise during the

formation, the maintenance, the disruption and the renewal of

attachment relationships. The formation of a bond is described

as falling in love, maintaining a bond as loving someone, and

losing a partner as grieving over someone. Similarly, threat of

loss arouses anxiety, and actual loss gives rise to sorrow;

whilst each of these situations is likely to arouse anger. The

unchallenged maintenance of a bond is experienced as a

source of security and the renewal of a bond as a source of

joy.”

(Bowlby, 1980)

Some Useful Definitions

• Bereavement – the objective situation of having lost someone significant (death, divorce...)

• Grief – the usual reaction to bereavement – primarily emotional response to loss

• Mourning – the social expression or acts expressive of grief that are shaped by the practices of a given society or cultural group

Activity: Reflective Questions

• When you think of bereavement across the individual and family life cycle, what comes to mind for you?

• Do you notice any themes or particular issues?

• Where have they come from – family of origin, education, faith and spirituality, culture, personal experiences

• What are your hopes for the day?

Spiritual and Cultural Issues

• Wide variation in cultural and spiritual beliefs about what happens after death

• Wide variation in beliefs about appropriate ways of expressing grief

• Wide variation in rituals/ways of mourning • Need to take account of the past and present

experience and needs of individuals and families • Need understanding of particular family/culture • Might there be a cultural/personal desire to

minimise our perceptions of others’ grieving?

Bereavement Research

• Grieving is normal......’masked’ grief

• Attempts made to understand grief in terms of stages/phases, tasks and process

• Bereavement can affect physical and mental health, and be more difficult for some of us

• Research limited by focus on small sections of world population

• Dual process of grieving alongside normal functioning can give false sense of coping and hide grief

• Responses to disaster

Grief: supporting/complicating factors

• Quality and significance of the relationship

• The kind of death

• Developmental stages

• Nature and quality of family and community support and resources

• Concurrent crises

• Attitudes of community and culture

• Disenfranchised grief

Theories of grief, loss and bereavement: Kubler Ross

• Historically significant as one of the early providers of grief and bereavement model

• Five stages:

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

• Misunderstood or misinterpreted?

Theories of grief, loss and bereavement: Worden

• Grief conceptualised as a process with tasks

• Accepting reality of loss

• Experiencing the pain of grief

• Getting used to living without the person who has died

• ‘Picking up the pieces’ of life

• Life function: shock, protest, disorganisation, re-organisation

Theories of grief, loss and bereavement: Murray Parkes

• Murray Parkes prefers to think of phases rather than stages

• Four phases are:

• Numbness occurring close to the time of loss

• A phase of yearning: for lost one to return - a denial of the permanence

• Disorganization/despair - bereaved person finds it difficult to function in their environment

• Reorganized behaviour...beginning to pull life back together

• Research suggests 2 – 5 years is to be expected..….

Theories of grief, loss and bereavement: Neimeyer

• Individual differences in grief experience require individualised approaches: dual process theory (meaning making and continuing bonds)

• ‘complicated grief’ marked by broad changes to all personal relationships, sense of meaninglessness, prolonged yearning or searching, and a sense of rupture in personal beliefs (more likely associated with sudden, unexpected and traumatic death)

• Challenge the widely held assumption that grief is ‘letting go’

• Foster a constructive continuing bond with person who has died: remembering the good times, internal dialogue with lost loved one, continuing to think of them on regular basis, imagining their reactions to current life events and problems

• Expression of positive emotion and ability to find meaning in loss

Theories of grief, loss and bereavement: Attachment

• Bowlby: sorrow and joy different sides of same attachment coin; grief is embodied, representational, relational and developmental

• CS Lewis: ‘it’s part of the deal’ ‘no one told me grief is like fear’

• Bion: like trauma, the only way out is through • Protest: anger of hope and anger of despair – a wish

for connection • Secure/insecure attachment styles and grieving • Processing is key: changes in representational systems -

integration and reflection

ATTACHMENT ALWAYS TWO SIDED

Attachment always has TWO sides. Responses to non-availability of our attachment figures:

PROTEST - anger…..(of hope, of despair) and VULNERABILITY – sadness One may be shown more than the other, or shown in rapid alternation. Internal conversation – potential ‘Strange Loops’

ATTACHMENT REPRESENTATIONS: The layers of attachment

PROCEDURAL MEMORY: memory for how we do things (R)

SENSORY MEMORY: visual images, smell, touch, auditory (R)

SEMANTIC MEMORY: cognition, beliefs, attitudes (L)

EPISODIC MEMORY: narratives, stories, inter-connected

experiences (L and R )

INTEGRATIVE MEMORY: reflection, meta-cognition, on-going monitoring of our speech and thought.. (L and R)

Right Brain – Implicit Left Brain - Explicit

Activity: Reflective Questions

• How are you responding to these models of grief?

• What resonances do they create?

• Are they useful? ..….Do they help you make sense of your clients’ experiences? …....How does your personal understanding of death and bereavement influence your practice…..…and when might it be different from that of your clients?

Working with Children and Families

• Infants: non-specific distress; protest, despair, detachment

• Grief: actions and somatic states (language and symbolic representation)

• Death permanence: projection in play – comfort and soothing

• Meaning and making sense of death, tolerate questions and yearning, straightforward communication, clear and realistic information – transitional objects, involve children in rituals

• Child’s view of self as worthy and deserving of care • Children’s social networks

Continued

• Use of words and symbols to organise experience – our responsibility for helping a child to understand – use of second guessing to introduce possible worries – talking while drawing

• Denial as a defence/adaptive; fears that own behaviour caused death; gender socialisation (a problem for boys??)

• Regressed patterns of behaviour, withdrawal, intrusive thoughts, sleep disturbance, somatisation

• Idealisation and identification – trying to recover lost person? (a wish to die to be with dead person?)

• Inhibit grief and strong need to be cared for – compulsive care giving?

Continued

• Pre-teens: understand what the loss means in the future

• Magical thinking may persist

• General irritability mislabelled?

• Quiet and withdrawn responses may not attract adult attention? Mutual protectiveness may mask grieving

• Biological and logical understanding of death – search for philosophical meaning/spirituality

• May still hold on to earlier worries

• Adolescence: stronger gender effects; ‘antisocial’ behaviour masking sadness; stepping into ‘vacated’ roles; suicidal ideation; substance use; risk-taking?

Intervention and Protective Factors

• Child: internal representations; maintain memory links; emotional expression – what have they been told and how do they understand it?

• Parental: replacement figure; practical and emotional needs; not overwhelmed by own grief?

• Family: flexibility in roles; open communication; concurrent crises?

• Friends: contact with other children at home and at school; adolescent support network

• School: open discussions about life and death; individual support and access to group support

• Community: culturally appropriate role models; rituals

Cont’d

• Open and straight forward communication – explanation and reduce confusion – avoid euphemisms

• Give time for ‘cognitive mastery’ – support questions, conversations and children’s play, photos, visiting grave, resemblances

• Making the loss real – rituals, reminders, not hiding feelings – anticipate anniversaries

• Support emotional coping – avoid unnecessary separations, talk about guilt feelings/anxiety that something will happen to them/parents

Rituals and Funerals

• Important for children to say goodbye • Including children in family rituals promotes

closeness at a time of sadness • Not pressured to attend funeral, but offered

choice – a special person to look after the child during the funeral

• Children need preparation and be allowed to ask questions

• Children’s participation: letter/picture/flower in coffin; help choose readings/poems/music; light candle; blow bubbles; decorate coffin, and so on

Communication and Memory

• Special times, special places and special things • Experiencing the presence of someone who has

died • Talking and communicating with the dead person • Keeping special things as a link to the dead

person • At first, clothes and items preserving smell may

be important • Young children may need prompts (photos etc) to

help them remember

Children’s Fears, Worries and Need for Reassurance

• The death is not their fault • They will be looked after even though parent/s are grieving • Their parent/s’ intense grief is normal • They are still loved and wanted • Anger, guilt and sadness are part of grieving • Important to carry on with activities like school and hobbies • It is still alright to enjoy some things • Other family members are alright and not likely to die until

they are much older • If appropriate, no one can ‘catch’ the illness that caused

death

Support for Families

• Immediate additional help to provide and care for family members

• Processing: listening, acknowledgement and acceptance, reassurance and information, tolerating silence, ‘being there’, talking about own experience of loss, not taking anger personally, support for family’s beliefs

• Participation in rituals of mourning

• Familiar with own feelings about death and bereavement

Reflective Practice

• What seemed helpful to the child/family?

• What seemed unhelpful to the child/family…….and how might I know?

• How might I have communicated things differently?

• How was I affected personally by this particular conversation about death and loss?

• What have I gained from this experience that will help me in my future practice?

DECONSTRUCTING TRAUMA and LOSS

Loss and danger an inevitable part of life

“The function of resolution is to enable the individual to take forward into the future information that is relevant to future protection and comfort and keep in the past that which was unique to the specific event. ‘Unresolved’ individuals are unable to differentiate these two classes of information.”

Crittenden, 2009

TRAUMA and LOSS

• Loss and danger inevitable part of life • What information from dangerous events we carry forward or dismiss

• Information held in different representational systems

• Resolved balance

• Unresolved

– Dismiss too much – remain unsafe - dismissed – Carry to much forward – anxious pre-occupied

• May intrude into our primary attachment strategies and disrupt coping – need a balance of pre-occupied and dismissing strategies for effective coping

TRAUMA and LOSS

• Resolution balance : – able to both carry forward relevant and also to discard irrelevant information – able to connect information from different representational system

• Dismissing

– Discard too much information – remain unsafe - ignore relevant cues to potential future danger

• Pre –occupied – Overwhelmed by carrying too much forward – remain anxious, hyper-vigilant,

over – aroused

• INTRUSIONS: – Memories, e.g. visions, smells, feelings may intrude into our primary attachment

strategies and disrupt coping

UNRESOLVED STATES – TRAUMAS and LOSSES

Pre-occupying - continual arousal Vicarious - events occurred to others Imagined - fantasised

Anticipated - real concern but extent exaggerated

Dismissed - severity of events minimised Blocked - no event remembered or claimed Displaced - effects on other source of concern Disorganised - multiple and complex Depressed - events beyond control

RELATIONAL APPROACH

• Development of unresolved states shaped by reactions of others – family, friends, communities

• Social support network, attachment figures, etc., centrally assist in processing dangerous, extreme events:

• Validate, acknowledge our experience

• Assist in developing coping strategies for future safety

KEY UNRESOLVED MARKERS

• Pre-occupying

– Intrusions of negative affect

– Intense animated imagery

– Confusions of self and others

– Confusions of time and place

• Dismissing

– Minimization of the importance of the event/s

– Absence of expected emotions

– Extreme brevity

– Erroneous beliefs of having caused the events

Some Useful Approaches when Working Therapeutically with People with Intellectual

Disabilities

• Family Trees (photographs)

• Art work

• Life story work

• Pictures

• Videos

• Drama

• Poetry

• Memory books/boxes

Some References

Bowlby J (1980) Attachment and Loss. Vol 3. New York: Basic Books Lewis CS (1966) A Grief Observed. London: Faber Melvin D & Lukeman D (2000) Bereavement: A framework for those

working with children. Clinical Child Psychology and Psychiatry, 5, 521-540

Murray Parkes C (2006) Love and Loss: The roots of grief and its complications. London: Routledge

Neimeyer R, Baldwin S & Gillies J (2006) Continuing bonds and reconstructing meaning: mitigating complications in bereavement. Death Studies, 13, 715-738

Wertheimer A (2001) A Special Scar: The experiences of people bereaved by suicide. 2nd Edition. London: Routledge

Worden JW (2003) Grief Counselling and Grief Therapy. 3rd Edition. London: Routledge

Some References

• Glenda Fredman (2003) Death Talk: Conversations with Children and Families. London: Karnac

• Rachel Hare-Mustin (1972) Family therapy following the death of a child. Journal of Family Therapy

• Lorna Bowlby-West (1983) The impact of death on the family system. Journal of Family Therapy

• Mary Ann Sedney, John Baker and Esther Gross (1984) ‘The story’ of a Death: Therapeutic considerations with bereaved families. Journal of Marital and Family Therapy

Sudden death

• Resources for those supporting people who have experienced a traumatic response to bereavement. Download from the bereavement page on Belfast Health and Social Care Trust website:

www.belfasttrust.hscni.net

And finally…

“People are much greater and much stronger than we imagine, and

when unexpected tragedy comes . . . we see them so often grow to

a stature that is far beyond anything we imagined. We must

remember that people are capable of greatness, of courage, but not

in isolation. . . . They need the conditions of a solidly linked human

unit in which everyone is prepared to bear the burden of others”.

(Bloom, 1969).