of 58 /58
Grief and Bereavement Workshop By December 14-15, 2013 Hospis Malaysia Amy Y. M. CHOW, Ph.D., R.S.W., FT., Associate Professor, Department of Social Work & Social Administration, The University of Hong Kong, Hong Kong Assisted by: Gilbert FAN, DProf, RSW, RC, FAPA Head, Department of Psychosocial Oncology Co-Chair, Patient Support, National Cancer Centre Singapore

Grief & Bereavement

Embed Size (px)


Grief & Bereavement Workshop

Text of Grief & Bereavement

Page 1: Grief & Bereavement

Grief and Bereavement Workshop


December 14-15, 2013Hospis Malaysia

Amy Y. M. CHOW, Ph.D., R.S.W., FT., Associate Professor,

Department of Social Work & Social Administration,

The University of Hong Kong,Hong Kong

Assisted by:

Gilbert FAN, DProf, RSW, RC, FAPAHead, Department of Psychosocial

OncologyCo-Chair, Patient Support,

National Cancer Centre Singapore

Page 2: Grief & Bereavement


• Challenges of working in the area of Grief and Bereavement

• Bereavement Care as part of the Palliative Care• Anticipatory Grief Work (Before death)• Assessment of Bereaved Persons• McKissock Model of Bereavement Intervention• ADAPTS Targeted Intervention• Dual Process Model Group Work for Bereaved

Older Adults

Page 3: Grief & Bereavement

A Relational Frame for Technical Proficiency in Grief Therapy (Neimeyer, 2012)

Page 4: Grief & Bereavement

Integrated Model of Death Anxiety (Chow, 2011, p.102)

Page 5: Grief & Bereavement

Death Anxiety

“…a cluster of death attitudes characterized by fear, threat, unease, discomfort and similar negative emotional reactions, as well as anxiety in the psychodynamic sense as a kind of diffuse fear that has no clear object.” (Neimeyer, Moser, & Wittkowski, 2003).

Page 6: Grief & Bereavement

Exercise: The Life Journey



Page 7: Grief & Bereavement

Exercise: Unpredictable Life (Letter to my beloved)


Page 8: Grief & Bereavement

An ancient Chinese character for “Death”depicting a person weeping

besides the body of the decease.

Page 9: Grief & Bereavement

Remembering that I'll be dead soon is the most important tool I've ever encountered to help me make the big choices in life. Because almost everything — all external expectations, all pride, all fear of embarrassment or failure - these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.

Page 10: Grief & Bereavement

Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

(Commencement address delivered by Steve Jobs, CEO of Apple Computer and of Pixar Animation Studios, on June 12, 2005)

Page 11: Grief & Bereavement

NICE Guidance and Bereavement (NICE,2004)

• Bereavement can give rise to a wide range of needs – practical, financial, social, emotional and spiritual.

• There might be needs for information about loss and grief, needs to pursue particular cultural practices, needs for additional support to deal with the emotional and psychological impact of loss by death or, in a small number of circumstances, specific needs for mental health service intervention to cope with a mental health problem related to loss by death. (p.156)

Page 12: Grief & Bereavement

A three-component model of bereavement support (NICE,2004)

Component 1 Grief is normal after bereavement and most people manage without professional intervention. Many people, however, lack understanding of grief after immediate bereavement. All bereaved people should be offered information about the experience of bereavement and how to access other forms of support. Family and friends will provide much of this support, with information being supplied by health and social care professionals providing day-to-day care to families.

Component 2 Some people may require a more formal opportunity to review and reflect on their loss experience, but this does not necessarily have to involve professionals. Volunteer bereavement support workers/befrienders, self-help groups, faith groups and community groups will provide much of the support at this level. Those working in Component 2 must establish a process to ensure that when cases involving more complex needs emerge, referral is made to appropriate health and social care professionals with the ability to deliver Component 3 interventions.

Component 3 A minority of people will require specialist interventions. This will involve mental health services, psychological support services, specialist counselling/psychotherapy services, specialist palliative care services and general bereavement services, and will include provision for meeting the specialist needs of bereaved children and young people (being developed as part of the Nation Service Framework on children and not covered here). (p.160)

Page 13: Grief & Bereavement

12.34 Providers should ensure that a leaflet is made available to families and carers around the time of the bereavement. Ideally, this should be developed locally, agreed by those involved in the provision of bereavement services, and include information on anticipated feelings and how to access local and national services.

Page 14: Grief & Bereavement

12.38 Those who offer bereavement services that include volunteer support workers should ensure mechanisms for recruiting, training, supervising and managing volunteers are in place. It is desirable that the workforce reflects the gender, age distribution and ethnicity of the clients they serve.

Page 15: Grief & Bereavement


Page 16: Grief & Bereavement

Common Themes raised by Bereaved Clients

• Unfinished business (unexpressed apology, forgiveness, appreciation love) with the deceased

• Uncertainties about decisions• Flashbacks of Memories in the final days• Loneliness

Page 17: Grief & Bereavement

Definition of Anticipatory Grief (Costello and Hangreaves, 1998)

• Emotional experiences some people have before the loss of a significant other person

• Affects both the dying persons and the family• Begins with the diagnosis of a life-threatening

illness and ends with the death• Emotional intensity increases as death


Page 18: Grief & Bereavement
Page 19: Grief & Bereavement

We Believe……

• Care from the family members are the things that patients longed for

• Precious opportunity for communications• Events happened will be reviewed for a life


Page 20: Grief & Bereavement

Guiding Beliefs:

Source of sufferings: -Inability to live in present moment

Life Review: Ego Integrity Vs Despair (Erikson, 1959)

- To integrate the experiences of earlier stages- To realize that one’s life has had meaning- To develop a sense of connectedness with

younger generations

Page 21: Grief & Bereavement

Finishing of Relational Unfinished businesses :- Guilt & Unexpressed Apology- Unexpressed Forgiveness- Unexpressed Gratitude- Unexpressed Emotional Statements

Page 22: Grief & Bereavement

Concepts of Bereavement

• Definitions of terms• Bereavement Vs Grief Vs Mourning

Page 23: Grief & Bereavement

Manifestations of Grief (Stroebe, Schut, & Stroebe, 2007, p.1964)

Page 24: Grief & Bereavement
Page 25: Grief & Bereavement

Health Consequences of Bereavement (Stroebe, Schut, & Stroebe, 2007)

• Increased Risk of Mortality• Higher Physical Morbidity• Higher Psychiatric Morbidity

Page 26: Grief & Bereavement

Stage Model (Kubler-Ross, 1993)

Page 27: Grief & Bereavement

• Bowlby (Numbing – Yearning & Searching – Disorganization – Reorganization) (Bowlby, 1971)

• Parkes (Alarm & Alarm Reaction – Searching – Searching – Mitigation – Gaining New Identity)(Parkes, 1986)

Page 28: Grief & Bereavement

Empirical Testing of Theories of Stages of grief (Maciejewski, Zhang, Block, & Prigerson, 2007)

Page 29: Grief & Bereavement

Dual Process Model (Stroebe and Schut, 1999, 2010)

Loss-Oriented Coping- Concentrating on, dealing with, appraising,

processing of some aspect of the loss experience

- Focusing on the relationship, ties or bond with the deceased

- Involving a painful dwelling on, even searching for the lost person

- Yearning for the deceased

Page 30: Grief & Bereavement

Restoration-oriented Coping- Restoration of the secondary stressors arisen from the loss- Dealing with the new roles, reorganization of life, mastery of

tasks carried out by the deceased- Reflecting a struggle to reorient oneself in a changed world

without the deceased person- Rethinking and re-planning one’s life in the face of


Oscillation- Alternation between loss- and restoration oriented coping, as a dynamic coping process- Back and forth process of juxtaposition of approach and avoidance

Page 31: Grief & Bereavement
Page 32: Grief & Bereavement

Depathologizing grief

Page 33: Grief & Bereavement

Assessment in Bereavement

High RiskGroupNormal Group

Risk Factor Assessment

Page 34: Grief & Bereavement

Based on your observations, what are the risk factors of bereavement?

Page 35: Grief & Bereavement

Risk Factors

Six Risk Factors (Rando, 1993)• Suddenness and lack of anticipation• Violence, mutilation, and destruction• Preventability and/or randomness• Loss of a child• Multiple deaths• Person encounter with death secondary to threat

of personal survival/ massive confrontation with the death

Page 36: Grief & Bereavement

Twelve Risk Factors (Mckissock & Mckissock, 1998)• Suddenness• Death of a child• Traumatic witness• Centrality• Perceived• Preventability• Ambivalence• Decreased role diversity• Decreased social support• Pre-existing factors (Alcoholism)• Concurrent crisis• Overly prolonged dying process• Lack of reality (Missing persons)

Page 37: Grief & Bereavement

Integrative Risk Factor Model (Stroebe, Folkman, Hasson, & Schut, 2006)

Page 38: Grief & Bereavement

Risk and Protective Factors (Stroebe, Schut, & Stroebe, 2007, p.1966)

Page 39: Grief & Bereavement

Risk factors identified in Hong Kong

• Dependency on the deceased• Loneliness (emotional and social loneliness)• Perceived Traumatic effect of the death

Page 40: Grief & Bereavement
Page 41: Grief & Bereavement

Assessment of Outcomes:

• Psychiatric Assessment (DSM5)• ADAPTS Assessment

Page 42: Grief & Bereavement

ADAPTS Assessment

• Anxious Mood• Depressed Mood• Adjustment• Physical Symptoms• Traumatization• Separation Distress

Page 43: Grief & Bereavement

Story-telling ApproachBereavement Counseling (McKissock & McKissock, 1998)

• Engagement• Contracting• Exploration• Facilitation• Review• Closure

Page 44: Grief & Bereavement

a. Engagement- Social ritual- Meeting and greeting- Setting the scene- Making the client’s familiarity with the

environment- Testing the climate

Page 45: Grief & Bereavement

b. Contracting- A passage from social chat to counselling- Explore gently about previous experience of

counselling- Explanation of the purpose and structure of

this interview- Define the time frame- Increase mutual understanding

Page 46: Grief & Bereavement

c. Exploration- Getting to the story through the structure of

chronological sequence

Page 47: Grief & Bereavement

Death- How & where death occurred- Whether client was present- If not, who told them

Effect- e.g. “Tell me about the day X died/tell me

about the time around x’s death”

Page 48: Grief & Bereavement

Viewing- When and where- How was it- E.g. “Did you have an opportunity to spend time with X after s/he


Funeral- Assess whether the client was involved on a ‘them-centred way’- Assess whether the funeral was emotionally/spirituality satisfying

Time Since- E.g. “And how has life been since the funeral?”

Page 49: Grief & Bereavement

d. Facilitation- Facilitation of expression of feelings involved- Also can be focused around bringing the deceased back

to life and continuing the relationship with the deceased.

e. Review- Leave around 10 mins for reviewing what has been

brought up, accomplished and unfinished business- Re-contract about the tasks of coming sessions

Page 50: Grief & Bereavement

f. Closure- Exit version of engagement, also involved with

social ritual- One question can be asked is “what do you

imagine you’ll be doing when you leave here today?”

Page 51: Grief & Bereavement

ADAPTS Targeted Intervention

Traumatization- Debriefing model- Minimizing Technique- Anchoring Technique- Emotional Freedom Techniques

Physical Symptoms- Linkage physical symptoms with emotions- Gestalt Approach: dialogue with the symptom

Page 52: Grief & Bereavement
Page 53: Grief & Bereavement

Emotional Freedom Technique (EFT) Demonstration.mp4

Page 54: Grief & Bereavement

Depressed Mood- Cognitive Therapy- Exercise and movement- Sunshine

Separation Distress- Continuing Bond- Gestalt Empty-chair technique- Letter writing

Page 55: Grief & Bereavement

Anxious Mood- Mindfulness Exercise- Breathing Exercise- Physical Exercise- Emotional Freedom Technique

Adjustment- Psychosocial Education- Resources referral- Dual Process Model Intrvention

Page 56: Grief & Bereavement

Dual Process Model-based Bereavement Intervention

Page 57: Grief & Bereavement

• an 8-session revised intervention model for Chinese widowed persons (Chow, 2012)

Page 58: Grief & Bereavement

• Thank you!