5/5/17 THE FUNDAMENTALS OF GRIEF AND TRAUMATIC BEREAVEMENT LAURA SULLIVAN, MA LMFT 1 OBJECTIVES: 1. Iden6fy defini6ons- three terms are used interchangeably: grief, mourning and bereavement A) Grief- Indicates the experience of one who has lost a loved one to death (Grief can be applied to other losses but for purposes of this presenta6on we are addressing loss related to the death of a loved one). Grief is thought of as an internal experience. B) Mourning- This term is applied to the process that one goes through in adap6ng to the death of the person. Acute phase, Ini6al stage, Adapted Stage and Integrated Stage are the simplified stages of mourning, if any one of these becomes “complicated” then the process of mourning becomes interrupted and at risk. Mourning is primarily an external process. C) Bereavement- This term defines the loss, and the adap6on process of integra6ng grief and mourning. Trauma6c bereavement is the persistent experience of trauma and grief following the suddent death of a significant other due to unnatural causes. 2. Emo6ons 3. Physical Sensa6ons 4. Domains of Life Affected 5. Risk Factors 6. Treatments and Supports 7. Goals 10. Therapeu6c techniques and Interven6ons 11. Resources 2 1
5/5/17 GRIEF EXERCISE • Close eyes and imagine the sudden loss of someone close to you. • Picture how you would feel physically- describe • Picture how you would feel emo6onally- describe • Picture how you would feel spiritually- describe 3 PREVALENCE OF SUDDEN DEATHS IN U.S. POPULATION • Accidents are the largest cause of death for people ages 1-44 • Among people age 15-34 accident, homicide and suicide are the top three causes of death • Remember, for each vic6m there are many survivors that are suffering • Therefore, this is the LARGEST trauma popula6on that there is • The impact on survivors can be life altering with many of them having their own mortality altered 4 2
5/5/17 CHARACTERISTICS OF EMOTION(S) RELATED TO LOSS: 1. Numbness 2. Shock (this occurs even in an6cipatory grief, but is much more pronounced with sudden death). 3. Yearning/Pining (more significant in widows/widowers and bereaved parents) 4. Loneliness (This relates to a`achment theory and rela6onship with the deceased, oaen this goes on for years). 5. Fa6gue (Many bereaved people talk about their experience of being unable to sustain their ‘normal’ level of func6onality from a physical and emo6onal standpoint). 6. Anxiety/Sensory Overload/Hypervigilance 7. Regret, Guilt and Self-Reproach (this is one of the emo6ons that needs to be watched very closely and that we as therapist can support in order to support integra6on of the grief). Preoccupied with guilt and regret and inability to think of anything else. 8. Sadness and Despair 9. Anger, Comparison and Rage (This anger can be translated as internal, external and spiritual/existen6al anger. There is also anger that results in the feelings of abandonment). 10. Helplessness and Hopelessness 11. Emancipa6on and Relief 12. Confusion 5 PHYSICAL SENSATIONS RELATED TO LOSS: 1. Inability to breathe/6ghtness in chest- breathlessness, consistent feelings of shortness of breath 2. Inability to move- Frozen feeling 3. Hollowness in stomach 4. Ea6ng issues (under or overea6ng- watch for significant weight changes) 5. Physical pain in heart (R/O heart failure and broken heart syndrome {takotsubo cardiomyopathy} common in acute phases of grief) 6. Frequent sore throats and a 6ghtness in throat 7. Development of Sensory Integra6on Issues (common in co-morbidity of PTSD as a result of loss). 8. Depersonaliza6on 9. Weakness in the muscles and pain in the joints 10. Lack of energy, fa6gue, and overall feelings of deple6on 11. Difficulty sleeping (insomnia) and/or sleeping too much 12. Dry mouth, dry throat, and dry eyes 13. Nightmares. 6 3
5/5/17 BEHAVIORS WHICH OCCUR AS A RESULT OF LOSS: 1. Sleep Disturbances 2. Appe6te Disturbances 3. Absentminded Behavior, memory loss, confusion and disorganiza6on 4. Avoidance Behavior, social withdrawal and isola6on 5. Dreams of the Deceased and possible nightmares 6. Inability to complete ac6vi6es of daily living and inability to maintain employment 7. Searching for answers to the point of obsession (seen in unexplained, accidental, suicide and homicide deaths). Preoccupa6on w/death 8. Addic6ve behaviors 9. Overworking and working too much/inability to cope with free 6me 10. Decreased self-care and engaging in risky and self destruc6ve behaviors 11. Hyperac6vity, preoccupa6on, distrac6bility and impulsivity 12. Hoarding 13. Crying and Pining 14. Irritability (very common in children) 15. Hallucina6ons (olfactory, auditory and visual) and/or imagining that loss didn’t happen 16. Loss of a Sense of Iden6ty 17. Feels as if life has no meaning. Difficulty accep6ng loss. 7 GRIEF EXERCISE Picture in your mind a loss that you’ve had some6me within the last five years, how is that loss different for you now versus when you ini6ally sustained the loss? Describe. 8 4
5/5/17 RISK FACTORS FOR COMPLICATED GRIEF AND A CO-MORBID DIAGNOSIS OF PTSD/PER THE BEREAVEMENT INDEX: 1. Sudden loss (more at risk for unexplained, unknown, suicide, drug overdose and homicide) 2. Age of the deceased (loss is at risk for complica6on if the individual was a young person- the highest risk ages 5-30) 3. Loss of a spouse (Especially if the spouse was the bread winner and/or primary “go to” in the marriage) 4. Loss of a child (increased risk if oldest child, only child, and if the parents are unable to have more children) 5. The presence of a concurrent life crisis 6. History of Mental illness and/or substance use 7. Having non-suppor6veness in social network 8. S6gma6zed and Trauma6c loss 9. Physical Health Issues (pre loss or post loss) 10. Bereaved women between the ages of 55-80 most at risk demographically (When losing children) and Bereaved men between the ages of 55-80 when losing spouses). 11. Lack of employment and/or loss of a job subsequent to the loss 12. Lower socioeconomic status (individuals that make under 30k per year upon the first two years of loss most at risk) 13. High Regret, Guilt and Shame 14. Secondary losses in the Two years upon ini6al loss (Seen in loss of other family members, friends, social support, homes, employment, income and/or pets) 15. Lack of spiritual belief and/or abandonment of spiritual belief subsequent to the loss 16. Having young children at home (under the age of 5), Having children with Special Needs lea at home and/or being a caretaker of family members 9 FACILITATING MOURNING- 6 R’S 1 2 3 4 5 6 Recognize Loss- tell React to the Recollect and Relinquish past ways Readjust to move Reinvest- Legacy- the narra6ve with a separa6on- FEEL reexperience the of a`achment and adap6vely into the Purpose therapist and/or deceased and the rebuild new ways of new world without supported tribe rela6onship a`achment with the forgeong the old- member deceased pain and joy simultaneously 10 5
5/5/17 TREATMENT CONSIDERATIONS: 1. Kinship (who died) 2. Nature of the A`achment 3. Death Circumstances (Proximity, finding loved one, removing life support, suddenness of death, age of individual, considera6on of trauma, mul6ple losses at one 6me [or within 12-24months], preventable death. Ambiguous death, s6gma6zed death- the more of these at 6me of loss the higher the risk and the more likely a comprehensive treatment is required) 4. Historical antecedents (Loss history and mental health history) 5. Personality mediators (Age, gender, coping style, a`achment style, cogni6ve style, ego strength, assump6ve world views) 6. Social Mediators (support available, support sa6sfac6on, social role, religious resources and ethnicity) 7. Concurrent Stresses (secondary losses, socioeconomic, level of responsibility, physical health) 11 HOW DO WE SUPPORT OUR 1. Normalize- Grief is the story of love aaer loss. It is not a state or a moment in 6me or a single emo6on. CLIENTS 2. Validate, Contain and Sit with client in their pain 3. Assess risk factors and con6nually monitor DURING THE 4. Iden6fy clients a`achment style and level of regret, guilt and shame (significant risk for later complica6ons) 5. Do a loss inventory and iden6fy who client may have lost in the past and assess their level of adap6on PROCESS OF and integra6on 6. If necessary create a safety plan and contact their tribe members for support for con6nual coverage GRIEF, 7. Address physical, cogni6ve and behavioral symptoms that are causing func6onal impairment and triage treatment (iden6fy ADL’s that need to be completed each day- ie: brushing teeth, ea6ng, washing self and iden6fy daily goals) 8. Encourage physical and basic CBC panel with primary care physician and possible psychiatric referral for MOURNING temporary support with an6-depressants, mood stabiliza6on and/or insomnia 9. Self-disclose own experiences with loss and admit if no experience but visualize having a loss of your own and then disclose (if appropriate what that would be like for you) AND 10. Encourage and facilitate social connec6on (family, friends, group support [this is one situa6on where group is almost always helpful], spirituality and possible online [really evaluate this support, as it can be harmful for some]) BEREAVEMENT : 12 6
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