THE FUNDAMENTALS OF GRIEF AND TRAUMATIC BEREAVEMENT LAURA - - PDF document

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THE FUNDAMENTALS OF GRIEF AND TRAUMATIC BEREAVEMENT

LAURA SULLIVAN, MA LMFT

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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

• ther losses but for purposes of this presenta6on we are addressing loss related to the death of a loved
• ne). 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

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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

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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

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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

• f 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

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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.

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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.

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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.

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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

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FACILITATING MOURNING- 6 R’S

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Recognize Loss- tell the narra6ve with a therapist and/or supported tribe member

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React to the separa6on- FEEL

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Recollect and reexperience the deceased and the rela6onship

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Relinquish past ways

• f a`achment and

rebuild new ways of a`achment with the deceased

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Readjust to move adap6vely into the new world without forgeong the old- pain and joy simultaneously

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Reinvest- Legacy- Purpose

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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)

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HOW DO WE SUPPORT OUR CLIENTS DURING THE PROCESS OF GRIEF, MOURNING AND BEREAVEMENT :

1. Normalize- Grief is the story of love aaer loss. It is not a state or a moment in 6me or a single emo6on. 2. Validate, Contain and Sit with client in their pain 3. Assess risk factors and con6nually monitor 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 and integra6on 6. If necessary create a safety plan and contact their tribe members for support for con6nual coverage 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 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) 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])

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THERAPEUTIC SUPPORTS CONTINUED:

• 10. Increase client’s ability to discuss the reality of the loss (grief exercises, discussion of the loss, allowing client

to tell their narra6ve [over and over], increase their experience of universality [group therapy, blogging, on-line support, grief conferences, and mee6ng face to face other individuals with similar losses]

• 11. Con6nuing to evaluate physical, cogni6ve and behavioral symptoms and evaluate necessary treatments and

interven6ons based on impairment and length of 6me. Normalize and validate what is their ‘new normal’ versus symptoms that may need addi6onal support

• 12. Teach interven6ons such as mindfulness, self-soothing, distress tolerance, sensory integra6on, a`achment

interven6ons and self advocacy

• 13. Encourage 5 aspects to the grief journey each day:

A) Some type of list with the necessary ADL comple6on B) Some type of body movement each day (15-30 mins) C) Some type of Emo6onal expression (journaling, talking, crying, art, prayer, communica6on) D) Some type of mindfulness ac6vity (breathing, medita6on, reading, yoga, prayer, spirituality) E) Some type of connec6on with another individual separate from work (tex6ng, phone call, social media, going to a coffee shop etc.)

• 14. Support bereaved in finding a way to maintain a consistent bond with the deceased while inves6ng in their

life (purpose, legacy, scholarship, helping others, plan6ng tree, memory making)

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GENERAL TREATMENT GOALS:

1. Help Survivor Actualize the Loss (talk and share, visit the gravesite [if there is one], look at photos together, reminiscent therapy, and facilitate growing awareness). 2. Help Survivor to Iden6fy and Experience Feelings (support clients in iden6fying and accep6ng their painful emo6ons and iden6fy different types of support for different types of emo6onal experiences; iden6fy when to self-soothe versus when to distract) 3. Assist Living Without the Deceased (iden6fy tribe members, community resources, books that may be suppor6ve, self help skills, decision making skills and problem solving) 4. Help Find Meaning in the Loss (legacy, scholarship, tree plan6ng, memorials, teaching, suppor6ng others, self-efficacy and sense of iden6ty) 5. Facilitate Emo6onal Reloca6on of the Deceased (spiritual belief, pets, other family members, within self, suppor6ng causes important to deceased etc.) 6. Provide 6me to grief (pa6ence, pa6ence, pa6ence and depending on rela6onship and a`achment to loss, this can take YEARS) 7. Interpret “Normal” versus Complicated Behavior (especially related to risk factors and assessments) 8. Allow for Individual Differences (based on rela6onship, age, gender, culture and spiritual beliefs) 9. Examine Defenses and Coping Styles

• 10. Iden6fy when to refer and when there may be further issues and/or a team is needed

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THERAPEUTIC TECHNIQUES:

1. Normalize 2. Valida6on 3. Self-Disclosure 4. Symbols/Metaphors 5. Wri6ng le`ers/journaling/expression 6. Art therapy (collage, soul collage, vision boards, memory boards, quil6ng, shadowboxing, etc.) 7. Role Playing (Gestalt, empty chair, experien6al, encourage communica6on with deceased) 8. Cogni6ve Restructuring (BE careful with this one, but it may be helpful with overgeneraliza6on and nega6ve self-talk) 9. Discuss regret, guilt, and shame (iden6fy differences and beliefs with client, iden6fy underlying belief and facilitate amends when appropriate) 10. Memory and/or Photo Books (help with process) 11. Directed Imagery 12. Sensory Integra6on 13. EMDR (Facilita6ng what bereaved would like to say) 14. Distress Tolerance 15. FIND A GROUP

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AREAS TO BE AWARE OF AS A PROVIDER:

1. Birthdays of the deceased will always be hard so help client to find a way to make meaning of these events and prepare for them. As a provider, place these significant dates in your calendar and support your client. 2. Iden6fy if on-line is suppor6ve or harmful for your client, some clients should reduce their presence on social media if it is hurtul 3. Provide psychoeduca6on to friends and family if necessary and/or support client in wri6ng a le`er to facilitate what they need (this le`er may or may not need to be delivered) 4. Ask client to iden6fy what is helpful and/or hurtul to communicate so that there is complete transparency in the rela6onship 5. A`end grief workshops regarding your clients specific type of loss in order to understand the cultural views of their experience 6. Prepare and discuss important dates such as mother’s day, father’s day, wedding anniversaries, sen6mental holidays and angel-versaries and discuss plans so that client is not off guard when these events happen 7. Prac6ce acknowledging loss with friends, family members and co-workers and ask them ques6ons about their loss. Do not be afraid to ask them what they need and what their experience is like in order to learn. This is not a process that can be generalized if we do not prac6ce with those closest in our lives. 8. Do not be afraid to touch your client in session, if diagnos6cally appropriate. Do not be afraid to cry with your client if appropriate. 9. Make sure you understand your clients belief about what happens aaer death, so that you are not puong your own beliefs into the room, which may be quite distressing for your client.

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QUESTIONS AND RESOURCES:

1. On-line support for widowed moms raising child age children www.jenniferwaugh.com

• 2. Widow support Group

www.modernwidowsclub.com

• 3. Widow and Widower Community

www.soaringspirits.org

• 4. Center for Complicated Grief and Treatment

www.complicatedgrief.Columbia.edu

• 5. Alliance for Hope related to Suicide Loss

www.allianceforhope.com

• 6. Friends For Survival, Inc. (suicide loss)

P.O. Box 214463 Sacramento, CA 95821 www.friendsforsurvival.org and email ffs@truevine.net

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RESOURCES CONTINUED:

• 7. Suicide/Homicide Bereavement

www.grievelpsacramento.com

• 8. Group for Bereaved Mom’s of Suicide Loss

Monday evenings from 6-8pm in Folsom Facilitated by Laura Sullivan (916) 742-2984 or email Laurasullivancounseling@gmail.com

• 9. Bereaved Parents of the USA

Monthly Mee6ng on the 1st Thursday of the month from 6-830pm www.bereavedparentsusa.org Chris Harder local chapter president (916) 768-3891

• 10. Open to Hope Founda6on (addresses all types of grief on web-site)

www.opentohope.com

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RESOURCES CONTINUED:

• 11. Hope Healing and Help Radio Show

www.hopehealinghelp.com

• 12. Heritage Oaks Memorial Chapel (offering workshops and resources related to grief)

6920 Des6ny Drive Rocklin, CA 95677 (916) 791-2273

• 13. Compassionate Friends (Organiza6on for Bereaved Parents, Grandparents and Siblings)

www.compassionatefriends.org (877) 969-0010

• 14. Grief Haven

www.grievaven.org

• 15. Child Bereavement

Su`er Children’s Center, Sacramento Bereavement Art Group Peggy Guishan Program Coordinator (916) 454-6555

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RESOURCES CONTINUED:

• 16. Angela Miller Child Loss

www.abedformyheart.com

• 17. Now I lay me down to sleep (for children)

www.nowilaymedowntosleep.org

• 18. Su`er Hospital Sacramento (Specific groups are also offered for the loss of a parent and/or spouse/partner)

Adult Grief Support Groups for guidance in the loss of a death or loved one (916) 388-6215 or (916) 388-6255 www.checksu`erfirst.org

• 19. Dinner Party- Life aaer loss- Group of 20-30 somethings who’ve each experienced significant loss. They get together to

connect and talk about the ways in which the loss has impacted their life. www.thedinnerparty.org

• 20. Many of these web-sites have books, ar6cles, blogs, facebook pages, instagram, camps and na6onal conferences specific to

different types of grief. Please check some of them out and if you are dealing with a par6cular type of loss and/or a specific popula6on feel free to contact me for addi6onal informa6on, research and reading material

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SOURCES:

Bowlby, J. (1980). A"achment and loss: Vol 3. Loss, sadness and Depression. New York: Basic Books. Shear, K. (2012). Complicated Grief and Treatment. New York: Springer Publishing Company. Worden, J.W. (2009). Grief Counseling and Grief Therapy. New York: Springer Publishing Company. Worden, J.W. (1976). Personal Death Awareness. Englewood Cliffs, NJ: Pren6ce-Hall.

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