GRIEF AND BEREAVEMENT

Croatian Association for Hospice and Palliative Care,mrb Melita Reiner, specialist in clinical psychology, Croatian-Austrian Training Center for NLPt

Multidisciplinary approach to bereavement:

Definition of terms

Siegmund Freud, PSYCHOANALYSISMourning is not pathological, it will be overcome after a time, and interfering with it is useless and probably harmful Freud, 1917

CONSCIOUS- UNCONSCIOUS

FREUD AND BEREAVEMENTWe all develop attachments (cathexis)

After a death we must detach and reinvest emotional energy in other ways

Detachment (hypercathexis) is achieved by confronting the loss

This is painful and time-consuming = griefwork

Avoidance = complicated grief

TWO GENERAL TYPES OF THEORIES: DEPRESSION MODELS OF GRIEF

Based on the psychoanalytic tradition, analyse grief as an emotional reaction; Freud (1917), Lindemann (1944), Bowlby (1980) STRESS MODELS OF GRIEF Consider bereavement as a stressful life event, offer explanations for physical health consequences of bereavement; Lazarus & Folkman (1984), W. Stroebe & Stroebe, 1987, Horowitz (1976/1986)

Theory enables those working with the bereaved to:

- Understand where the bereaved person is within the grief experience

put the grief within the family context

develop creative ways of working with the loss experience

STAGES OF GRIEF (Elisabeth Kubler-Ross, STAGES OF DEATH & DYING)

SHOCK disbelief, denial, feeling numb,paralysed...

ACUTE MOURNING acute somatic and emotional discomfort, social withdrawal

RESTITUTION PERIOD integrating the loss into personal history, redirecting energy towards present and future

MANIFESTATIONS OF NORMAL GRIEF

PHYSICAL SENSATIONS

Fatigue/lack of energySleep disturbances Appetite disturbances Tightness in the chest Feeling short of breathWeakness in the musclesHeadachesAnd other ..

EMOTIONAL REACTIONS

Intense emotions of fear, sadness, anger Feelings of guiltLonelinessShameHopelessnessHelplessness NumbnessPanicand other .

OTHER PSYCHOLOGICAL REACTIONS

Inability to concentrateLack of interestLow self-esteemInability to experience pleasureSocial withdrawal and other .

SPIRITUAL REACTIONS

Anger with God/ Life...Feeling abandoned by GodDoubts about belief systemInterest for life after deathQuestions regarding meaning of life

and other

Studies of Bereavement Broken Heart Study, Murray Parks C., Benjamin B., Fitzgerald R.G.: Statistical Study of Increased Mortality of Widowers during the first 6 months after death of spouse 40% higher mortality rate than expected

Recent study of 1,5 milion adults age 35 84 20 - 35% excess mortality from isochemic heart disease within 5 years after death of spouse

Family Physicians and Grieving Patients, Department of Family Medicine, Wright State University,- GRIEF RESPONSIVE PHYSICIAN

INSTITUTE OF MEDICINE COMMITTEE ON HEALTH CONSEQUENCES OF THE STRESS OF BEREAVEMENT Specific approaches for physiciansReviewing details of illness and deathFostering realistic expectations about course of bereavementProviding reassurance and support for normal grieving processIdentifiying individuals at risk for complicationsMonitoring progressReferring bereaved patients to professionals and community resources

D. Klass & P. SilvermanContinuing Bonds new understandings about grief

Continuing Bonds: New understandings of grief

The healthy resolution of grief depends upon the bereaved being able to maintain continuing bonds with the deceased

P. Silverman (1996)

Continuing bonds model of griefBonds are not severed but flow on in time

Emphasizes the inner representations of the loss

Death is not a finality but an invitation to a new relationship

Based on premise that the bereaved do not want to forget their loved ones

The continuation of the presence of someone who has died as an important and vital relationship

Tony Walter challenged established theorists (1996)

Bereavement is a process that explores how families keep in touch with the past and how society as a whole keeps in touch with the past as part of the future

Challenged the ideal of letting go detaching from the deceased

Bereavement has to do with group history as well as individual psychology

Continuing Bonds Bereavement is a Life TransitionDeath does not end our relationship with the deceased.

Grief shapes our experiences and who we are. People, living or dead, are part of what we are. We dont get over people. We live in a web of relationships. We are still connected to the dead. We need to reorganise, find a place for this relationship, and develop other selves.

Grief does not have a final outcome.

People can help each other with the grief experience.

(Ref. Ed. Klass, D., Silverman P.R. and Nickman S.L. Continuing Bonds: new understandings of grief (Taylor and Francis, 1996)

POSITIVE ASPECTS OF BEREAVEMENT (Post-traumatic Growth - PTSG)Psychological and spiritual developmentDeeper connection with oneself, knowing selfRespect for real human valuesMore compassion for othersAwareness of the importance of living here and nowand other

Support in Bereavement, Grief Counselling and Grief Therapy

HELP AND SUPPORT FOR THE BEREAVEDPsycho-social support: - INDIVIDUAL - SUPPORT GROUPS

Counselling and Psychotherapy

FOUR TASKS OF MOURNING- William Worden

The Tasks of Mourning1.Accepting the reality of the loss

Give repeated information about what has happened in language appropriate for the stage of development.

Avoid euphemisms and metaphors.

Reinforce the finality of the separation

Discuss funeral and rituals

Visit the grave or crematorium.

What helps..Rituals of mourning.

The Tasks of Mourning

2.Working through the pain of grief

Talk about feelings.

Allow time for and time out of grief.

Maintain familiar routines.

Ensure compassion from carers.

Talk about how feelings change.

New Orleans September 2005

The feeling is like some one pushing hard on your chest, there is air in there but you cannot breathe, its trapped like your state of mind, you are in a thousand places at one time and there is no way out, not now

The Tasks of Mourning

Adapt to life without the deceased

Give opportunities to keep memories alive.

Allow time to grieve and adjust.

Use mementos and symbols.

Continue to mark important anniversaries.

Talk about the changes

Memorial Concert for Princess Diana

The Tasks of Mourning

Investing in new relationships

Ensure the person has time for reminiscence about the past.

Give permission to be happy, enjoy life and make new attachments.

Adapted from Worden J.W. (1996)

GUIDELINES FOR HELPING THE BEREAVED W.WordenHelp the client actualise the loss.Help them identify and express feelings.Assist living without deceased.Facilitate emotional relocation of the deceased.Provide time to grieve.Interpret normal behaviour.Allow for individual differences.Provide continuing support.Examine defences and coping style.Identify pathology and refer.

UNRESOLVED GRIEF RISK FACTORSRelationship was: - very close - ambivalent - conflicted - dependentPerceived lack of social supportPast history of depressionCurrent life events interfere with grievingPoor physical healthPersonality factors (emotional stability, locus of control)Reduced material resources

RISKS OF UNRESOLVED/ COMPLICATED GRIEF Depression Anxiety disorders Changes in:Immune systemEndocrine systemAutonomic nervous systemCardiovascular systemsIncreased vulnerability to external agents

Working with someones beliefFinding sense and defining a key messageTurning from survival to personal developmentIntegrating life experience (by harmonizing Bereavement panorama)Death & Dying in Europe key findings

Hospice care bereavement

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