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Personal Loss: Bereavement and Grief

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Megan Baker

on 31 October 2013

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Transcript of Personal Loss: Bereavement and Grief

Chapter 12:

Personal Loss:
Bereavement and Grief

1. A period of sorrow following the death of a significant other
2. An objective state or condition of deprivation that is especially caused by death and is then followed or accompanied by grief
Uncomplicated Bereavement:
a process that occurs as the bereaved individual works through a variety of tasks to move forward in life without the person who died
a psychic state or condition of mental anguish or emotional suffering and a result or anticipation of the bereavement-- grief is unique and multidimentional
Complicated or Prolonged Grief:
individual is preoccupied with the deceased and may have recurrent, intrusive images or thoughts of the death

Traumatic Grief:
additional requirement that the person witnessed or was in close proximity to the violent, sudden, unexpected, horrifying death of a loved one-- typically accompanied by PTSD symptoms
Disenfranchised Grief:
when a person has experienced deep and meaningful attachment, experienced loss, and cannot openly acknowledge or grieve the loss or have it validated by others
Historically, rural communities cared for their own dying friends and relatives
Death was also more present in people's everyday lives:
shorter life expectancy, infant mortality, famine, epidemics-- People saw death all around them
Death in modern Western society has been sanitized
standardized by laws, regulations, and specialists
not fully a negative aspect-- some funeral homes offer grief counseling for clientele and the community
Sociocultural Mores
Spirituality and Religion
Religion helps to make meaning of and understand death
Faith, beliefs, and religious practices are foundations for dealing with death
They offer: comfort, hope, support, and connection when one feels hopeless, unsupported, and disconnected
Provide guidance to family and friends in how to honor the deceased and mourn their loss.
But attempting to make sense and meaning of loss can challenge one's most deeply held religious and spiritual beliefs

Any end-of-life assessment and counseling should include a bio-psycho-social-spiritual network
Dealing with the Loss
Death of a Child
Assessment for PTSD
Couple counseling and intervention
Assessment of family problems and potential (strengths)
Parent survivor support group
Reading and media material

Separation and Divorce
Almost 50% of all marriages in the US end in divorce
Depression is common
“Intense” feelings of fear and emotional turmoil

Dealing with the Loss
Separation & Divorce
Feelings of grief, guilt, worthlessness and failure are common.
Intervention strategies:
Individual counseling
Support group work
Referral resources

Death of a Pet
The loss of a pet can elicit feelings similar to the loss of a human
The loss of a pet can provide an opportunity for parents to introduce the concept of death/dying
Individuals who have lost a pet can experience feelings of grief and depression.
High grief: disturbed by memories of their lost pet and hang on to their pets’ belongings
Low grief: comforted by dreams and memories of their pet, gave away their pets belongings

Dealing with the Loss
Death of a Pet
Individual counseling and intervention
Group work

Loss due to Caregiving
Dealing with the Loss
Bereavement in an HIV infected Client
Job Loss
Caregiving is a major issue for spouses and parents
Caregiver population predicted to grow in the U.S. as the Baby Boomer generation ages and continuing advances in medical science prolong more lives into degenerative disease territory
Grief and bereavement over lost relationships are compounded by frustration over the ambiguousness of the loss
Sense of loss of their identity as they move farther and deeper into caretaker roles
Caregivers live in subtranscrisis or transcrisis states due to the pervasive threat of medical or financial crises for the disabled person and their own continual stress in caring for them
Length of time in dying has an effect on the surviving caregiver
Long-term caregivers reported more relief and less depressive symptoms

Dealing with the Loss
Loss Due to Caregiving
Program components of crisis workers:
Support groups
Get relief through off/out programs
Plan for future events
Obtain psychological first aid or supportive psychotherapy
Normalize negative feelings
Find outside help
Obtain financial, medical, and legal advice
Psychoeducation about caregiver issues
Develop meaningful narratives about their losses

Brings grief to its victims, significant others, and families
At risk of infection, being subject to stigmatization, marginalization, and social, occupational, domestic, and sexual hostility
Face potential abandonment, isolation, and physical pain
Isolation resulting in problems maintaining intimate relationships
In the U.S., the poor, minorities, women, youth, gay and bisexual men, drug addicts, and people who are homeless or mentally disabled are all at high risk
Disproportionate percentage of people who have fewer resources to combat it
May face negative social pressures and ostracism by being identified as homosexuals, drug users, prostitutes, or unfaithful

Crisis Intervention:
Collaborative role between worker and client
Exploring lethality level
Sensitive and empathetic listening
Reframing cognitions about the disease
Set goals and challenge clients to achieve a meaningful quality of life by dividing multiple issues of loss into discrete, manageable components
Safe sex education and general health-promoting practices
Workers in this population have high potential for countertransference and burn-out
Support groups – helps HIV-infected clients regain a sense of control over their life by breaking down the prevalent feelings of isolation, enhance sharing of personal grief, and promote healing
Employment counseling

Jobs account for our status and identity, our sense of participation and purpose, and the social interaction and network that work brings
Suffer secondary victimization similar to rape or other assault victims
Much like those bereaved who suffer traumatic loss due to death, the assumptive world of the newly unemployed is shattered, their view of a just world is challenged, and views of themselves as valuable and worthy are invalidated
Grieving workers in the workplace can make poor business decisions, miss business opportunities, have accidents, and cause financial loss

Children's grief may be covert, leading others to believe children are not affected by death
Death of a parent, sibling, or friend can lead to disenfranchised, traumatic, and complicated/ prolonged grief
Bereavement in Childhood
Dealing with the Loss
Job Loss
Career Counseling
Vocational outplacement counselors help individuals look for work while also engaging in crisis support therapy for grief, anxiety, depression, and stress

Bereavement in Childhood
18 months- 3 years
death and "going away" are conceptually the same
may feel that they caused the death
may exhibit increased levels of anxiety, seen as agitated or restless behavior, excessive crying, thumb-sucking, biting, and tantrums
Bereavement in Childhood
3- 5 years
may display feelings of sadness, anger, crying spells, feelings of remorse and guilt, somatization, separation anxiety, needing to be held, not wanting to sleep alone
may believe they caused the death
not yet able to understand permanency
start to play out the event
euphemisms may be taken literally
Bereavement in Childhood
Primary School Age
6- 7 years
concrete stage- understand universality and irreversibility of death
may report matter-of-fact details of the death-- seeming cold and uncaring by adults or may become agitated if they hear details
may be able to balance pros and cons of the death (missing sibling, but more time with parents)
may exhibit difficulty concentrating in school, somatic complaints, difficulty controlling behavior (radical changes from quiet and shy to verbally aggressive and acting out)
Play Therapy-
if play becomes extensive, intensive, and focused on the trauma it has moved into traumatic childhood grief
Bereavement in Childhood
Middle School Age
understand the permanence of death
may develop a sense of foreboding and doom about a foreshortened future and may see their existence as pretty meaningless
mood swings may occur often and dramatically as they attempt to cope with emotional dysregulation
may become judgmental about behaviors related to the deceased and handling the events of the trauma
Bereavement in Childhood
approach treatment in terms of each child's understanding and developmental stage
Reassurance & Support
children may ask the same question over and over for reassurance
simple, truthful, rassuring words
Do not sugar coat or use euphemisms
They should not be forced to participate in activities when they decline to do so, but included when they request it
5 tasks:
Resilience- building stress management skills
Affective expression skills development
Cognitive coping skills
Trauma- specific interventions (trauma narrative)
Grief- focused interviews
Bereavement in Adolescence
90% of middle and high school students have experienced loss associated with death
peer death is particularly traumatic because it is nonnormative, often violent, and may be seen as preventable.
Adolescents need to be included in the family's grief, but also given time alone
may feel a deep sense of pain, fear, anger, guilt, helplessness, confusion, loneliness, and grief but may not know how to express or feel comfortable expressing these emotions
Bereavement in Adolescence
Individual or group counseling:
include the surviving parent when a parent has died
Peer loss:
important that the loss is understood and acknowledged by adults
discounting the loss may turn it into disenfranchised grief
Parents must be careful about criticizing immature behaviors of their child's peer that resulted in the death; this discredits the friendship and feelings of their child
Bereavement in Elderly People
commensurate issues arise involving finances, health, cognitive difficulties, and social support systems
compounded by decreases in sensory acuity, general decline in health, and reduced mobility, and decrease in coping skills (cause unknown)
Loss of friends and family continue to decrease the elderly person's social support
increased number of losses compared to younger counterparts
The Ultimate Loss- loss of a spouse:
increases the risk of the loss becoming prolonged grief and bereavement
Dealing with the Loss
Bereavement in Elderly People
Individual Counseling:
assess grief and coping ability, physical and mental capacities to cope, children's ability to help
address economic, medical, and legal needs
revalidate the elderly person as a worthwhile person separate from the lost loved one
Group Counseling:
rebuilding social support
creating resiliency and finding new meaning in life are critical when helping an elderly person deal with loss
Complicated/ Prolonged Grief, Bereavement, and Mourning Reaction
continuous distressed yearnings, pangs of severe separation anxiety, intense intrusive thoughts, feelings of increased aloneness and emptiness, excessive avoidance of tasks related to the deceased, loss of interest in personal activities, and disturbances in sleeping, eating, and other daily living patterns present more than a year after the loss
37% of the general population suffer from complicated or prolonged grief
higher incidence of suicidal ideation and risk of suicide
Predominate dynamics that do not allow individuals to move on:
1. person denies, represses, or avoids aspects of the loss, its pain, and the full realization of its implications for the mourner
2. person holds onto and avoids relinquishing the lost loved one
Other Specified Trauma- and Stressor- Related Disorder
symptoms characteristic of trauma and stressor related disorder cause significant distress or impairment in social, occupational, or other areas of functioning predominate but do not meet the full criteria for any of the disorders
Record as "other specified trauma- and stressor- related disorder persistent complex bereavement disorder"

Condition for Further Study:
Persistent Complex Bereavement Disorder (PROPOSED CRITERIA):
A. The individual experienced the death of someone with whome he or she had a close relationship
B. Since the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:
1. Persistent yearning/ longing for the deceased. In young children, yearning may be expressed in play and behavior, including behaviors that reflect being separated from, and also reuniting with, a caregiver or other attachment figure.
2. Intense sorrow and emotional pain in response to the death.
3. Preoccupation with the deceased.
4. Preoccupation with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through the themes of play and behavior and may extend to preoccupation with possible death of others close to them.
C. Since the death, at least six of the following symptoms are experienced on more days than not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:
Reactive distress to the death
1. Marked difficulty accepting the death. In children, this is dependent on the child's capacity to comprehend the meaning and permanence of deaht.
2. Experiencing disbelief or emotional numbness over the loss.
3. Difficulty with positive reminiscing about the deceased.
4. Bitterness or anger related to the loss.
5. Maladaptive appraisals about oneself in related to the deceased or the death (e.g., self-blame)
6. Excessive avoidance of reminders of the loss
Social/identity disruption
7. A desire to die in order to be with the deceased.
8. Difficulty trusting other individuals since the death.
9. Feeling alone or detached from other individuals since the death.
10. Feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased.
11. Confusion about one's role in life, or a diminished sense of one's identity
12. Difficulty or reluctance to pursue interests since the loss or to plan for the future
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The bereavement reaction is out of proportion to or inconsistent with cultural, religious, or age- appropriate norms.
Traumatic Death/ Traumatic Grief
degree of trauma is increased by
suddenness and lack of anticipation
violence, mutilation, and destruction
preventability and/ or randomness
multiple deaths
the mourner's own confrontation with death or witnessing of violence or mutilation
treatment for PTSD and complicated grief is generally recommended
16 characteristics on pg. 435*
clients who are in crisis for no legitimate reason, always assess for unresolved grief and loss issues.
Dealing with Loss
Compicated Grief: Death of a Mother
Unfinished business can be a major problem in grief counseling

May employ "empty chair" from Gestalt Therpay to address unfinished business

Objectify unfinished business
Conceptual Approaches to Bereavement: Stage/Phase Models
Kübler-Ross’s Stages
Best known loss model to the general public
Five stages of grief and grieving process:
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
Little empirical evidence

Stage/Phase Models
Bowlby’s Attachment Theory
Focuses on the nature of the griever’s relationship to the deceased
Failure to grieve intensely is seen as problematic in not coming to terms with the loss of the object
The need to emotionally turn loose or “detach” from the person or object is the end goal of the grief process
Stage/Phase Models
Schneider’s Growth Model
Eight-stage holistic, personal growth-promoting
model within a context of stress, loss, and grief:
1. Initial awareness of a loss
2. Attempts to limit awareness of the loss
3. Attempts at limiting awareness by letting go
4. Awareness of the extent of the loss
5. Gaining perspective on the loss
6. Resolving the loss
7. Reformulating loss in a context of growth
8. Transforming loss into new levels of attainment

A Counterpoint to Traditional Models
Concepts of grief and loss have become more dynamic
Perspective that each individual experiences loss according to psychophysiological, affective, and cognitive-behavioral factors

A Counterpoint to Traditional Models
The Dual Process Model
Approach-avoidance model with two components:
1. Loss Orientation- stressors associated with the loss itself, which may be experienced in ruminating about it and having behavioral, emotional, and cognitive reactions to it that oscillate between avoiding and confronting the disrupted bond with the object of loss
2. Restoration Orientation- occurs when grievers start to come to grips with the consequences of the loss and begin to form new roles and identities, develop new relationships, make life changes, and engage in new activities that distract their grief
Major advantage: Recognizes grief as not being static

A Counterpoint to Traditional Models
The Adaptive Model
Three basic grieving styles that operate along a continuum:
1. Intuitive grieving- respond in terms of emotion
2. Instrumental grieving- think through grief and/or act on it
3. Somewhere between the two- majority of people have a blended style
Heavy emphasis on spiritual components

The Crisis Worker’s Own Grief
Working with loss and bereavement has high potential for burnout
Crisis workers working with grieving clients who do not take care of themselves emotionally, physically, and spiritually, become vulnerable to vicarious traumatization and compassion fatigue, particularly if they have not resolved their own losses
Worker’s own grief experience should not be projected or imposed on clients

The Crisis Worker’s Own Grief
Worker vigilance in preventing vicarious trauma,
compassion fatigue, and burnout in themselves:
1. Emotional investment in the client
2. Bereavement overload
3. Countertransference
4. Emotional replenishment
5. Facing one’s own mortality
6. Sense of power
7. Tendency to rescue
Effectiveness of interventions is relatively unknown, testing is “sparse”
Grief interventions do not have the same positive outcomes as other interventions
Interventions may cause the client to feel worse
Clients should not be pushed to make progress before they are ready

Being There for Grievers
This is very important and includes:
Empathic presence: listening, silence, encouragement
Gentle conversation: avoid clichés and easy answers
Providing available space: help the client find support, do things they cannot do themselves
Elicit trust: communicates that clients have the ability to recover and grow


Styles of Grief
Counselors must remain flexible during the counseling process
Clients may fluctuate between loss orientation and restoration orientation. This process is encouraged

Styles of Grief
Dual Process Model
Explore stressors and avoidance/confrontation responses of the client
Initial fixation in the loss orientation is normal.
Identify evidence or absence of oscillation between loss and restoration
Normalize the process by explaining how the model works
Address problematic avoidance mechanisms
Do NOT push client towards restoration

Styles of Grief
The Adaptive Grieving Model
Integrates affective, behavioral, cognitive, and spiritual modalities.
Affective strategies allow the client to experience full catharsis from crying to swearing.
Behavioral strategies incorporates positive active behaviors for static behaviors.
Cognitive strategies address maladaptive thinking.
Spiritual strategies address the loss through faith based activities.
Styles of Grief
Cognitive-Behavioral Approaches
Strategies focus on changing maladaptive thinking
Helpful for both loss and restoration orientations
The focus is to assist clients in making sense of their loss and re-defining their purpose

Styles of Grief
Narrative Therapy
Involves the telling and re-telling of stories that illustrate the meaning of loss
Helps the client challenge the maladaptive narratives that have been created to help rationalize the loss

Assessment Tools
Attachment Theory & Therapy
Based on the idea that emotional attachments are formed at birth
A key component is the “coherent narrative”
The coherent narrative is the way the parent recalls their own life (how they made sense of what happened to them as child)
Blends well with Narrative Therapy

Styles of Grief
Styles of Grief
The Texas Revised Inventory of Grief (TRIG)
Most widely used inventory to measure grief
Consists of two scales, Current Grief and Past Disruption, which allow workers to determine what progress in grief resolution has been made
Provides good cross comparisons and a wealth of normative data

Assessment Tools
Grief Experience Inventory (GEI)
Assesses the longitudinal course of grief
Self-descriptive items that are answered true/false compromise the inventory

Assessment Tools
Hogan Grief Reaction Checklist (HGRC)
Designed to discriminate grief reactions from depression or anxiety
Can discriminate variability in the grieving process as a function of cause of death and time elapsed since death

Assessment Tools
Inventory of Complicated Grief (ICG)
Specifically targets symptoms of grief that are distinct from bereavement-related depression and anxiety, and predicts long-term functional impairments

Loss: universal human phenomenon-- any loss is a form of death and results in some degree of grieving
Primary Loss: significant loss such as death
Secondary Loss: resultant of the primary loss
Ambiguous Loss:
1. when a person is physically absent but psychologically present
2. when a person is physically present but psychologically absent
Mourning: social or cultural state or condition expressing grief-- can apply to both death and nondeath losses
Cultural Dynamics
grief is largely biological and common across societies, while mourning and bereavement are culturally based and vary between societies.

influenced by: beliefs, values about meaning, rules and conduct for behaving, support networks, religious practices and healers, individual or collectivist society, traditions and rituals, communication style, levels of acculturation and assimilation, ethnicity
Dia De Los Muertos
3 day celebration from Oct. 31st to Nov. 2nd
The dead are believed to visit the living
offerings are placed on gravesites to the dead loved ones, often favorite foods or possessions of the deceased
various adaptations to the same ritual worldwide
Death of a Spouse
One of the most emotionally stressful and disruptive events in life
There are more widows than widowers
Survivors face personal, physical, emotional, economic, social, career, family & community problems
The death of a spouse increases the chances of the death of the surviving spouse
Dealing with the Loss
Death of a Spouse
Immediate crisis intervention
Trans-crisis individual counseling and intervention
Spouse-survivor support group
Conjoint child-parent sessions

Death of a Child
The ultimate loss to endure
Parents have a hard time dealing with the fact that their child died before them
Still report longing for their children years later
Every parent suffers the loss of their child differently

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