Grief & Grief Counselling

Types of Loss
1. Physical
  1. Tangible
  2. Includes the death of a significant other and loss of valued possessions (lands of indigenous people)
2. Symbolic
  1. May include the loss of a previous role or status, or lost opportunityies
  2. Eg. Divorce, retirement
3. Ambiguous
  1. May be physical and symbolic
  2. Absence of public validation or recognition of loss
  3. Public visibility-invisibility; acceptability-unacceptability
Loss Associated with Own Chronic Illness
1. Loss of control over body
2. Loss of control over disease
3. Loss of identity
4. Loss of independence
5. Loss of social support
6. Loss of certainty - over own life and health
Bereavement
1. refers to the objective situation of an individual who has recently experienced the loss of someone or something significant and of personal value.
Grief
1. is the emotional (affective) response to that loss, e.g., sadness, anger, helplessness, guilt
Mourning
1. refers to the acts of expression of grief. Culturally defined.
Components of Grief
1. Somatic experiences
  1. physical experiences
    1. Somatic Expressions of Normal Grief
      1. Bodily weaknesses, which includes many elements of depression, Hollowness in stomach, Oversensitivity to noise, Lack of energy, Sleeplessness, Dry mouth, Muscle weakness,Tightness in chest and throat, Breathlessness, Depersonalisation
2. Cognitive experiences
  1. thoughts, beliefs
    1. Cognitive Expressions of Normal Grief
      1. Preoccupation with the image of the deceased person or how things were prior to the loss, Hallucinations, Helplessness, Disbelief, Confusion, Impaired concentration
3. Affective experiences
  1. emotional experiences
    1. Affective Expressions of Normal Grief
      1. Sadness, Guilt, self-reproach, Anger, Anxiety, Loneliness, Fatigue, Shock, Yearning, Numbness
4. Behavioural experience
  1. Behavioural Expressions of Normal Grief
    1. Daily activities show change, Sleep and appetite disturbances, Crying, Social withdrawal, avoidance, Difficulty in initiating or maintaining behaviours, Restless overactivity, Sighing, Absent-minded behaviour
Models of the Normal Course of Grief
1. Process/Phase Model
  1. Passive movement through a number of inevitable stages
    1. A disrupted concept
2. Task Models
  1. More active process
    1. The bereaved person negotiates a series of tasks in relation to their loss
Phase Model of Normal Grief (Stroebe & Stroebe)
1. First phase: Numbness, shock, disbelief
  1. Sense of unreality, Most pronounced when totally unexpected, Possibly gives time to mobilize resources, May appear unaffected because of the failure to quite grasp the change, But reality of absence leads to lessening of denial
2. Second Phase: Yearning and Protest
  1. Somatic and Cognitive experiences
    1. Awareness of reality, Extreme psychological distress and physiological arousal, Searching for the deceased (vigilance), Physical symptoms, elements of depression, choking, breathlessness, crying, loss of appetite, stomach ache, chest pains. Preoccupation with the image of the dead person, daydreams of interactions with dead person, hearing or seeing them (hallucinations).
  2. Affective experiences
    1. Yearning. Guilt, self-reproach and trying to understand their contribution to the death, self- accusations of negligence and exaggerations of small omissions, low self-esteem, helplessness. Anger and hostility towards others.
  3. Behavioural experiences
    1. daily activities change, restlessness, lack of capacity to initiate and maintain organised patterns of behaviour. Activities lose significance in absence of other person.
3. Third Phase: Despair
  1. Despair – searching abandoned, despair that anything will be meaningful again, apathy, depression and withdrawal. Permanence of loss is recognised – thus may be even more devastating than earlier time. Inability to concentrate or start new things.
4. Final Phase: Recovery and Restitution
  1. Growing acceptance of changed situation, more frequent positive feeling, requires effort, recurrence of old symptoms. New identity, re-establish old friendships, make new ones. Frequently requires effort to regain purpose, adopt new roles, manage loneliness. More realistic (not idealised) memories of the dead person.
Worden’s (1982) Four Core Tasks of Resolving Grief
1. !. To accept reality of loss
2. 2. To experience the pain of grief
3. 3. To adjust to an environment in which the deceased in absent
4. 4. To withdraw emotional energy from the deceased and reinvest in other relationships
Dual Process Model of Grief (Stroebe & Schut, 1999)
1. Oscillation between two contrasting modes of functioning.
  1. “Loss orientation” – the griever engages in emotion- focussed coping, exploring and expressing the range of emotional responses associated with the loss.
  2. “Restoration orientation” – griever engages in problem- focused coping and is required to focus on the many external adjustments required by the loss, including diversion from and attention to ongoing life demands.
Time Course of Grief
1. People may get used to being without their loved one, but it is most usual that they continue to have an emotional involvement with the loved one – don’t really break bonds
2. In this sense, grief never ends, but rather changes.
3. Carnelley et al (2006) found that people continue to experience memories and have conversations about their deceased spouse beyond 4 years after the loss. As long as 20 years after the loss, the typical respondent still thought of their spouse once every week or two and had a conversation about him or her on average once a month.
Trajectories Through Grief
1. Bonanno et al (2002) identified five distinctive trajectories or patterns of grief: Common grief or recovery (11%), Stable low distress or resilience (46%), Depression followed by improvement (10%), Chronic grief (16%), Chronic depression (8%)
Determinants of Outcome of Grief
1. Bonanno et al (2004) found that the highest levels of distress were exhibited when:
  1. There were high levels of personal dependency prior to the death
  2. A lack of expectation or psychological preparation for the loss
2. Worden (2008) identified seven factors determining outcome:
  1. The extent of the loss physically, psychologically and spiritually, The nature of the attachment, Mode of death (or loss) , Historical antecedents, Demographic and personality variables, Social variables – social support, sociocultural and cultural variables, Concurrentstressors
Pathological (Complicated) Grief
1. An unsatisfactory concept. The range of normal grief is so wide.
  1. But when it continues to interfere with life for a prolonged period, or a person falls into an unabated depression, commits suicide, or suffers health consequences, the notion of pathological grief may be useful.
Persistent Complex Bereavement Disorder (DSM5)
1. Described as a combination of separation distress and cognitive, emotional and behavioural symptoms that can develop after the death of a significant other;
2. The symptoms must last for at least 12 months in adults
3. And cause significant impairment in social, occupational and other important areas of functioning;
4. Symptoms may include: sleep disruption, substance abuse, depression, compromised immune function, hypertension, cardiac problems, suicide, and work and social impairments.
Maladjusted Outcomes
1. Physical
  1. General ill health and symptomatology
  2. Psychosomatic disorders – immune function impairment and corticosteroid effects
  3. Death
2. Psychosocial
  1. Psychiatric and other psychosocial disorders, e.g., • Anxiety states • Shoplifting • Depression (suicidal thoughts and actions)
  2. Altered relationship patterns – e.g., over-protectiveness of children
  3. Vulnerability to loss – cope less well with future loss
  4. Anniversary phenomenon – re-awakened grief (I think normal rather than pathological)
Psychoanalytic Theories of Grief
1. Freud proposed that: Love is conceptualised as the attachment of libidinal energy to the mental representation of the loved person. The psychological function of grief is to free the individual from these ties to the deceased.
2. Grief work – rechanneling of intense feelings of attachment, process of reliving and working through past events which involved the deceased and the survivor so that the survivor can work out how they could do similar things with some-one else.
Attachment Theory and Grief
1. Role of attachment in children
  1. What happens when attachment figure not present in children (protest – despair – detachment)
2. Attachment in adult life
  1. When adult attachment figure not present a similar detachment process is engaged in
Behavioural Approach
1. Grief and loss of reinforcement
2. Loss of company - loneliness
3. (Doesn’t account for different feelings when some- one is away but not dead)
Stress and Crisis Models
1. Initial crisis throws the individual into a state of helplessness where coping strategies are no longer effective in mastering the problem.
2. Defences are weakened. But the crisis can not continue and the individual must adapt over time and develop new coping strategies.
Role of Counselling
1. Normalise the diverse emotions of grief (anger, helplessness, sadness)
2. Normalise the unusual experiences of grief (e.g., hallucinations)
3. Support the experience and expression of feelings, clarify ambivalent feelings – removing guilt
4. Provide time to grieve
5. Assist living in the presence of the loss
6. Assist in finding new ways to gain pleasure in life and new roles (behavioural interventions, problem solving)
7. Assist in looking at positive rather than negative aspects of situation (cognitive restructuring, CBT)
8. Exposure therapy – overcoming avoidance of reminders that limit moving forward.
9. Provide continuing support
10. Identify grief responses that are not normal and treat or refer
11. Effectiveness of Grief Counselling
  1. Recent debate in the literature has questioned the effectiveness of grief counselling. But the most comprehensive and appropriate analysis shows that grief counselling is helpful, especially for self-referred clients and for the recently bereaved (Allumbaugh & Hoyt, 1999; Larson & Hoyt, 2007)
Supporting a Grieving Person
1. There is no right or wrong way to grieve – avoid telling the bereaved what they should be feeling Grief may involve extreme emotions – don’t judge or take grief reactions personally. There is no set timetable for grieving - don’t pressure bereaved to move on
2. Listen with compassion – accept an acknowledge feelings, offer comfort without minimizing the loss. Offer practical assistance – take the initiative as the grieving person may not wish to impose. Provide ongoing support – be there for the long haul. Watch for warning signs – difficulty functioning in daily life, extreme focus on death, take talk of suicide seriously

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