Loss

1
Loss Attachment

• Enabling others cope with loss
• Core Module Course presented by
• Alec Deary Secretary, Fife Men Project
• Lambda Centre 5 South Fergus Place
• Kirkcaldy KY1 1YA
• Email alecd_at_btconnect.com

2
Training Programme

• Participants Professional workers within the
  care support agency-
• Aims
• To build upon professional practice and clarify
  established expertise
• To consider issues of enabling others to cope
  with loss
• Introduction to the core module 7141401

3
Training Programme

• 9.30 - 9.50 Introductions Groundrules
• 9.50 - 10.30 My Treasure Chest
• 10.30 - 11.00 Types of Loss
• 11.00 - 11.15 Morning Break
• 11.15 - 12.30 The Grief Wheel
• 12.30 - 13.15 Lunch

4
Afternoon Training Programme

• 13.15 - 14.00 The Task of Grieving
• 14.00 - 14.30 Complicated Grief
• 14.30 - 15.00 Moving On
• 15.00 - 15.15 Afternoon Break
• 15.15 - 16.00 Practice Case Studies
• 16.00 - 16.15 Ways of Helping
• 16.15 - 16.30 Handouts Evaluations

5
Training Groundrules

• Group Individual Responsibility For
• Confidentiality
• Participation
• Ownership
• Positive, Supportive Challenge
• Non Judgmental Attitudes
• Anti-Discriminatory Practice

6
Working Rules

• Safeguards are important for the success of your
  training course
• Detailed information on issues raised in
  discussion should not be discussed outwith this
  forum
• Participants make their own decisions on how far
  they are willing to share personal information,
  beliefs etc

7
Working Rules

• Everyone is entitled to their own views,
  attitudes and opinions
• Anyone is entitled to challenge these in a
  positive and supportive manner
• It is expected that any views which the group
  feel are sexist, racist, homophobic or in any way
  discriminatory will be challenged by the group or
  facilitator

8
Role of the Facilitator/Trainer

• The facilitator/trainer should encourage
  participants to
• Work together in a positive and creative way.
• Participate in as much of the group team building
  activity as possible
• Challenge matters relating to discrimination

9
Role of the Facilitator/Trainer

• Adhere to your services equity diversity policy
  statements
• Work within the safeguards agreed by the
  participants, especially in relation to the
  respecting of client, employee and employer
  confidentiality
• Ensure that the outlined aims and objectives of
  the training course are achieved

10
My Treasure Chest

• AIM
• To clarify your aims and experience
• To encourage self-exploration and information
  sharing
• To broach the important issues that will be
  integral to the course and your professional
  practice

11
Treasure Chest

• 1 My professional knowledge and experience of
  loss
• 2 My personal experience of loss
• 3 Personal skills and qualities I can share
• 4 What I hope to gain from the course
• 5 How I hope to use this experience
• 6 How I remain sane - my experience of support

12
Exploring Grief

• Examine your responses in your treasure chest -
  what emotional responses to grief are in there?
• What physical responses to grief are there?
• What psychological responses to grief are in your
  treasure chest
• How did you move on?
• What was unresolved about your grief?

13
Physical Reactions To Grief

• Numbness - (Also an emotional response)
• Palpitations - Rapid breathing
• Tightness in the chest
• Migraine and/or headaches
• Skin Rashes
• Fatigues and/or tiredness
• Gastric and/or bowel upsets

14
Emotional Responses To Grief

• Shock - Numbness -also a physical reaction
  Sadness - Despair - Loneliness - Pining - Longing
  - Anger - Guilt - Outrage - Confusion - Yearning
  - Anxiety - Relief - Helplessness - Hopelessness
  - Vulnerable - Sentimental - Etc...

15
Different Sorts of Loss

• Having children
• Adoption
• Children growing up
• Children leaving home
• Children developing relationships and forming
  partnerships
• Marriage

16
Different Sorts of Loss

• Divorce
• Separation
• Death of a pet
• Loss of innocence
• Loss of virginity
• Loss of face
• Loss of security

17
Different Sorts of Loss

• Becoming parents
• Becoming grandparents
• Still birth
• Abortion
• Miscarriage
• Cot Death
• Having a disabled child

18
Different Sorts of Loss

• Loss of faith
• Loss of bodily function - incontinence
• Loss of limb
• Loss of hearing/eyesight
• Loss of hair/appearance
• Ageing

19
Different Sorts of Loss

• Rape
• Unemployment
• Retirement
• Moving home, school, work
• Loss of income
• Loss of credit
• Theft, burglary

20
Self-Harm and its link with Substance Misuse
21
What is Self-Harm?

• Cutting
• Burning
• Overdosing
• Smoking
• Drinking
• Shopping
• Dieting
• Comfort Eating

22
Self-Harm?

• All of these behaviours are all injurious to
  self, depending on what the person gets from
  them, the frequency and motivation behind them.
• A better description for what we shall look at
  is the term Self Injury

23
Self-Injury

• Self-injury is any act that involves
  deliberately inflecting pain and or injury to
  ones own body not necessarily with suicidal
  intent
• Working With Self-Injury
• Arnold Magill 1996

24
Ways young people self-injure

• Overdosing.
• Rubbering.
• Hitting.
• Cutting.
• Burning with heat or corrosive substances.
• Pulling Hair.
• Picking Skin.
• Swallowing harmful substances.
• Inserting things under the skin.

25
Self-Injury is
26
Reality of Self-Injury
27
Question 1 Why Do people Self-Injure?

28
Why do people self-injure?

• Some reasons given are
• It helped block out despair
• To punish myself
• To know I was still alive, only the living
  bleed
• To release pressure
• So I could feel something, as I was numb inside

29
The Eight Cs Of S-H

• Coping and Crisis intervention
• Calming and comforting
• Control
• Cleansing
• Confirmation of existence
• Comfortable numbness
• Chastisement
• Communication

30
Motivation and Outcome

• Cutting
• Burning
• Overdosing
• Smoking
• Drinking
• Shopping
• Dieting
• Comfort Eating

• Coping and Crisis intervention
• Calming and comforting
• Control
• Cleansing
• Confirmation of existence
• Comfortable numbness
• Chastisement
• Communication

31
The Eight Cs Of S-H

• Coping and Crisis intervention
• Calming and comforting
• Control
• Cleansing
• Confirmation of existence
• Comfortable numbness
• Chastisement
• Communication

32
Experiences that lead to self-injury?

• Research shows that young people who self-injured
• Felt abusive life experiences had led them to
  self-Injury.
• In two thirds of cases, these had occurred in
  childhood.
• Nearly 50 per cent reported childhood abuse or
  neglect.
• Around 25 per cent referred to lack of family
  communication.
• Bristol Crisis Service 2001

33
Statistics

• Self-injuring is a very private act often done
  in secret, as a result there is very little
  research about self-injury.
• However the research that we do have, gives us
  some guidance as to what leads to self-injury.

34
Self-injury Prevalence In Young People

• Lowest figures show
• 1 in 100 five to ten year olds
• Rising to 1 in 15 teens
• This number increased significantly if the young
  person was found to be experiencing mental ill
  health, communication difficulties or serious
  life trauma.
• However like much research carried out about
  children the children themselves were never asked
  and these figures are the result of interviews
  with parents.
• National Statistics Office

35
Self-Injury Commonalities

• Self-Injury was found to be more common among
  young people who
• Were from lone parent families
• Were from single child families
• Where from families of four child or more.
• Had experienced increased stressful life events,
  e.g. parental separation, serious illness and
  abuse.
• Were raised with a family were unhealthy coping
  strategies were present e.g. drug or alcohol
  misuse
• National Statistics Office

36
When we think of self-Harm we
37
The Impact of You

• Your personal feelings, thoughts and fears around
  self-harm will greatly yet subtly affect the way
  you work with young people who self-harm.
• If your personal view is strongly entrenched you
  would need to address this before beginning
  self-harm work.
• Its not a case of compromising your personal
  views just a case of being fully aware of what
  your views are.

38
Question 2 What responses to self-Injury were
most helpful?

• Being believed
• Feeling as if they were being heard.
• Trying to understand the person behind the
  self-injury.
• Acceptance (the nurse that smiled)
• Patience
• Avoiding prejudice and stereotyping.
• Being given information about support.
• Help to find alternative to self-injury.
• Not being judged adversely.

39
Question 3 What might professionals who support
those who self-injure need?

• Knowledge in order to overcome fears and
  ignorance.
• Awareness of support services for clients and
  professionals.
• Empathy not sympathy.
• Adequate supervision and support for themselves.
• Understanding of the reasons behind self-injury
  and the alternatives.
• Recognition of professional limits.

40
When Does Self-Injury Begin?

• Although Self-Injurious behaviour often starts
  in adolescence, nearly a third of the people
  interviewed said that they had begun hurting
  themselves in childhood, often in a haphazard or
  superficial way. The youngest age of onset
  reported was six.
• Bristol Crisis Service 2001

41
Morning Summary

• Something Ive learned?
• Something I still want to know more about?

42
Working With Self-Harm

• Welcome
• Back
• Self-Injury Art Work

43
Fable

• It's only attention seeking.
• Self-Harming is often done in private and not
  shown to others, so is often not a very
  effective way of seeking attention, however
  Self-Harm always indicates that something in that
  person needs attending too.
• Louise Pembroke, Andy Smith The National
  Self-Harm Network, September 1996

44
Fable

• "It's self-inflicted so it's not serious."
• How severe a wound is doesnt necessarily equate
  to how bad a person feels.
• Louise Pembroke, Andy Smith The National
  Self-Harm Network, September 1996

45
Fable

• "Self-harmers are usually young people who grow
  out of it.
• Traditionally this has been the assumption yet
  there is no evidence to show young people "grow
  out" of it and self-injury can begin at any age.
• Louise Pembroke, Andy Smith The National
  Self-Harm Network, September 1996

46
Fact

• It can happen once, or many times.
• Some young people hurt themselves just once or
  twice. Other young people use self-harm to cope
  over a long period. They might hurt themselves
  quite frequently during a bad patch.

47
Fact

• young people do stop self-harming.
• Many young people stop self-harming - when
  theyre ready. They sort their problems out and
  find other ways of dealing with their feelings.
  It might take a long time and they need help to
  do this. But things can get better.

48
C.A.S.H

• Culturally
• Acceptable
• Self-harm
• One of the best ways of understanding the
  influence culture has on self-harming behaviour
  is to look at our own C.A.S.H.

49
Cultural Influences

• Its vital to remember Self-injury is not a new
  way of responding to distress.
• Self-harm, self-denial and self-purging is often
  sanctioned and even encouraged by some religious
  and cultural teachings going back centuries.
• Meeting the requirements of the national service
  frame work,
• Appendix Eight

50
Cultural Influences

• Modern cultural influences see many pop bands
  include self harm as part of their stage act and
  self-injury is often respected by young people as
  an accepted and even cool way of behaving.

51
Self-Injury Communication

• The skin is often used as an outward sign of what
  is going on inside. Cosmetics, tattoos and body
  piercing all provide a way of communicating who
  we are to others.
• Some young people use Self injury as a way of
  communicating an inward state of turmoil.
• Meeting the requirements of the national service
  frame work,
• Appendix Eight

52
Self-Injury In context

• Youre Working with
• Tracy
• Sukvinder and
• Tyrone
• What's your response?

53
Tracey

• Tracey has told us that she was feeling angry,
  bad, dirty, unloved and unheard. She stated that
  she felt invisible to others.
• others had betrayed me and my whole life had
  been controlled by others without regard for my
  feelings or wishes.

54
Tracey

• Tracey told us that by self-injuring she was
  expressing her feelings especially anger at
  other times self-injuring was helping her avoid
  unbearably painful feelings of loss.
• Sometimes she wanted to show the world she
  existed and was taking control.

55
Sukvinder

• Sukvinder's reason for self-injury stemmed from
  her change in role within the family leaving her
  with a diminished sense of choice and control.
• I had liked being the big sister and this all
  changed over night suddenly everyone was treating
  me like I was a little girl again no one
  respected me anymore.

56
Sukvinder

• Sukvinder said that self-injuring helped her
  express feelings of frustration and anger at the
  change in her life it also enabled her to release
  the unbearable pressure she felt.
• Id had to stop seeing Jamie and he is the one
  person who would have helped me through not being
  able to talk about what was happening just made
  everything so much worse. It was a way of
  showing me and I guess others that I wasnt fine

57
Tyrone

• Tyrone said I felt a failure, I was ashamed and
  angry because I couldnt keep my mum and sister
  safe.
• I was shouting my mouth of that I could support
  my mum and sister but inside I was terrified I
  would lose my mum and deep down I felt helpless
  and pathetic.

58
Tyrone

• Self-Injury seemed a safe outlet for the pain
  and anger I felt inside, at the time I felt I
  deserved to be punished in some way for letting
  people down by not protecting them. Things felt
  chaotic inside me and it was almost a sense of if
  I hurt myself it would stop me hurting others

59
Child Protection Issues

• What are your responsibilities to them?
• What are your agencies Procedures?

60
Responding to Self-Injury

• It takes a long time for a person to be ready to
  give up self-injury.
• Acknowledge that each step is a major
  achievement.
• Examples of very valuable steps might be
• Taking better care of the injury.
• Putting off harming for a day or an hour.
• Reducing the severity or frequency of the
  injuries even a little.
• In all cases more choice is being exercised the
  "hold" of self-injury is being loosened.

61
Responding to Self-Injury

• Don't always see stopping self-injury as the most
  important goal.
• A person may make great progress in many ways and
  still need self-injury as a coping method for
  some time.
• Self-injury may also worsen for a while when
  previously buried issues or feelings are being
  explored, or when old patterns and ways of living
  are being changed.
• This can be frightening but is understandable.

62
Responding to Self-Injury

• The poor self-esteem of young people who
  self-harm may mean that minor annoyance or shock
  on your part can be interpreted as barely
  contained hostility a potent environment for
  misunderstanding.
• Make your communication clear, concise and
  unambiguous.

63
Barriers to Responding Helpfully to Self-Injury

• For most professionals the biggest barrier is
  fear fear of how they will react when they see
  self inflicted injuries.
• Fear Shock Withdrawal
• Professionals Clients

64
Alternatives to Self-Injury

• Initially young people who self-injure need
  practical alternatives coupled with support and
  information to help them understand and reduce
  their self-injurious behaviour.
• Alternatives to self-injury can include
• Carry Safer Things stones, crystals, stress
  relieving squishy things.
• Writing and journaling.
• Collage work pick colours, pictures or phrases
  that express feelings.

65
Alternatives to Self-Injury

• Surfing the net again this keeps fingers and
  brain busy.
• Red felt tip pen
• Elastic bands
• Holding Red Ice!
• Dyeing hair.
• Keep both your hands and your brain occupied.
  Tiled puzzles the idea of restoring order, of
  being in control of something can help you get
  through the unsafe, unbalanced, scary times.

66
The Impact of Self-Injury

• Working with self-injury can have a detrimental
  effect upon professionals.
• How might working with self-injury affect you
  detrimentally?

67
Taking care of the professionals

• Working with self injury can resort in the
  professional experiencing
• Vicarious trauma
• Re-emergence of own trauma
• Feelings of professional insecurity, if
  self-injuring behaviour continues.
• Feeling they are working way beyond their
  professional competence.

68
Taking care of the professionals

• To combat this its vital that you receive
• Training.
• Professional supervision.
• Time to discuss the personal impact the work is
  having upon you.
• Peer support, its great to know youre not the
  only staff member with fear or concerns.
• If you are working with self-injury without the
  above support networks your practice could be at
  the least diminished, at the worst dangerous.

69
Jackie
70
Conclusion

• Self-harm is more common than we think, we may
  have all self-harmed in one way to cope with
  pressure.
• Our biggest barrier to working with self-harm is
  ourselves. Take time to consider your own
  experiences, feelings and belief systems and how
  they impact on your ability to work successfully
  with someone who uses self-harm around self-harm.
  
• Never be afraid to say no!
• If you are unable to work with self-harm for any
  reason you need to say so.
• Neither you nor the client will benefit from this
  kind of working relationship.
• Finally make a list of what skills and personal
  qualities you have that may assist someone who
  self-harms, you may surprise yourself.

71
Q A
72
Loss Social Isolation
73
Social Isolation
74
Infant loss

• We lose the total protection we once enjoyed as
  dependent babies

• But we become increasing able to undertake and
  achieve actions for ourselves

75
Throughout childhood

• The imperceptible loss of parental protection
  continues

• But we gradually develop skills which increase
  personal independence and self esteem

76
By Adolescence

• Young people are no longer excused personal
  failings, purely on the basis of age they have
  to assume responsibility for mistakes that in
  childhood, might have been forgiven due to
  inexperience.

• But the adolescent is able to explore many new,
  exciting enterprises and experience many new
  forms of personal relationships, previously
  denied to them

77
In early adulthood

• Each individual develops their optimum physical
  abilities and social confidence, and so can seek
  to attain their maximum prestige and status.

• Yet, adults find themselves in a competitive
  world where they are expected to assume many
  duties and roles which restrict their achievement
  and personal freedoms.

78
In middle age

• Greater wisdom and improved social performance
  can arise from the experiences of life

• Sometimes the sense of adventure diminishes some
  aspects of physical performance begin to decline.

79
The Grief Wheel

• Stages of grief
• Loss - Shock
• Protest
• Disorganisation
• Reorganisation
• Life function - assimilation

80
Your Reaction To Loss

• In small groups discuss how you felt when someone
  close to you died.
• 1 How you felt at the time of death - the day and
  the time afterwards
• 2 How you felt after the funeral

81
SHOCK

• Numbness
• Denial and Disbelief
• Emotions - unaffected, hysterical, euphoric
• Thinking - unaffected, slowed, chaotic, effected
• Activity - unaffected, slowed, superdrive
• Guilt - suicidal thoughts

82
Protest

• Sadness - Dreams Nightmares
• Anger - Yearning
• Guilt - Searching
• Fear - Preoccupation
• Relief - Physical Distress

83
Disorganisation

• Confusion
• Apathy Aimlessness
• Loss of Interest
• Restlessness
• Low Self-Esteem
• Anguish
• Depression

84
Disorganisation

• Anxiety
• Loneliness
• Concentration Memory Difficulties
• Sadness
• Loss of Meaning
• Loss of Faith Challenges to Value Systems -
  Inner Conflict

85
Disorganisation

• Hopelessness
• Suicidal Ideas
• Decreased resistance to Illness

86
Reorganisation

• Developing balanced memories
• Pleasure in remembering
• Control over remembering
• Return to previous levels of functioning
• Changed values
• New meaning in life
• Restored balance

87
The Task Of Grieving

• Task 1 Accepting the loss
• Task 2 Feeling the pain
• Task 3 Adjusting
• Task 4 Letting go

88
The Grieving Process

• What do you think are the most significant issues
  presented in the case study?
• How concerned are you about the subject and why?
• Where would you place the subject in terms of the
  Grief Wheel and the Tasks of Grieving?
• What help, if any, would you like to offer?

89
Our Flag

• AIM
• To enable you to consider your own feelings in
  the event of the death of someone close to you
• To consider that whilst you may suffer a loss,
  there are, however, small and apparently
  insignificant, gains which can result from that
  loss

90
Our Flag

• About Yourself
• 1 The aspect of your personality you like the
  most.
• 2 The aspect of your personality you like the
  least.
• About your relationship with.
• 3 The aspect of a relationship you like the
  most.
• 4 The aspect of a relationship you like the
  least.
• 5 The most difficult thing I would have to face
  in the event of their death
• About Moving On
• 6 In the event of their death, what I would be
  able to do

91
My Death

• 1 What would I like to do in the final six
  months?
• 2 What unfinished business do I have which I
  would like to complete (for example, sorting our
  finances, repairing relationships)?
• 3 Where would I like to die?
• 4 Who would I want to care for me in my final
  days, and why?
• 5 What arrangements would I make for my
  funeral?

92
Functions of Funerals

• Confirm the reality of the death viewing the
  body, saying farewell.
• Encourage the recognition and expression of
  emotions.
• Provide an opportunity to reflect on the
  deceaseds life.
• Provide the opportunity for action maintaining
  order in the face of chaos.

93
Functions of Funerals

• Allow family and friends, the social network, to
  come close and begin to reintegrate the bereaved
  person into the community.
• Can provide the context of meaning.
• Serve as a vehicle for rehearsal of ones own
  mortality.
• Confirm that community goes on in spite of death

94
Planning Your Own Funeral

• You are told that you have three months to live.
  For part of that time at any rate you will be fit
  enough to do what you can at the moment.
• How would you spend that time?

95
Planning Your Own Funeral

• How would you like your body to be disposed of?
  Cremation? Burial, Where?
• What form of commemoration would you like? Music?
  Poems or readings?
• Who would you want to be there?
• Who would you not want to be there?
• Is there to be a meal, or a party or sandwiches?

96
Planning Your Own Funeral

• Do you want a permanent reminder of your life and
  death a plaque or stone or tree, or a medical
  institution or library? If so, what would this be
  like?
• In 10 years time what would you want people to
  be saying about you if and when you came up in
  conversation?

97
Grief The Person With Learning Disabilities

• Define needs within the client group
• Seek to define the understanding of death
• How is grief expressed
• Outline the support you may have to give
• Find out about the resources that are available
  for the service user in relation to loss and
  bereavement

98
What Is Complicated Grief?

• In terms if the Grief Process -
• Absent grief There appear to be no signs of
  grief in a person following a bereavement
• Delayed grief The person puts off embarking on
  the Grief Wheel, but then finds themselves
  overwhelmed with grief after a number of months

99
What Is Complicated Grief

• Inhibited grief There are some signs that the
  person is grieving, but these are less than you
  would expect, given the nature of the loss.
• Unbalanced grief the person is clearly grieving,
  but when you meet them you are struck by the
  expression of one particular emotion.

100
What Is Complicated Grief

• Chronic grief
• The person appears to have been stuck for a long
  time in one particular part of the Grief Wheel

101
What Is Complicated Grief

• In Terms of the Task of 2 Grieving
• Task 1 not tackled The person is not
  acknowledging the reality of the loss
• Task 2 not tackled The person has not allowed
  themselves to experience the pain of grief
• Task 3 not tackled The person is unable to
  adjust to living without the person
• Task 4 not tackled The person is unable to let
  go. And does not therefore, have the energy to go
  forward and rebuild a life for themselves

102
Pointers To Complicated Grief

• 1 It feels as if the loss happened yesterday,
  although when you ask about it, you find that it
  was a number of years ago.
• 2 You feel that the emotion expressed by the
  person is out of proportion to the loss they are
  describing.
• 3 The person simply avoids talking about the
  loss, although they are happy to talk about other
  things.

103
Pointers To Complicated Grief

• 4 The deceased is never mentioned, and there
  are no photographs or mementoes on display.
• 5 The person has made radical changes in their
  life shortly after they were bereaved.
• 6 The person has phobias about illness and
  death, or is convinced that they have a
  life-threatening illness. They may have some of
  the symptoms, though medical investigations prove
  to be negative.

104
Pointers To Complicated Grief

• 7 The deceaseds belongings remain untouched,
  they are talked about in the present tense, or
  the bereaved is very aware of their presence.
• 8 The bereaved keeps their grief very close to
  them. They are concerned that others will fail to
  understand how special the deceased person was
  and still is.

105
Pointers To Complicated Grief

• 9 There is an unacceptable sadness, repeated
  episodes of depression, or repeated suicide
  attempts.
• 10 There are repeated relationship
  difficulties.
• 11 There is long history of alcohol or drug
  abuse.

106
Ten Ways To Help The Bereaved

• 1 By being there
• 2 By listening in an accepting and
  non-judgmental way
• 3 By showing that you are listening and that
  you understand something of what they are going
  through
• 4 By encouraging them to talk about the deceased

107
Helping The Bereaved

• 5 By tolerating silences
• 6 By being familiar with you own feelings about
  the loss and grief
• 7 By offering reassurance
• 8 By not taking anger personally
• 9 By recognising that you feelings may reflect
  how they feel
• 10 By accepting that you cannot make them feel
  better

108
Childrens Reactions To Loss

• Children tend to be quite resilient
• Children need to have the realities of
  bereavement explained in terms that they can
  understand, and given time to express their
  feelings of loss
• Children tend not to enter into depressive
  behavioural episodes
• Adolescence does however, bring reactive adult
  behaviour such as depression

109
A Framework For Therapy

• Assessment -
• Observe Collect Information
• Gather information about the situation, the
  person, their feelings and behaviour consider
  where the person is in relation to the Grief
  Wheel and Tasks of Grieving

110
Assessment

• Define and agree the problem
• Discuss the apparent problems with the person and
  agree what the wish to work on and in which order
  of priority

111
The Life Map

• Individually, draw a line to represent the course
  of your life, and put on it any events which were
  particularly significant to you.
• Instead of words you may wish to use pencil
  drawings or symbols
• Now share your life map with another participant
  on the course
• Are there any similar life events?

112
Therapy - Hypothesis

• Make your best guess as to the root of the
  problem
• Why are they stuck?
• What are the acute issues?

113
Treatment Planning

• Decide what, if any, intervention needs to
  achieve. Choose what course of action is most
  likely to be effective most quickly and simply

114
Intervention

• Action the agreements
• Do it!

115
Evaluation

• Assess whether the information has been
  successful.
• Discuss with the person and decide whether
  further help is needed.
• If so, decide how it can be most appropriately be
  given.
• If not, help the person back to their own support
  systems.

116
Day Two

• Welcome back Review
• Case Study
• Real Play
• Techniques
• Evaluation
• Next Steps

117
Some Helpful Techniques

• In Assessment - The Life Map
• Facing the first two tasks of grieving
• Photographs and mementoes
• Dustbins and china cabinets
• Painting and drawing
• Cataloguing the springs
• Things I miss/ Things I do not miss
• Flag exercise
• Challenges thinking time

118
Resolving Particularly Difficult Emotions

• Anger
• Letter writing and disposal
• Talking to the offender
• Painting and drawing
• Strenuous physical activities

119
Facing Task of Grieving

• Task 3 Adjusting to an environment without the
  deceased
• Tackling practical tasks -
• Challenges -
• Records of achievements
• Timetables
• Lists

120
ATTACHMENT  

121

• Human relationships, and the effects of
  relationships on relationships, are the building
  blocks of healthy development. From the moment of
  conception to the finality of death, intimate and
  caring relationships are the fundamental
  mediators of successful human adaptation.
• Shonkoff Phillips 2000

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What is Attachment?

• The need to form a close bond with another human
  being.
• Biologically, it serves to offer protection.
• Attachment behaviours arise when threat is
  evident.
• Attachment behaviours seek to increase proximity
  to the caregiver in order that anxiety may be
  allayed.
• Attachment figure offers a secure base
• This presupposes that the attachment figure is
  available, physically /or psychologically.

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Importance of attachments

• Attachments are related to security / insecurity
• Internalised primary relationship(s)
• Responsive/sensitive/
• caring parent
• secure attachment
• Unresponsive / insensitive/
• uncaring parent
• insecure attachment

125
Importance of Attachment Attachment is
essential for

• Self esteem and identity
• Development of views on others and the world
• Ability to develop relationships empathy
• Cognitive development
• Ability to regulate emotions
• Social development
• Behavioural control

126
Importance of Attachment essential for

• Attainment of full intellectual potential.
• Ability to think logically
• Development of a conscience.
• Ability to trust others.
• Ability to become self-reliant.
• Ability to cope with fear and worry, stress and
  frustration developing coping skills
• Reduce feelings of jealousy

127
Attachment

• 50 of what we need to know for life is learned
  in our first year of life!!
• 25 second year
• 25 the rest of our lives!

128
The Development of Attachment

• Interaction Determinants of
• Attachment Security
• Synchronicity
• Warmth
• Involvement
• Responsiveness
• Sensitivity
• Inter-subjectivity
• Consistency
• See Handout

129
Attachment and substance misuse

• There are significant associations between
  attachment representations and reports of illicit
  substance use
• (Caspers et al, 2006)
• Individuals identified with attachment problems
  have a higher incidence of substance misuse
  problems

130
Attachment and recovery

• Individuals identified with attachment problems
  reported low rates of participation in treatment,
  despite substantial problems with substance
  misuse/dependence
• The process of promoting recovery may also rely
  heavily on attachment. Assessment of both
  substance use problems and attachment may improve
  likelihood of successful recovery from substance
  use problems.
• (Caspers et al, 2006)

131
What is Attachment disorder?

• A condition in which individuals have
  difficulties forming genuine, loving, lasting and
  intimate relationships.
• Leads to significantly higher levels of
  emotional, cognitive and social difficulties,
  including developmental delays, behaviour
  disorders, mental health difficulties and
  antisocial and criminal behaviour.

132

• Parental/Caregiver influences
• Abuse and / or Neglect
• Ineffective, insensitive, inconsistent
  parenting/care
• Substance misuse
• Mental health issues and psychological
  disturbances of parent(s)
• Intergenerational attachment difficulties
  history of separation, loss
• Unwanted pregnancy
• Prolonged absence desertion, prison
• Sudden separation from carer/parent
  (bereavement/illness of mother imprisonment,
  abandonment)

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• Environmental influences
• Violence victim and/or witness
• Poverty
• Multiple and/or frequent moves between care
  placements
• Multiple caregivers
• High stress marital conflict family
  disorganization and chaos violent/dangerous
  community

134
Contributing Factors

• Child influences
• Premature birth
• In utero trauma e.g. exposure to drugs or alcohol
• Birth trauma
• Medical conditions unrelieved pain e.g. inner
  ear.
• Hospitalizations separation and loss

135
Risks associated with substance misuse

• Parental disharmony
• Violence
• Both parents drinking problematically
• The drinking taking place within the family home
• .

136
Risks associated with substance misuse

• Possible adverse impact on abilities to parent
  and bond
• e.g. on responsiveness, involvement, consistency,
  synchronicity etc

137
The child of a substance misusing parent may feel

• Shameful, unworthy, unloveable
• Ignored, unimportant
• the keeper of secrets
• Others are unavailable, cold, uncaring,
  disinterested scary, confusing
• Responsible for the parent
• - parent child roles are switched
• - overentwinement confusion of feelings

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The child of a substance misusing parent may feel

• out of step
• Frightened
• - high levels of generalised anxiety left
  unsoothed
• Anger / Rage
• frozen numb unfeeling
• Continuing sense of neediness

139
Patterns of Attachment

• Organised
• Secure
• Insecure - Avoidant
• - Ambivalent
• Disorganised
• Disorganised/disoriented
• See Handout

140
Recognising Attachment Disorder Traits and
Symptoms (1)

• Emotional
• Inappropriately demanding or clingy
• Intense anger/resentment and rage, irritable,
  inappropriate emotional responses
• Poor impulse control inability to regulate their
  emotions e.g. anger/rage outbursts
• Indiscriminately affectionate with strangers
  yet-
• Refusal to receive or give affection to those
  closest lacks genuine affection with primary
  caregivers

141
Recognising Attachment Disorder Traits and
Symptoms (2)

• Behavioural
• Aggressive and abusive / violent (to others
  or/and self)
• Destructive e.g. property or possessions fire
  setting
• Restlessness constant need for stimulation and
  activity (often leading to antisocial behaviours)
  poor attention span/concentration
• Can act as if their new carers were responsible
  for their past abuse and hurt
• Obvious lying (crazy lying)

142

• Early/inappropriate sexual activity
• Stealing
• Preoccupation with fire, blood, weapons, death or
  gore dark side of life

143
Recognising Attachment Disorder Traits and
Symptoms (3)

• Social / Relationships
• Difficulty in forming/maintaining friendships
• Lacks trust controlling (bossy) fights for
  control of situations
• Blames others for their own actions, mistakes or
  problems

144
Recognising Attachment Disorder Traits and
Symptoms (3)

• Causing emotional pain to others
  victimizes/bullies cruelty
• Superficial and charming with strangers
• Avoids asking for help, being loved do not enjoy
  receiving praise

145
Recognising Attachment Disorder Traits and
Symptoms (4)

• Developmental/other
• Lacks cause and effect thinking
• e.g. consequences
• Lack of conscience or remorse seeming inability
  to experience remorse or sincere regret for their
  actions
• Abnormal/odd eating patterns
• (gorging, stealing or hoarding food, refusing
  to eat particularly in the presence of others)
  reflecting early failures of nurturing and
  repeated experiences of hunger and neglect

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• Accident prone high pain tolerance
• Maintain a very shameful, negative concept of
  themselves (often feeling overwhelmed by shame)
  Self is worthless, bad, unloveable
• (negative internal working model of self,
  others, world)

147
Possible roles substances may play for a young
person with attachment difficulties

• Modelled behaviour from parent(s)
• - as coping mechanism, mood enhancer
• Self- medicating
• - numbing or obliteration of feelings
• Way of challenging parents/system
• - attack express distress escape
• Form of anti-social adjustment
• Form of self-harm
• - where unable to vent anger outwards towards
  parent

148
Parents, Carers (and services) often feel

• emotionally exhausted, helpless, demoralized
• angry, frustrated or burnt out
• sense of failure
• inadequate and guilty
• manipulated or abused
• controlled by the antics of the child can cause
  withdrawal

149
Parents, Carers (and services) often feel

• systems become critical of parents
• Danger of pathologising the family
• parents appear to be hostile and frustrated

150
Effective interventions

• The overarching purpose of attachment
  interventions is to help the child/young person
  resolve a dysfunctional attachment. The goal is
  to help the child bond to the parents/carers and
  to resolve their fear of making and breaking
  contact, loving and being loved.

151
Elements of effective interventions

• Willingness to be open, flexible, and draw upon a
  number of strategies and approaches -
  integratively
• Ability to sit with and face the intensity and
  depth of traumatic feelings that these young
  people have kept hidden together
• Use the relationship itself to model healthy
  relation-shipping
• Collaborative and effective inter-agency working
• See the young person as a person, not a thing to
  be fixed

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Some main goals include

• Developing reciprocal relationships trust
  bonding
• Learning about, and modulating feelings
  emotions
• Developing internal control
• e.g. coping skills, impulsivity
• Resolving early losses and rejections

153
Some main goals include

• Re-doing missed developmental stages
• Developing self-esteem and respect
• Learning acceptable responses to external
  structures and rules
• Feeling safe and belonging

154
Some main goals include

• There is a significant relationship between
  attachment style and substance misuse re.
• Childhood victimisation
• Adult perpetration
• Therapeutic / service engagement

155
END OF PRESENTATION

• Thank you!

156
References

• Kristin M Caspers, Rebecca Yucuis, Beth Troutman
  and Ruth Spinks (2006) Attachment as an
  organizer of behavior implications for substance
  abuse problems and willingness to seek
  treatmentSubstance Abuse Treatment, Prevention,
  and Policy 2006, 132     

157
Thinking About Changed Roles

• Lists
• Exploring changed relationships
• Check
• Role Play
• Sculpts
• Pin People Maps

158
Tackling Task 4

• LETTING GO
• How I will remember you
• Goodbye letters
• Special memorial
• Hopes and fears about the future

159
Review Evaluation

• Thank you for attending the course
• Should you wish to have a personal word with the
  facilitator/trainer, please do not hesitate to do
  so
• Please complete part one of the evaluation form -
  this helps us plan further training
• The second part of the form should be shared with
  your line manager at supervision

160
Reference Material

• Your training pack contains all the information
  we have used today
• In addition the PC disc has reference material
  and internet links relevant to your course of
  study
• Todays trainer/facilitator can be contacted
  through the Fife Men Project