A PSYCHOLOGICAL APPROACH TO COPING WITH LOSS

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A PSYCHOLOGICAL APPROACH TO COPING WITH LOSS
BEREAVEMENT

• DR LORNA ROBBINS DR ANNA SAMPSON
• CLINICAL PSYCHOLOGY LEARNING DISABILITY SERVICE

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Aims

• To reflect upon models of loss bereavementand
  how these might apply to people with learning
  disabilities.
• What is different in supporting those with
  learning disabilities through a grieving process,
  and what our role might be within that?
• How Learning Disabilities Services in LPFT can
  help.

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Bereavement

• The loss of a loved one is one of the most
  intensely painful experiences any human being can
  suffer, and not only is it painful to experience,
  but also painful to witness, if only because we
  are so impotent to help
• (Bowlby, 1980, p7) A normal human process

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Loss Bereavement

• Some definitions ...
• Loss not having something you once had.
• Bereavement Loss through death of someone you
  had a relationship with.
• Grief psychological physiological reactions to
  loss
• Mourning the process following loss (both
  conventions and emotions)

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Different types of loss

• External (moving house, loss of friends or
  carers)
• Internal (feelings, ideas, adapting to changes)
• Developmental (biological, social, aims goals)
• Idiosyncratic (traumas, accidents)

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What usually happens after a loss?

• The way we actively grieve or mourn
• is shaped by the institutions and
• norms of our social group.

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Factors that can affect the meaning and response
to loss

• Past history
• Current circumstances
• Circumstances of the loss
• Beliefs (Cultural, religious or social)
• Coping styles
• Social and cultural context
• Cognitive development
• Age
• Gender

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There is a commonality in responses to
bereavement and loss
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Grief responses (Worden, 1991, p.21-36)
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Kubler-RossShuchter Zisook (1993)

• Stages of Grief /Loss

Loss
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THE GRIEF WHEEL Grief Education Institute,
Denver, 1986
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Disenfranchised Grief

• Historically people with learning disabilities
  were not perceived to have individual needs, or
  to be aware of the thoughts and feelings of
  either themselves or those around them.
• By the 1980s people such as Maureen Oswin began
  to discuss the normality of grief and argued that
  people with learning disabilities have the same
  right to grieve as anyone else and proposed some
  guidelines for facilitating this.
• However the bereavement needs of some people with
  learning disabilities are still not recognised.

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some research findings

• Emerson (1997 ) reported that 50 of the people
  with learning disability who presented with
  sudden emotional and behavioural difficulties had
  experienced the recent death of a person close to
  them.
• The death of a family member can trigger a need
  for crisis intervention and cause symptoms of
  complicated grief for people with learning
  disabilities (Bonell-Pascual et al. 1999 Dodd et
  al. 2005 Emerson 1997Kloeppel Hollins 1989
  MacHale Carey 2002).
• 54 of people with learning disabilities do not
  attend their parents funeral (Hollins
  Esterhuyzen 1997). Additionally, people who have
  been excluded from the funeral or who have not
  been told about the death for some time after the
  event may need the professional help of a
  bereavement counsellor (Read 2000).

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research findings cont

• Aberrant behaviours and psychiatric disturbance
  are more evident in this population.
• Behavioural expressions of grief can be
  inadvertently misdiagnosed as issues of disturbed
  challenging behaviour or as evidence of
  psychiatric disturbance. (MacHale Carey, 2002)
• People with learning disability may exhibit
  reactions to grief which are labelled as
  'challenging behaviour' or 'psychiatrically
  disturbed' because of their limited comprehension
  and ability to express grief (Hollins
  Esterhuyzen 1997).
• Sinason (1992) suggests that people with learning
  disabilities adopt what she calls a handicapped
  smile to adapt to societys need not to see
  their pain.

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What is different about loss in LD?

• Exposed to more loss and change events
• Less control and choices and ways of expressing
  that pain
• May not be told about their loss, or find out in
  an unhelpful way
• May be excluded from the process of loss/change
• May be encouraged to recover from the change/loss
  quickly and not be allowed the time to
  acknowledge, understand and deal with it

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Factors which may exacerbate the grief process
of loss
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Unacknowledged loss connected to

• Moving home
• Relationships attachments
• Sexuality
• Loss of a child
• Loss of friends
• Loss of staff
• Loss of choice
• Loss of dignity
• Loss of autonomy
• Loss of individuality

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Case study
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Sarah

• Historical Context
• Presenting Problems Presentation
• Psychological Formulation
• Theoretical Frameworks
• Psychological Intervention
• Discussion

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Theoretical Framework

• Psychoanalytic theory (Freud)
• Attachment theory (Bowlby)
• Person centred (Worden)
• Cognitive Behavioural Therapy (Beck)
• Narrative Therapy (White)
• Systemic Approaches

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What should I do if Im concerned about someone I
care for
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When should you be worried?

• When reactions are excessive, disproportionate or
  protracted
• Inappropriate emotional reactions
• Protracted apathy, increased irritability or
  aimless hyperactivity
• Sudden unaccountable mood change
• Serious suicidal intent
• Changes in behaviour
• Seem to be profoundly missing the deceased person
  
• Social withdrawal
• Assessed as not coping with bereavement.

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When to refer on

• Most grieving people cope with their loss in
  their own social circle (Worden,1991), however if
  more support is required.
• Gain support from mainstream services.
• If concerns remain a referral can be made to LPFT
  Learning Disability Service single point of
  access.
• Where the bereavement is complicated in some way,
  or the bereavement occurred over one year
  previously, psychological intervention may be
  most appropriate.
• Psychologists may work directly with the
  individual (e.g. psychotherapy), with the
  individual and their family, or indirectly with
  staff / carers (e.g. consultancy approach).

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How can you help?

• Preparatory and supportive work for thinking
  through issues related to death/loss/change
• Listen to the person.
• Where possible keep the person informed and
  involved about any changes. What do they think
  about it?
• Build a life storybook with individuals which
  looks at changes in their lives and keep adding
  to it.
• Help the person to collate items of meaning from
  the past.
• Help individuals to develop an awareness of the
  normal life cycle, (i.e. birth-child-young
  adult-middle age-old agedeath).

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References

• Bonell-Pascual E., Huline-Dickens S., Hollins S.,
  Esterhuyzen A.,Sedgwick P. et al. (1999)
  Bereavement and grief in adults with learning
  disabilities. A follow-up study. Br J Psychiatry,
  17534850.
• Beck, A.T. (1976) Cognitive Therapy and the
  Emotional Disorders. New York International
  Universities Press.
• Bowlby, J. (1980). Attachment and loss Loss,
  sadness and depression. Vol. 3. New York Basic
  Books.
• Dodd P., Dowling S. Hollins S. (2005) A review
  of the emotional psychiatric and behavioural
  responses to bereavement in people with
  intellectual disabilities. J Intellect Disabil
  Res, 49 53743.
• Emerson P. (1977) Covert grief reactions in
  mentally retarded clients. Mental Retardation,
  15 467.
• Freud S. (1917) Mourning and melancholia. In
  Strachey J., editor. Standard edition of the
  complete psychological works of Sigmund Freud
  Vol. 14. London, Hogarth Press.
• Hollins S. Esterhuyzen A. (1997) Bereavement
  and grief in adults with learning disabilities.
  Br J Psychiatry, 170 497501.
• Kloeppel D. Hollins S. (1989) Double handicap
  mental retardation and death in the family. Death
  Studies, 13 31.

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Cont

• MacHale R. Carey S. (2002) An investigation of
  the effects of bereavement on mental health and
  challenging behaviour in adults with learning
  disability. British Journal of Learning
  Disabilities, 30 1137.
• Read S . 2000. Bereavement and people with
  learning disabilities. Nursing and Residential
  Care, 2(5), 230-234
• Sinason, V. (1986) Secondary mental handicap and
  its relationship to trauma. Psychoanalytic
  Psychotherapy, 2, 131 -154
• Sinason, V. (1992) Mental Handicap and the Human
  Condition. London Free Association Books.
• Worden, J. W. (1991). Grief counselling and grief
  therapy A handbook for the mental health
  practitioner (2nd ed.). New York Springer
  Publishing.
• White, M. (1989) Re-authoring Lives. Adelaide
  Dulwich Centre Publications.
• White, M Epston, D (1989). Literature Means to
  therapeutic ends. Adelaide Dulwich Centre
  Publications. (Republished 1990) as Narrative
  Means to therapeutic ends. New York Norton)