Thinking about Losses and Grief Differently

1
Thinking about Losses and Grief Differently

• Universal phenomena
• Is challenging and distressing
• But it can be transformational, and most of us
  overtime develop skills and attitudes that
  assimilate our losses in our lives in a
  functional manner

2
Psychotherapy and Psychotherapists

• Often miss or fail to identify the presence of
  loss and grief unless of course the intake
  tells us the person is coming for bereavement
  counselling
• However, grieving a death of a loved one is
  similar to other losses and may invoke similar
  responses

3
Loss Responses Non-Death and Death

• We experience
• Sadness, we confront and avoid painful emotions,
  we attempt to reorganize our world, we struggle
  with connection and disconnection
• Our new losses trigger material from our old
  world (attachment theory) we year to return to
  these preloss circumstances
• We try to make sense of losses, or make meaning,
  we are paralyzed, we are transformed, and
  struggle to integrate losses into our lives

4
Loss and Grief Terminology

• Bereavement period of sorrow following the death
  of a significant other
• Loss real or perceived deprivation of something
  deemed meaningful (death or non-death related)
• Grief an emotion generated by an experience of
  loss characterized by sorrow and/or distress, and
  the personal and interpersonal experience of
  loss.
• Coping Time limited reaction in which an event
  is endured or momentarily managed with coping
  skills
• Loss Adaptation Process of adjusting to
  loss/grief (active process of modification,
  revision, reorganization, and assimilation over
  time

5
Changing Ideas

• Not linear - there is not necessarily a
  characteristic set of processes that each griever
  experiences or phases he / she must pass through
• Not abnormal dont necessarily need to
  detach/sever from object we are grieving over
• Grief doesnt necessarily end
• We are not passive victims over our grieving
• We must assume personal, social, familial,
  historical, and culture, influences our grieving
  and healing but not necessarily get caught by
  them

and all grievers are the same!
Not all losses, all grief
6
Grief is an individual phenomena!
Moving Away from Linear Models
7
Lets Chat about these Cases

• Kito
• Elena
• Jane
• Billy

8
The Counseling Professional Working with Loss and
Grief

• What loss and grief loss requires the counselor
  to do
• Prioritize uniqueness of our clients and their
  experiences within the context of their lives
• Recognize normality of grief, empower clients to
  be actively involved in their adaptation to loss,
  support clients without attempting to cure or fix
  them
• Respect clients as experts on themselves
• Lets talk about the last one

9
Three Roles

• Witness
• Facilitator
• Collaborator

10
The Witness

• To observe, to listen, to hear, to remember, and
  to understand at the deepest level the powerful
  narratives of loss and grief
• We bear witness
• Thus as a witness we
• Listen more than we talk
• Employ respectful silence
• Fully attend (see what is here)
• Exhibit comfort
• Allow grief (dont fix even when clients request
  rescue)
• No judgment

11
Facilitator Role

• Provide a framework conducive to functional loss
  adaptation
• Focus and structure
• Typical questions and framework
• How can I be of help? How is the session going
  thus far? Where should we be spending our time?
• We facilitate the clients work, but we dont do
  the work for them!

12
Facilitator Medicine

1. Encourage recognition and use clients strengths,
   resources and abilities
2. Respect the natural ebb and flow of the grieving
   journey, including periods of disorder, impasse,
   resistance, and confusion as part of the loss
   adaptation process
3. Consult with clients regularly as to direction of
   therapy, and usefulness of various techniques /
   activities
4. Assist clients where they are - not where the
   counselor wants them to be

13
Collaborator Role

1. Collaborative counselors are more interested in
   client perspectives than they are in preconceived
   notions about grief based on expertness of others
   
2. Neither directive nor nondirective
3. Fellow explorer
4. Help clients educate themselves about themselves
   and their world past, present, future

14
Collaborator Medicine

1. Respect clients as narrators of their own stories
2. Encourage and attitude of exploration and
   discovery
3. Rely and what and how questions to encourage
   reflection and ownership
4. Encourage divergent thinking (ideas)
5. Promote client resiliency

15
Key Technique in Working With Loss, Grief, and
Bereaved Clients

• Master the Art of Silence
• Respectful silence is bearing witness
• Silence punctuates moments, prompts reflection,
  provides support, deepens process, and is healing
  
• We are creating a space for coping, holding,
  adapting
• We do not solve grief
• We do not rescue grief

16
Video Emersion Practicing The Three Roles
17
Listening To and Listening For Loss and Grief

• Listen to this song?
• What do you think is going on?

18
Lets not Get Ahead of ourselves?

• Why do we grieve?
• Love somebody?
• What is love?

19
Why Loss / Grief Clients

• Some clients specifically come for counseling due
  to loss and as a result of
• Bereavement
• Divorce
• Separation
• Loss of livelihood
• Because they believe they are not adjusting well

20
Why Loss / Grief Clients (cont.)

• However, most loss and grief experiences appear
  far more often in therapy not as the presenting
  problem, but as an underlying cause or
  contributing factor to client troubles.
• As we explore client anger often we reveal core
  losses that have never been addressed or were
  adequately grieved for.
• Refer to text pg. 19

21
Primary and Secondary Losses

• Primary Loss significant loss event such as
  death
• Secondary Loss come about as a result of a
  primary loss

22
Secondary Losses

• Acts a dominoes and can arise as a chain of
  events from primary loss
• Death of spouse brings about loss of
  companionship, financial security, sexual
  intimacy, family role, social status
• Job loss self-esteem, identity, financial
  security, sense of future
• Childhood sexual abuse loss innocence, trust,
  sense of control, etc.
• Mental illness loss of control over emotions,
  thoughts, family role, loss of occupation

All these losses bring grief
23
The question to ask then or to understand in
facilitating adaptation to loss that we must ask
our clients?

• WHAT HAVE YOU LOST?
• Primary Loss Relationship
• Questions we need to know

24
(No Transcript)
25
Ambiguous Loss (AL)

• Two types
• Physically absent / psychologically present (e.g.
  kidnapping, people missing from natural disaster,
  divorce situations, baby put up for adoption,
  etc.)
• Physically present / psychologically
  absentperson is emotionally and cognitively
  missing (Alzheimers, traumatic brain injury,
  addictions)
• The uncertainty characteristics of (AL) can bring
  about long term dysfunctional coping often
  contributing to complications in the grieving
  process

26
Stigmatized Losses

• Losses that reveal transgressions of societal
  norms or go against norms, mores, and folkways
• These include losses related to HIV/AIDS,
  suicide, violence (e.g., homicide, genocide,
  domestic violence, homelessness, sexual abuse,
  addictions, to name a few)
• Stigma attached to the loss, should they be
  allowed to grief? Family hides the secret
• These sufferers usually experience and have a
  difficult time getting over guilt, shame, blame
  and their support networks can often be limited

Disenfranchised Grief
27
Cultural losses

• Historical oppression
• Racism
• Residential school
• Immigration

28
Psychosocial Factors Facing Our Loss

• Now that we have seen that grief and loss are
  unique to the sufferer and that different losses
  bring with them different obstacles to adaptation
  lets look at psychosocial factors that impact
  grief and healing.
• Adaptive strategies
• Affective (emotional response / regulation)
• Cognitive (analysis, reframing, distraction or
  avoidance
• Behavioral (problem solving, activity,
  behavioral distraction)
• Spiritual (prayer, meditation, rituals)

29
Adaptive Strategies

• Can be used both positively and negatively
• Everyone has their own combination of adaptive
  strategies based on personality and life
  experience
• The idea is for the counselor and client to use
  which ones that are most helpful

30
Attachment Theory

• Definition of Attachment
• An enduring emotional tie to a special person,
  characterized by a tendency to seek and maintain
  closeness, especially during times of stress.
• Healthy and unhealthy attachments can predict
  duration and intensity of bereavement

31
Disrupted Meaning Structures

• Basic truths about the world assumptive world
• Loss can shatter our assumptive world
• I dont know who I am anymore shakes us to our
  foundations
• An important job of the grief counselor is to
  help clients deal with disruption of their
  pre-loss meaning structures

32
Meaning Reconstruction 3 Phases

• Sense or meaning making
• Begins with exploring the why
• And maybe ends with letting go of the why
• Moreover, the counselors aim here is to examine
  the meaning structures that once made ones world
  comprehensible, then renewing, redefining, or
  revising them to so as to restore balance

33
Benefit Finding Phase 2

• Learning to find personal growth in loss
• We may find a greater faith
• Transform our identity
• Develop competence or independence
• Its not above moving on its about thriving in
  the aftermath of a reality we cant change

34
Identity Change

• Process of reorganizing and rebuilding a sense of
  self fragmented by loss
• Help client revise ones self narrative in a way
  that maintains continuity of a person while also
  incorporating altered aspects of the self
• We are always becoming

35
Video Emersion Shattered Assumptive Word
36
Video II Disrupted Meaning Structures
37
Other Psychosocial factors

• Personal history of Loss and Separation
• Developmental considerations
• Womens / Womanist development
• Racial Identity development
• Homosexual Identity development
• Faith Development

38
Social Support

• The better the quality of the grievers support
  network, the more functional is her or his loss
  adaptation
• Sometimes our notions of who will support us does
  not happen or our initial grief reactions, or
  deficits in our interpersonally functioning limit
  our reaching out to others.
• The latter support mechanisms and tendencys need
  to be explored by counselors

39
Uncomplicated and Complicated Grief

• Uncomplicated grieving
• Self-limiting
• Common symptoms gradually diminish (e.g. sadness,
  yearning, confusion, numbing, and loneliness)
• There is an increasing acceptance of the reality
  of death
• Steady integration of loss
• Grief is seen as normal
• Easing of symptoms can be observed 6 months to a
  year following the death

40
Complicated Bereavement Grief (Prigerson et al.
1995)

• Used to denote specific symptoms and level of
  distress due to a death (distinguishing primary
  disorder)
• Grief is prolonged
• Grief symptoms intensify rather than diminish
• Disability of death lingers, and loss is not
  observed to have been integrated

41
Toward Diagnosis Four Proposed Criterions

• Symptoms must last for 6 months
• Symptoms cause marked dysfunction in social,
  occupations or other important domains
• Yearning, pining, longing for deceased must be
  experienced at least daily over past month to a
  distressing or disruptive degree
• 4 symptoms of 8 must be experienced in the past
  month as extreme
• These are

42

1. Trouble accepting death
2. Inability to trust others since the death
3. Excessive bitterness about the death
4. Feeling uneasy about moving on with ones life
5. Feeling emotionally numb/detached from others
   since death
6. Feeling life is meaningless without the deceased
7. Feeling the future holds no meaning without the
   deceased
8. Feeling agitated, jumpy, or on edge since the
   death

43
Lets talk about pathologizing grief
44
Contemporary Models of Loss Adaptation

• Martin and Dokas Adaptive Grieving Styles
• Dual Process Model of Coping

45
Adaptive Grieving Model

• Model focuses on
• Specific patterns of grieving that is natural to
  the person, and
• The preferred cognitive, behavioral, affective,
  and spiritual strategies an individual uses to
  manage our innate response to loss

46
Continuum 3 Basic Grieving Styles
47
A Closer Look at The Intuitive and Instrumental
48
Adaptive Grieving Styles

• Our style can shift along the continuum, but for
  the most part is generally consistent across time
  
• The models grieving styles reflect and respect
  innate differences among individuals that result
  from personality, culture, familial,
  developmental, and social influences

49
Preferred Coping Strategies

• Affective
• Cognitive
• Behavioral
• Spiritual
• Any adaptive strategy may be used by an
  individual person, but there appears to be a
  clear preference for each grieving style
• Thus, an instrumental griever and intuitive
  griever may employ the same strategy, but its
  use will be put in action for different means
• Sharing a story for an intuitive is done to
  express emotion and connect on emotional level
  with others, whereas an instrumental tells a
  story to to gather info, organize a response, or
  solve problems

50
Affective Strategies
51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
Strategies at Work Some Details

• Strategies that work at the beginning may not
  work during later adaptation
• Your strategy of adaptation may clash with
  spouse, siblings, and family, causing
  deterioration in overall support
• What if your counselor has a different innate
  adaptive strategy?

55
Strategies at Work Some Details

• Counselors must what to make sure clients are
  utilizing their primary adaptive strategies
• Its good to have secondary strategies, but the
  secondary strategies may be ineffectively applied
  
• Counselors job to root this out

56
Dissonant Responses

• Common for grievers to initially use secondary
  strategy and go against their natural style of
  grieving
• This can further complicate grief
• The discrepancy is resolved when the
  client/individual moves into innate response or
  in counseling when we fetter out clients primary
  strategy
• Reasons for dissonant responses include
  personality, gender role socialization, type and
  intensity of grief, image management, substance
  abuse, etc.

57
(No Transcript)
58
(No Transcript)
59
What are we seeing here?

• Intuitive is going against her / his nature
• Dissonance typically occurs when the intuitive
  attempts to limit their internal experience

60
Dissonance response intuitive (cont.).

• They begin to use behavioral and CBT strategies
  such as
• Avoid people who would otherwise elicit a
  emotional response, rationalize / intellectualize
  experience,
• Use alcohol / drugs to suppress emotion, overuse
  physical exercise to deny reality of loss, focus
  on everyone but themselves
• This type of strategy can lead to physical /
  emotional exhaustion, psychosomatic illness,
  estrangement from others, complications may also
  from risky behaviors

61
Dissonance Response More Instrumental Griever
62
What are we seeing Here?

• Instrumental griever is in dissonance because
  they believe they should be feeling (believe
  there is something wrong with themselves)
• They are self critical and blame themselves
• Distance themselves from others because they
  believe they are cold, uncaring, and insensitive
• May conjure up feelings or loosen inhibitions
  (drink / rather than numb) to feel
• Provoke violence to feel
• Martin and Doka report that instrumental grievers
  may come to therapy for the problems created by
  the dissonance not the dissonance itself

63
Counseling Implications?