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Complicated Mourning: Competent Caring Baylor University School of Social Work 2008.

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Presentation on theme: "Complicated Mourning: Competent Caring Baylor University School of Social Work 2008."— Presentation transcript:

1 Complicated Mourning: Competent Caring Baylor University School of Social Work 2008

2 Death and Grief Happen Among our peers at work In our families In our country In our friends In our neighborhoods In our churches

3 Sometimes, it happens badly When we judge When we prescribe When we “celebrate”only When we excuse When we abandon When we think we know just how someone feels

4 The Known Death is universal; it comes to us all Grief is universal; we will all experience it many times. While the average life expectancy in the United States continues to grow, the mortality rate is still the same. One out of one will die.

5 Definitions: Loss: Change that includes being without someone or something; physical loss of something tangible like a person, a car, a house, a breast; psychosocial loss of something intangible like a divorce, an illness, a job, a dream, a hope. Bereavement: comes from the same Latin root word as “to have been robbed….” i.e. to have experienced loss. Rando, Complicated Mourning, p. 20.

6 More definitions: Secondary loss: other losses as a result of a primary loss. Example, loss of income when bread winner dies. Grief: reaction or response to loss; includes physical, social, emotional, intellectual and spiritual dimensions. Mourning: rituals or behaviors associated with grief; i.e. courses of action in response to loss. Rando, Complicated Mourning, p. 22.

7 Grief Takes Time Whole first year is one loss after another Beware of special occasions and holidays all year Uncomplicated mourning is normally 2-3 years Complicated mourning may be a 5-7 year process. Grief continues for a lifetime through major life milestones.

8 Grief impacts us holistically…

9 Physical responses: Appetite (eating) disturbances Energy, fatigue, lethargy Sleep disturbance Cold (especially for children) Anxiety (sweating, trembling, etc.) Gastrointestinal disturbance Compromised immune response; increased illness

10 Intellectual Confusion; “What is real?” Difficulty concentrating; ex. Read the same page several times Short attention span; ex. Can’t finish a 30 minute TV program Difficulty learning new material; short term memory loss; ex. Income taxes Difficulty making decisions

11 Social… Withdrawal Isolation Searching Avoidance Irritability Self absorption Clinging/dependence

12 Emotional… Angry Depressed Sad Crying Irritable Afraid Lonely Relieved/Guilty/Regretful

13 Spiritual…assumptive beliefs are challenged… The question “Why” reverberates Where was God? If God is all powerful, why allow this? If God loves me, how could this be? Prayers weren’t answered…

14 Common and Unique… Death and grief are unique. Each person’s experience is his or hers alone. Each experience is unlike any other. So, I can never know exactly how someone else feels.

15 Grief Takes Time Whole first year is one loss after another Beware of special occasions and holidays all year Uncomplicated mourning is normally 2-3 years Complicated mourning may be a 5-7 year process. Grief continues for a lifetime through major life milestones.

16 Complicated Mourning… The term complicated mourning as used by Therese Rando, Junietta Baker McCall, Kenneth Doka and others has to do with grief that does not follow the “normal course” or process to successful completion.

17 Terms seen in the literature: Absent grief (prolonged) Delayed grief Inhibited grief Pathological mourning Chronic Mourning Dysfunctional grief Unanticipated grief Conflicted grief Distorted grief Unresolved grief Grief with mental disorders Grief with physical disorders

18 Theorists you should know… Freud: Mourning and Melancholia (anniversaries, attachment and relinquishment) Erich Lindemann: Grief Work (emancipation, readjustment and formation; morbid reactions)

19 More Theory….. Charles Anderson (1949): research on pathological grief with particular emphasis on World War II. Rando, 1993 John Bowlby (1950s and 1960s): Attachment and Loss; four phases: numbing, yearning and searching, disorganization and despair, and reorganization; chronic mourning Rando, 1993

20 Don’t give up yet… George Krupp (1972): family systems perspective of death and loss. Rando, 1993 Mardi Horowitz (1977): The stress response syndrome (outcry, denial and numbing, intrusion, working through and completion) Rando, 1993 Alan Keith-Lucas: children and grief-shock and denial, protest, mastery or detachment.

21 The One We All Know… Elisabeth Kubler- Ross: Anticipatory Grief Shock and denial Anger Bargaining Despair Acceptance

22 Disciplines that deal with grief… Chaplain/pastor Social Workers/Counselors Nurse/Physician Other medical professionals (PT….) Teachers/Coaches Lawyers/Accountants Everyone

23 Social work and grief Context Crisis Short term Long term Tangential

24 Social Work and Grief Normal Grief: Case Management; Peer Support Groups; Counseling/guidance for journaling, etc. Complicated Mourning: Individual therapy; Group Therapy; Family therapy; Advanced Case Management

25 Models for Normal Grief Elisabeth Kubler-Ross (Anticipatory Grief) Alan Keith-Lucas (Children & Separation) William Worden (4 Tasks) Alan Wolfelt (Bereavement Needs) Therese Rando (The Six “R”s)

26 Grief is Work: Worden’s Four Tasks Experience the reality of the loss Experience the pain of the loss Adjust to an environment without the deceased Withdraw emotional energy from the deceased and invest it in new relationship(s) (William Worden, Grieving)

27 Alan Wolfelt’s 6 Reconciliation Tasks: Acknowledge the reality of the death. Move toward the pain of the loss while being nurtured physically, emotionally, and spiritually. Convert the relationship with the person who has died from one of presence to one of memory. Develop a new self identity based on a life without that person. Relate the experience of the death to a context of meaning. Experience a continued supportive presence in future years. (Alan Wolfelt, Healing the Bereaved Child)

28 Rando’s 3 Phases and 6 Processes Avoidance Phase – Recognize the Loss Confrontation Phase – React to the Separation Recollect and reexperience the deceased and the relationship Relinquish the old attachments to the deceased and the old assumptive world Accommodation Phase – Readjust to move adaptively into the new world without forgetting the old – ReinvestRando, 1993

29 AVOIDANCE RECOGNIZE THE LOSS – Acknowledge the death – Understand the death (Rando, 1993, Complicated Mourning)

30 CONFRONTATION REACT TO THE SEPARATION – Experience the pain – Feel, identify accept, and give some form of expression to all the psychological reactions to the loss – Identify and mourn secondary losses (Rando, 1993, Complicated Mourning)

31 CONFRONTATION Recollect and re-experience the deceased and the relationship – Review and remember realistically – Revive and re-experience the feelings Relinquish the old attachments to the deceased and the old assumptive world (Rando, 1993, Complicated Mourning)

32 ACCOMMODATION Readjust to move adaptively into the new world without forgetting the old – Revise the assumptive world – Develop a new relationship with the deceased – Adopt new ways of being in the world – Form a new identity Reinvest (Rando, 1993, Complicated Mourning)

33 Risk Factors for Complicated Mourning

34 Risk Factors for Complicated Mourning McCall, 2004 & Rando, 1993 General Factors Nature of the relationship Nature of the Loss Physical, psychological, sociological, and spiritual condition of the survivor Resources available Multiple losses Severe trauma Violent death Concurrent mental illness Axis 2 traits Isolation Guilt Life Skill Deficits Parents who lose children

35 Extrapolation for Assessment: Example 1 Nature of the relationship – Length/duration – Importance – Culture/Roles – Quality – Dependence – Hopes and Dreams – Amount of Daily Change

36 Extrapolation for Assessment: Example 2 Physical condition of the survivor Age (Erikson, Freud, Piaget) Physical Health Independence/Dependence Pain Caregiving Mental Health Finances/Access to services/

37 Assessment For Complicated Mourning: Use Rando’s Grief and Mourning Status Interview and Inventory (GAMS II) From Treatment of Complicated Mourning by T.A. Rando, 1993, Champaign, IL: Research Press. Copyright 1993 by T. A. Rando. Reprinted by permission. For Dysfunctional Grieving: Use McCall’s “Symptoms and Behavior that Can Indicate Dysfunctional Grieving McCall, 2004.

38 TREATMENT PRINCIPLES All social work treatment is based on an assessment. All social work treatment is based on a contract for work with the client. Treatment is based on theory and research that validates particular interventions for particular issues.

39 Treatment Principles: Complicated and Dysfunctional Grief Most clients of social workers will be clients for some reason other than their grief experience. Most clients of social workers will be clients for some reason than the issue that makes their grief complex or complicated. That makes assessment and contracting more important, not less important.

40 Treatment Principles: Practical If there is a physical or mental health complication, the treatment plan or contract must address the treatment for that complication. If the complication includes family or other relationships, the treatment plan or contract must address systems work. Reimbursement for treatment must be addressed.

41 Rando’s Treatment Approach Assess around the six “R”s and determine where the mourner is “stuck” and not making progress. Base treatment on interventions that address that “R.” “Explore with the caregiver the identity and roles with the lost loved one and the meaning of the relationship.” Rando, 1993, p. 181

42 Rando: Treatment Tips Secondary victimization occurs when support systems isolate, blame, and stigmatize. Multiple losses require multiple adaptations over time and make intervention very complex. Homogenity in support groups helps normalize experience. (Rando, 1993, Complicated Mourning)

43 Rando therapeutic techniques Gestalt therapeutic exercises (empty chair, role play) Bereavement rituals Psychodrama Writing/journaling Creative works; music, art, scultping Rando, 1993, p. 595

44 Specifics for our time together……. Crisis intervention is one of the most important ways to prevent complicated mourning. Crisis includes tragedy, murder, suicide, war death, etc. The death of a child is particularly difficult. Parent and sibling grief is explored. Suicide is a serious complicating factor in mourning.

45 Dealing with Crisis Sudden, unexpected death/loss is a major complicating factor in grief. Much complicated mourning could be averted with good crisis management at the time of the crisis. Crisis work and grief work are NOT the same. Effective crisis work requires SKILL.

46 Crisis material is taken from: Coping with Public Tragedy ( 2002 Hospice Foundation of America) Edited by Marcia Lattanzi-Licht and Kenneth Doka The National Center for PTSD, Special Edition, Disaster Assistance (2001) Growing through Grief after Sudden Loss (1999 Hospice Foundation of America) Edited by Kenneth Doka

47 What exactly are we talking about? The first and most pressing question in a crisis is: What just happened? Immediately following is the question: How can I manage right now? Finally, the larger questions of grief and meaning are formulated. What Happened? How will I Manage It? How do I Go on?

48 What is your first memory of public disaster or tragedy? The assassination of President Kennedy? MLK Jr? Robert Kennedy? Mount Carmel? Columbine? Oklahoma City? 9/11? A natural disaster?

49 Public Tragedies in our Living Rooms We live in an increasingly small world Major events have global impact, including impact on our lives The media brings distant events into our living rooms Live and constant coverage immerse people in the details of tragedy Most of us have some connection with others who are touched by the event

50 Layers of stress and concern: Fear and anxiety with uncertainty Sense of helplessness and feeling out of control Normal life stressors of job and family continue Exacerbation of grief that comes with losses…death, moves, relationships… Multiple funerals and images of the grief of others

51 Understanding the phases of tragedies: The initial event, early aftermath…i.e. Crisis Phase The short-term aftermath…i.e. Processing Phase The long-term aftermath…i.e. Adaptation Phase Licht and Doka

52 Crisis Management means: First focusing on basic needs: Shelter, safety, sustenance, information, protection Second, allowing those affected to begin to figure out what happened…tell their story, process the event and its meaning for them. Always validate and normalize the responses ….listen carefully…reflect the language

53 Assessment is essential Hearing the story will help you assess the needs and the strengths of each person Listen each time as though it is the first time you heard the story Assess strengths…support system available to the survivor Assess spiritual beliefs/source of strength Be careful of trite, glib religiousity

54 Adaptation Phase Part of your assessment will include awareness of how long you will be available to help Contract for work and for referral Remember that crisis work eventually leads to grief work which is LONG term Encourage the use of ritual and the arts to personalize the experience and provide formal, structured support. Lattanzi-Licht and Doka

55 Critical Incident Stress Management… Mitchell model, Follows a traumatic event Coping skills are overwhelmed Goal, to prevent or limit development of PTSD Provide distance Demobilize or debrief Lattanzi-Licht and Doka

56 Debriefing includes… Explain process and ground rules (not psychotherapy…not operational critique) Allow description of what happened and respective roles Explore “first thoughts” and event processing Facilitate ventilation: What was worst? Identify symptoms of distress Normal crisis reactions Teach stress management and coping skills Summarize, provide follow up as needed Doka

57 Other options: Defusing….small group discussion of traumatic event Informal Held immediately after an incident Designed to reduce tension Focus on facts of the crisis and reactions Offer family/organizational consultation Offer follow/up and referral Lattanzi-Licht and doka

58 Families of Dying and Grieving Children Need Resources….financial, transportation, errand, chores, helping with well siblings Permission to feel what they feel without our judgment or condemnation Hope without fantasy Presence Care for well siblings Time with each other

59 Grieving Parents Need…. Permission to feel Awareness that grief lasts a lifetime Help with marital differences in grief Help with remaining children Concrete help with finances, tasks, etc.

60 Grieving Children Need: Information at their age level Preparation Inclusion in caregiving Inclusion in family ritual Presence of a trusted adult Long term attention

61 Remember the five areas of focus Physical Needs: warm foods and clothing; increased susceptibility to illness Emotional Needs: Grief bursts of emotion Social Needs: Few peers can relate. Consider a group experience. Cognitive: Difficulty with concentration, learning new material, attention span. Be sure the teacher knows. Spiritual: Beware of the trite phrases that confuse and frighten…asleep in Jesus; God took her; God needed an angel.

62 And then there are teens…. Listen, listen, listen Provide contact with peers Affirm feelings; model seeking support Give them something positive to DO Encourage activities they enjoy with others National Centger for PTSD

63 When is it time for referral? Consider grief complications…ie suddenness of the death, troubled relationship, violence, arousal of fear Consider support available Consider coping skills and other stressors Consider length of difficulty…i.e. duration of distress Always assess for suicidal ideation.

64 Sudden Death Acute Natural Causes Accidental Death Disaster Deaths War Deaths Murder Suicide

65 Shneidman (1972) “I believe that the person who commits suicide puts his psychological skeleton in the survivor’s emotional closet. Rando, 1993, p. 523

66 Suicide and complications Feelings of responsibility Cultural responses leading to guilt and shame Anger at the deceased Fear re becoming suicidal No opportunity for closure

67 Interventions after suicide Support groups of others whose loved ones have committed suicide Permission to explore the “why” and to recognize there may never be an answer Support to avoid self blame Help with intensified feelings including anger Suicide assessment and prevention

68 Assessment and Intervention See Sattler’s assessment of children’s risk for suicide. ASK: “Are you thinking of killing yourself?” ASK as often as you wonder. If yes, “how would you do it?” If the client has a plan, do they have the means to implement the plan?

69 Intervention/Prevention If yes, a plan, and the means to implement the plan, you have an emergency. Do not leave them alone. Hospitalize. Remove lethal means. If no plan, use cognitive behavioral therapy to address the thinking leading to suicidal ideation. Use contracting.

70 Treatment Tips Flashbacks: Psychoeducational approach re normal response; teach control over responses; anxiety management; verbal skills to describe. Blocking the trauma: Therapy to remove blocks to allow healing; safe place and relationship; stimuli to recreate memories

71 Caregiver Self care is essential to work with complicated mourning Model good grieving around own losses Stress management Transference and Countertransference Permission to make mistakes Rando, 1993, p. 653


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