Ted Talk: What I learnt about Loss 17 minutes

Ted Talk: What I learnt about Loss 17 minutes
Ted Talk: Embracing Death 14 minutes Bereavement Loss & Change Dr Colin Murray Parkes Part 1 12minutes Bereavement Loss & Change Dr Colin Murray Parkes Part minutes The Grieving Process - Coping with Death 4 minutes Avoidant Attachment Style

Administration The Building

Health & Safety At the start of the course, please ensure that students understand what to do in the event of a fire. The assembly point for any evacuation is in KEAN STREET Take the laminated room number sign from the classroom wall and instruct students to assemble with you, using the room number as your ‘flag’. If students have mobility problems, direct them to the student lounge on that floor and someone should wait with them until a Fire Marshal arrives to assist them to safety (via the fire-fighting lift) There is a full set of guidelines in each room

First Aid Telephone 2801 to contact a first-aider via the internal telephones in the student lounges or in room 218 Second Floor rooms 206 and 210 have First Aid Boxes.

Ladies: floors G,1,3,4,6 Gents: floors G, 2, 5 Disabled: Each level
Toilets Ladies: floors G,1,3,4,6 Gents: floors G, 2, 5 Disabled: Each level

Student Administration
Signing the register Completing Feedback Forms at the end of the Day

Adrian Scott MSc Senior MBACP Accredited www.counsellingme.co.uk

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My Experience MBACP Senior Accredited Counsellor
MBACP Senior Accredited Supervisor for Individuals and Groups Managed Counselling services in Voluntary Sector Bereaved, Homeless, Mental health, Carers

My First Working Bereavement Working Experience
Bereavement Counsellor at the London Hospital in 1989 Led by Dr. Colin Murray Parkes Theory / Case Study

Expert Not a guru or Bereavement expert Do not know everything
Ideas to be Debated / Challenged

Other City Literary Courses
Introduction to Psychodynamic Counselling Introduction to the Unconscious Working with Bereavement and Loss Psychology of Attachment

Living through Bereavement & Loss

Morning Session 10.30 Introduction 10.45 Icebreaker Exercise Break
Theory and Group Discussion 1pm Lunch

Afternoon Session 1.45pm Exercise - Reflecting on Bereavement Break
2.30 pm Attachment / Counselling Session 3pm Case Examples - Video Round Up / Feedback Forms Administration 4pm End

Your Experience & Ideas Case Examples

Learning Outcomes Icebreaker Exercise - Counselling Skills
Listening, Hearing, Reflecting back Understanding Bereavement & Loss Theory Models and Attachment Assessment Exercise - Own Experience/ Attachment Personal Experience – Own Therapy Understanding of Bereavement Counselling Criteria Methods Video Case Examples Seeing others peoples’ reaction to Bereavement and Loss

The Day Wide range of skills in the room
Hope you all get something out of it I am not an expert on Bereavement Encourage you to have your own view

Boundaries Look after yourselves Bereavement can be a difficult and emotive subject Do not say anything you do not want to say. This is not a therapy group! Confidentiality Agreement - All information should be kept to this room and with this group of people.

Icebreaker Exercise Ask Your Colleague: 1. What brought you here?
2. What is your interest and experience of the subject? 3. What do you want from the day? You will be asked to briefly and concisely to report back what your colleague has told you to the group, and check with your colleague how you did!

Icebreaker Exercise Learning Outcomes
Basic Counselling Skills Listening Hearing Reflecting back

What do you want from the Day?
Are there any Topics, Issues, that you would like to focus or discuss today? Write on flip chart

Preamble before Bereavement Theory
General Principles of Counselling? Training in Bereavement Counselling – last bastion of old volunteer model? – Discuss A way to reflect on feelings Learn about relationship with ourselves Generic Counselling Approach Integrative

The Intelligent Human adult..
…knows that it fruitless to dwell on painful memories and the intrusive images of traumatic events are sometimes so painful that we will go to great lengths to avoid them. We may do this by shutting ourselves up in a safe place (usually our home), and avoiding people and situations that will remind us of the trauma and deliberately filling our minds with thoughts and activities that will distract us from the horror. But it is a paradox that - “ in order to avoid thinking about something we have to think about it”. That is to say, at some level we remain aware of the danger that we are trying to avoid. Hence it should not be a surprise to us if our attempts at avoidance commonly fail. In sleep and a time of relaxed attention painful memories tend to float back into our minds and we find ourselves reliving the trauma yet again. Colin Murray-Parkes

Link to Counselling “ in order to avoid thinking about something we have to think about it”.

Link to Counselling Counselling is a craft, practice of -
“being with and containing feelings” Thinking / Avoiding - Discuss

Colin Murray Parkes Bereavement: Studies of Grief in Adult Life Paperback: 288 pages Publisher: Penguin Books Ltd; 3New Ed edition (1998) ISBN-10:

“Bereavement Expert” Since 1966, Parkes has worked at St. Christopher’s Hospice in Sydenham, where he set up the first hospice-based bereavement service and carried out some of the earliest systematic evaluations of hospice care. Parkes has also edited books on the nature of human attachments, and Bereavement Parkes is a former chairman and now life president of the charity Cruse Bereavement Care

A Theory of Bereavement
For this course today: Bereavement is a process of grieving Loss is the person or object Life is bereavement Minor bereavements all the time Beginnings and endings: relationships, friendships, jobs, work projects, holidays, moving house Days, weeks, years We cope with major / minor bereavements in the same way??

Types of Loss Actual loss Death from old age, illness, accidents
Old person - more acceptable loss? Younger person less acceptable loss? Hierarchy of Loss Different countries value of life? Discuss Perceived loss Person’s view of loss Determined by? Culture, history, family, socialisation?

Bereavement Study Colin Murray Parkes Psychiatrist at Royal London Hospital Effect of the loss of husbands on group of widows in London’s East End Discuss: limitations? 1987 Case study of Henry who survived capsized ferry in Zubbregge, Holland Discuss: accidents/ terrorism /wartime/peacetime?

Process of Bereavement
Start after loss? Fade away? Remain repressed not allowed to begin? Part of the process begins / Other parts held back. Bereavement is like a tide: it flows back and forth through the stages Individual / Personal

The Cost Of Commitment Gain Investment in relationships: emotional,
physical, financial. Lives enriched but there is a ………. Cost Risk of losing Gain

BEWARE! Comment on Bereavement Stages:
“the stages might lead people to expect the bereaved to proceed from one clearly identifiable reaction to another in a more orderly fashion than usually occurs. It might also result in … hasty assessments of where individuals are or ought to be in the grieving process” P.351 Handbook of Bereavement, Cambridge 1993

Bereavement is like a tide

Summary so far “ in order to avoid thinking about something we have to think about it”. Link to Counselling Bereavement is a process of grieving Loss is the person or object this is lost The Cost Of Commitment Bereavement is Individual and Personal The stages to do not occur in order Bereavement can be like a tide ebb and flow

Stages of Bereavement Theory
1. Alarm 2. Searching 3. Mitigation – Lessening the Impact 4. Anger & Guilt 5. Disorganisation (Chaos) & Despair 6. Gaining a New Identity Theory is theory - feel able to agree or contradict it! Discuss Colin Murray-Parkes

1.Alarm Tension, Shock, Panic, Disbelief Restlessness
Numbness – some emotions break through Preoccupation / obsessiveness with thoughts of the lost person. Self-care neglected Breakdown of customs / behaviour Sensitive to noise, conflict, administration Shut down to avoid feelings

2.Searching Calling for the lost person Sobbing, tearfulness,
Feeling of loss / lost Discuss Visit places of experience Aimless searching – irrational? Find lost person

3.Mitigation–Trying to Lessen the Impact of Bereavement
Components of grief work Pre-occupation / wish to find the person Repeating, painful recollection of the loss Patterns, Obsessive thoughts, PTSD Making sense of the loss to fit assumptions - meaning Dreams - common dream - happy interaction with the dead Pining / Avoidance of Pining Idealised person - forget the negative

4.Anger and Guilt Familiarity - loved ones, family members
Misdirection - Hospital staff / GPs Blame / Self Blame Anger guilt becomes irreconcilable - leading to family splits Resistance to sadness, grief under the anger and guilt

5.Disorganisation and Despair
Period of uncertainty Take on the reality of what has happened Identifying with lost person – method of avoiding the loss of that person Old model of the world abandoned New set of expectations created - with time and acceptance Other people become a support, security, & protection.

6.Gaining a New Identity Taking on role/interest that lost person had
New versions of old relationships New relationships New interests New updated view of the world Less repressed / more flexible

6 March people killed The British ferry Herald Of Free Enterprise capsized off the coast of Belgium The ferry overturned without warning only a mile outside Belgian port Zeebrugge Despite the best efforts of rescue crews, it became the worst ferry disaster in British history.

Colin Murray Parkes – Case Study
Henry - An Extreme Example The case of Henry who consulted me two months after several members of his family had been killed in the Herald of Free Enterprise, illustrates these bereavement stages.

The Event - Alarm He recalled how he had left his family below and was smoking a cigarette on the top deck of the Herald of Free Enterprise when the boat suddenly heeled over and then capsized outside Zeebrugge harbour. His immediate reaction was to save his own life. He managed to smash a window and escaped onto the outside of the boat that was now lying on its side and half submerged. Only now did he realise that his family were still below. In his alarm, he tried to climb back into the ship but was deterred by a fellow survivor who warned him “You’d never get out of there alive”.

Maintaining alarm Henry remained on board for five hours, helping with the rescue operation and watching anxiously as each new survivor emerged from the ship. But none of his own family came out alive and, in the course of the next two weeks he was to identify the bodies of four of them as, one by one, they were recovered from the wreck. Henry - Extending the Event- Searching

Avoidance Panic Throughout this period he exerted a rigid control on himself and he was still not crying two months later when he was persuaded to seek psychiatric help. At this time he was tense, chain smoking to control his nerves and feeling numb and depressed. He was easily upset by loud noises and was particularly sensitive to the sound of rushing water. He had shut himself up at home and seldom went out. His surviving daughters feared that he might kill himself. Henry - no interest in himself Suicidal Stuck

Re-Enactment Three months after the disaster a heavy thunder storm took place and, when I saw him the following day, Henry appeared haggard and exhausted. “It was the thunder,” he said, “it was the same noise that the boat made as it turned over. I heard the children screaming”. He then related, in great detail and with tears pouring down his cheeks, his memories of the disaster. The experience was so vivid that I too felt caught up in the situation. After a while I said, “You’re still waiting for them to come out aren’t you?” Henry - Routine Event re-enacts trauma - moves stuckness

Post-Traumatic Stress Disorder
The case illustrates the features of Post Traumatic Stress Disorder (PTSD) As long as Henry succeeded in avoiding the thoughts of what had happened he could not escape from the memories that were constantly threatening to emerge. The thunderstorm acted as a trigger to his memories and allowed him to begin the process of grieving.

Summary Stages of Bereavement Theory
1. Alarm 2. Searching 3. Mitigation – Lessening the Impact 4. Anger & Guilt 5. Disorganisation & Despair 6. Gaining a New Identity

Summary - Henry Saved himself – anger guilt
Stayed on the boat - maintained alarm Avoidance Panic - isolated himself to cope Trigger – overwhelmed by feelings Re-enacted trauma with counsellor

9/11 Twin Towers

Recovery Process Model
What We Learned From 9/11 A Terrorism Grief and Recovery Process Model

Other Models of Grief.. …..need to be explored closely and should not be blindly accepted as being representative of a terrorist grief and recovery process model.

Most existing grief models…
…….. identify grief as a normal process of experiencing the psychological, emotional, social, and physical reactions to the experience of loss, which generally relates to the loss of a person

Terrorism a particular form of trauma
Single, short-term, and relatively brief but extreme exposure or a long-term, repeated or prolonged exposure to an extreme and powerful threat resulting from an identifiable stimulus or catalyst event characterized by overwhelming an individual’s customary coping skills and sense of safety and security.

Terrorism a particular form of trauma
Terrorist attacks generally include an ‘‘extreme and powerful threat’’ and perhaps actual injury to the physical and emotional integrity of self or others and can involve injury and death. They can also involve the loss of resources, such as jobs and homes, as was seen in New York after 9/11. Many will be overwhelmed emotionally and psychologically.

Grief Terrorism Model Stages
Stage 1 Disequilibrium, Immediate Aftermath Stage 2: Denial – Outward Adjustment Stage 3 Integration – Coming to Terms

Personal Protective Factors
Stress buffers and resiliency, Age, gender, and ethnicity Predisposing factors (e.g., psychiatric histories, previous trauma, and educational disadvantages) Peri-disposing factors (e.g., proximity and duration of exposure to the terrorist attack) Post-disposing factors (e.g., family and other support systems)

People’s Beliefs The world as they knew it
Human nature Spirituality, Themselves - inner world cannot continue in the same way as before the attack Transformation in order for them to ‘‘find their place’’ and reintegrate themselves into the world. Assimilate or accommodate new values Able to return to their old values and beliefs. Others might ‘‘get stuck,’’ unable to deal effectively with the terrorist attack and its impact.

Goals of Terrorism Make a political statement and ‘‘to disconnect people from resourceful positive states of consciousness to non resourceful fearful states of consciousness’’ Terrorist attacks often result in unbalancing relationships (family, family subsystems, couple) or in changed parenting (by being either overprotective or abusive and neglectful) Psychological disequilibria, experienced as a result of a hazardous event or situation that contributes a significant problem cannot be remedied by using familiar coping strategies’’

Terrorist Attacks Impact
Minimal to acute distress, and even debilitating effects on individuals, families, communities, and whole nations, disrupting people’s behaviour, cognition, and psychological well-being

Increased risk of developing PTSD
Failure of normal adaptation to a traumatic event Extreme fear, helplessness, or horror experienced at the time or later In part it is a general response to any adverse event In part it is a specific response involving memory (e.g. flashbacks) and identity (e.g. dissociation)’’

Grief Issues Retelling the story of the trauma
Somatic reactions such as palpitations, choking feeling, sighing respiration, deep inner pain Vulnerability to illness Numbing and avoiding Diminished interest in activities and reduced ability to enjoy activities A time of reminiscing about the deceased, as a way to remember Sadness Impaired concentration Anger and irritability Sleep disturbances Intrusive images, crying, disbelief, emotional numbness, fatigue, disorganization, anxiety, despair

Grief Terrorism Issues
Retelling the story of the loss Somatic reactions such as palpitations, choking feeling, sighing respiration, deep inner pain Vulnerability to illness Numbing and avoiding Diminished interest in activities and reduced ability to enjoy activities Avoidance of reminiscing to avoid remembering the trauma Sadness Impaired concentration Anger and irritability Sleep disturbances Intrusive images, crying, disbelief, emotional numbness, fatigue, disorganization, anxiety, despair Fear, irritability, sense of suspended reality, anxiety, horror, fear, aggression, and often guilt—survivor guilt

Recovery So what factors that aid or hinder bereavement recovery?

Who is the Bereaved Person?
Age Gender Personality positive negative Proneness to Grief Inhibition of Feelings Openness / Flexibility to Vulnerability Expression of grief Situation and Environment of the Bereaved Socio-economic Status (Social Status /Class) Nationality Cultural Factors of Grief UK? Religion Community /Over arching belief system

What facilitated the Bereavement process?
Traditional family Good family support Predictability of death Practical tasks of funeral arrangements Supportive people making few demands Social Networks Mutual Self Help Groups Bereavement Counselling Support Groups – Group Counselling

What determines how a Bereavement affects a person? Stressors
The Trauma Stress & Trauma of the Bereavement Type of stress - multiple deaths, violence, age of deceased The Person Coping strategies - avoidance /drink /drugs /isolation Perception – world view /core values / emotional intelligence Capacity to tolerate strong feelings Processing feelings Self Esteem High /Low

Before the Bereavement
Relationship to the Deceased Good /Bad Type of Relationship Fixed Role /Flexible Strength of Attachment Dependence / Independence Security of Attachment Secure/ Ambivalent / Involved Degree of reliance Reason to live Childhood Experiences Other Bereavement Experiences Coping? Previous mental health Life Crises prior to the Bereavement Type of Death

After the Bereavement Social Support Prevention of Isolation
Secondary Stresses: financial Life Opportunities – Options open to Bereaved

Summary Facilitates the Bereavement – Situation and support of the bereaved Type of Trauma Type of person – ability to cope – background Before the Bereavement - relationships After the Bereavement – support / resilience

Theory and Counselling Skills Link
The way we react to bereavement is linked to the way we have been taught how to deal with bereavements in the past

Mourning and Melancholia (1917) Freud's psychoanalysis of loss
Mourning comes to an end when emotional attachment is broken to the lost one Normal grieving is overwhelming and unending Bereaved must break the unconscious bond with the deceased Healthy response to grief is suspect and interpreted as unresolved grief in the unconscious. Linking previous losses to the current loss

Dr Elisabeth Kübler-Ross
Pioneer of personal trauma, grief and grieving, associated with death and dying Improved the understanding of bereavement in hospice care Her five stages of grief model: Personal change model beyond death and dying.

Grief model applies to less serious traumas
redundancy, relocation, crime, disability and injury, relationship break-up, bankruptcy, etc. Model to understand personal reaction to general trauma.

1 - Denial Denial is a conscious or unconscious refusal to accept
Natural defence mechanism Can be locked in this stage

2. Anger Angry with themselves and Others,
Especially those close to them.

3. Bargaining Bargaining for people facing death can involve attempting to bargain with whatever God the person believes in. Bargaining in relationships: "Can we still be friends?.." when facing a break-up. Bargaining rarely provides a sustainable solution Also preparatory grieving Dress rehearsal or the practice run for the 'aftermath' Means different things depending on whom it involves. It's a sort of acceptance with emotional attachment.

4. Depression Natural to feel sadness and regret, fear, uncertainty
Shows person beginning to accept the reality

5. Acceptance Varies according to the person's situation,
Broadly an indication that there is some emotional detachment and objectivity. People dying can enter this stage a long time before the people they leave behind Grief Cycle Model first published in On Death & Dying Elisabeth Kübler-Ross, 1969

Kübler-Ross Summary Some similarities to CMP model
1. Denial – refusal to accept 2. Anger with anger loved ones 3. Bargaining 4. Depression 5. Acceptance

Attachment Theory John Bowlby
What is Attachment? - A Secure Base? Attachment - emotional bond to another person. Earliest bonds in childhood have life long impact Attachment survival mechanism - keeps infant close to the mother

A Good Attachment Primary care givers are available & responsive to infant's needs creating a sense of security. The infant knows that the caregiver is dependable Creates a secure base for the child to explore the world

Experiment with rhesus monkeys
Monkeys offered two objects to attach to Soft mother dummy without food Hard mother dummy with food

Monkeys preferred soft dummy without food
Discuss – reaction against Freud’s Instincts Theory

Bereavement is an extreme broken attachment / separation from a loved one
First experience - primary care giver and child Main Carer’s emotional state critical around baby’s birth Primary Carer & baby relationship major influence on adult life

Attachment Theory Conclusions
Counselling explores attachment figures Secure Base of counselling time, place, frequency Explore early attachment relationships Notice relationship between counsellor and client Expectations and perceptions of attachment figures Reflect on the accuracy of self images Holding and Containing

Attachment Styles What is attachment and why is it important?
Attachment refers the particular way in which you relate to other people. Your style of attachment was formed at the very beginning of your life, during your first two years. Once established, it is a style that stays with you and plays out today in how you relate in intimate relationships and in how you parent your children. Understanding your style of attachment is helpful because it offers you insight into how you felt and developed in your childhood. It also clarifies ways that you are emotionally limited as an adult and what you need to change to improve your close relationships and your relationship with your own children.

Attachment Styles Early Attachment Patterns
Young children need to develop a relationship with at least one primary caregiver in order for their social and emotional development to occur normally. Without this attachment, they will suffer serious psychological and social impairment. During the first two years, how the parents or caregivers respond to their infants, particularly during times of distress, establishes the types of patterns of attachment their children form. These patterns will go on to guide the child’s feelings, thoughts and expectations as an adult in future relationships.

Adult Attachment Styles
Secure Personality: People who formed secure attachments in childhood have secure attachment patterns in adulthood. They have a strong sense of themselves and they desire close associations with others. They basically have a positive view of themselves, their partners and their relationships. Their lives are balanced: they are both secure in their independence and in their close relationships.

Dismissive Personality: Those who had avoidant attachments in childhood most likely have dismissive attachment patterns as adults. These people tend to be loners; they regard relationships and emotions as being relatively unimportant. They are cerebral and suppress their feelings. Their typical response to conflict and stressful situations is to avoid them by distancing themselves. These people’s lives are not balanced: they are inward and isolated, and emotionally removed from themselves and others.

Preoccupied Personality: Children who have an ambivalent/anxious attachment often grow up to have preoccupied attachment patterns. As adults, they are self-critical and insecure. They seek approval and reassurance from others, yet this never relieves their self-doubt. In their relationships, deep-seated feelings that they are going to be rejected make them worried and not trusting. This drives them to act clingy and overly dependent with their partner. These people’s lives are not balanced: their insecurity leaves them turned against themselves and emotionally desperate in their relationships.

Fearful-Avoidant Personality: People who grew up with disorganized attachments often develop fearful-avoidant patterns of attachment. Since, as children, they detached from their feelings during times of trauma, as adults, they continue to be somewhat detached from themselves. They desire relationships and are comfortable in them until they develop emotionally close. At this point, the feelings that were repressed in childhood begin to resurface and, with no awareness of them being from the past, they are experienced in the present. The person is no longer in life today but rather, is suddenly re-living an old trauma. These people’s lives are not balanced: they do not have a coherent sense of themselves nor do they have a clear connection with others.

Developing an “Earned Secure Attachment” The good news is, it’s never too late to develop a secure attachment! Although your patterns of attachment were formed in infancy and can follow you throughout your life, it is possible to develop an “Earned Secure Attachment”at any age. One essential way to do this is by making sense of your story. According to Dr. Dan Siegel, attachment research demonstrates that “the best predictor of a child’s security of attachment is not what happened to his parents as children, but rather how his parents made sense of those childhood experiences.” The key to “making sense” of your life experiences is to write a coherent narrative, which helps you understand how your childhood experiences are still affecting you in your life today. In PsychAlive’s online course with Drs. Dan Siegel and Lisa Firestone, they will walk you through the process of creating a coherent narrative to help you to build healthier, more secure attachments and strengthen your own personal sense of emotional resilience.When you create a coherent narrative, you actually rewire your brain to cultivate more security within yourself and your relationships.

Parent Attachment Styles
Developing an “Earned Secure Attachment” Because our attachment ability is broken in a relationship, it is often best to be fixed in a relationship. According to Dr. Lisa Firestone, “One of the proven ways to change our attachment style is by forming an attachment with someone who had a more secure attachment style than what we’ve experienced. We can also talk to a therapist, as the therapeutic relationship can help create a more secure attachment. We can continue to get to know ourselves through understanding our past experiences, allowing ourselves to make sense and feel the full pain of our stories, then moving forward as separate, differentiated adults. In doing this, we move through the world with an internal sense of security that helps us better withstand the natural hurts that life can bring.”

Secure Attachment: Ideally, from the time infants are six months to two years of age, they form an emotional attachment to an adult who is attuned to them, that is, who is sensitive and responsive in their interactions with them. It is vital that this attachment figure remain a consistent caregiver throughout this period in a child’s life. During the second year, children begin to use the adult as a secure base from which to explore the world and become more independent. A child in this type of relationship is securely attached. Dr. Dan Siegel emphasizes that in order for a child to feel securely attached to their parents or care-givers, the child must feel safe, seen and soothed.

Avoidant Attachment: There are adults who are emotionally unavailable and, as a result, they are insensitive to and unaware of the needs of their children. They have little or no response when a child is hurting or distressed. These parents discourage crying and encourage independence. Often their children quickly develop into “little adults” who take care of themselves. These children pull away from needing anything from anyone else and are self-contained. They have formed an avoidant attachment with a misattuned parent.

Ambivalent/Anxious Attachment: Some adults are inconsistently attuned to their children. At times their responses are appropriate and nurturing but at other times they are intrusive and insensitive. Children with this kind of parenting are confused and insecure, not knowing what type of treatment to expect. They often feel suspicious and distrustful of their parent but at the same time they act clingy and desperate. These children have an ambivalent/anxious attachment with their unpredictable parent.

Disorganized Attachment: When a parent or caregiver is abusive to a child, the child experiences the physical and emotional cruelty and frightening behavior as being life-threatening. This child is caught in a terrible dilemma: her survival instincts are telling her to flee to safety but safety is the very person who is terrifying her. The attachment figure is the source of the child’s distress. In these situations, children typically disassociate from their selves. They detach from what is happening to them and what they are experiencing is blocked from their consciousness. Children in this conflicted state have disorganized attachments with their fearsome parental figures.

Population Attachment Styles

Mother and Baby D.W.Winnicott
Attachment between Mothers and Babies Studied mother baby interactions Potential space between mother and baby How does primary relationship enable separation to be tolerated by the baby? Good enough parenting and mothering Culture originating in Potential Space as experience of relationship (Face studies conducted by Brazelton & Cramer)

Different Perspective
The Other Side of Sadness. What the New Science of Bereavement Tells Us About Life After Loss George Bonanno Basic Authors 2009 Review in Weekly blog 21st September 2012

Different Perspective
George Bonanno Psychologist Focusing on behaviours Statistics CBT Cognitive Behavioural Therapy IAPT Improving Access to Psychological Therapies

How Humans Cope with Bereavement
Equipped hard wired In-born psychological processes that help us do the job Optimistic, flexible, resilient Self-serving bias telling us we are stronger than we are. Positive experience

Evidence Gathering Freud’s work based on interviews with no basis for theory Kubler- Ross studied people who were dying- not bereaved people Bowlby studied attachment issues of children and parents not bereaved people.

Sadness Grief not overwhelming but partly intense sadness
Normal and natural Sadness makes people more reflective: a forced time out. Oscillation between pain and sadness important: Bereaved temporarily reconnects with others Then continues the process of mourning.

Resilient People In Western Culture Normal not exceptional.
Expectation for bereaved people to feel constant sadness and grief Individualistic cultures based on peoples’ feelings

No trauma Majority of people in Nagasaki no trauma symptoms
New York residents after 9/11 had no trauma symptoms.

Coping Strategy Resilient people do not use avoidance as a coping strategy Think a lot about the loss or avoid the pain - Positive emotions and memories keep them stable Is there a resilient type? Evidence shows that some people cope with adversity better: but not specifically grief work. No clear pattern emerges in the way bereaved people describe their past that might account for their resilience. No general rule to the type or quality of the relationship to the lost person that promoted the healthiest forms of grieving. Relationships to others do not determine whether people cope with their loss

Memory Comfort from memory
Resilient people find comfort from the memory of the relationship. The relationship is not completely gone Share relationship experience with others In traditional theory comfort from memories is not dealing with the reality of loss. Comforting memories are just a fantasy substitution Resilient people are confident, more flexible with a broader repertoire of behaviours. Resilient people express emotion, but can also keep their feelings to themselves when appropriate.

10-15% of people Do not fare do well with Bereavement
The bereaved feels as if everything is missing, they are unable to hold onto positive relationships. Pain of grief can block all memories of the good. Prolonged grief is dominated by yearning for the lost person. Depression is global and has no object. All thoughts circle back to the lost person. Safety and happiness turn to fear and dread. link between prolonged grief and emotional dependency

Other Cultures Other cultures think more about the interactions between people and what they do Individual and their feelings are not so important

Chinese Culture In research Chinese people better at getting over grief that US. More grief work Memoires, feelings, thoughts about the deceased searched for meaning and how to make sense of the loss. In Chinese not related to suffering: grief work not related to level of distress.

Chinese Culture Chinese mourning rites focused on deceased
is on the imagined experience of the deceased: to help them to the land of the dead and find a good life. Crying at Chinese funerals is more deliberate: tightly orchestrated so that it occurs at the right moment of the ritual. Professional mourners and musicians hired to help. Crying sends a message to the deceased loved one. Focusing on the deceased rather than the bereaved apes the continued bond. For the Chinese the continued bond was more common with Chinese and more healthy. The more early bond made to the deceased the less distress they felt.

Chinese Culture In Asia continuing bond is sewn into the culture.
Many towns have ancestral temples to honour the dead, and commune with them Chinese ceremony – about honouring loved ones and particularly family and connection.

US Culture In the West for some this bond is healthy and for others not. If you are anxious about engaging in rituals that might not be accepted they lose their power Crying in the West when we cannot hold back the pain. The more Americans experienced grief work early on: the more difficult it was for them.

US Culture In US continued bond caused more distress for some and less distress for others Continuing bond is more adaptive in an culturally supported environment

Bonanno Conclusions Past evidence poorly collected
85% of bereaved recover well Hard-wired Most people are resilient Culturally resistant to Bereavement

Lunch John Montagu, 4th Earl of Sandwich

Bereavement Exercise

Bereavement Exercise Use this Assessment Guide to facilitate you to talk about Bereavement. You will only be asked to make comments to the large group that you wish to share. Brief History AT TIME OF LOSS Describe the events around the death PRE-LOSS What kind of relationship did you have to the Deceased. What sort of relationship was it? Good, ambivalent, poor? SINCE LOSS How are you coping? What are your feelings towards the Deceased? What do you miss. What do you not miss? LIFE EVENTS Do you have any experience of any other major/minor bereavements? FUTURE Do you see the future still in terms of the Bereaved Are you ready to move on? If not what prevents you? FAMILY NETWORK What support do you have? INTELLECTUAL Do you think you should be getting over it? IDENTITY Have you changed? What identity did the deceased give you if any? EMOTIONAL How did you feel about the deceased. How do you feel now? If you were to start Counselling what expectations would you have? Do you have any goals? HEALTH Has the Bereavement affected your physical or mental health. SEXUAL Any close relationships to deal with the bereavements PHILOSOPHY What are your values? Are you Religious? How does this help you cope? How are you coping with bereavement in general? LIFESTYLE Any Addictions PRACTICAL Housing, Benefits, Money ANY OTHER ISSUES Are there any other issues that you have that have not been mentioned. You might have talked about this already!

Ten Key Points of Bereavement Counselling
1. Listening … Hearing 2. Reflecting and Empathising 3. Acceptance / Trust 4. The Presenting Past 5. Bereavement / Attachment Theory

6. The Client’s Feelings/Our own reaction to the Client’s Feelings / Own Bereavement 7. Hidden / Unknown Feelings 8. Confidential Counsellor – Client Relationship 9. Boundaries – Space / Time / Frequency /Continuity 10. Beginning, Endings, Breaks

Working with Bereavement & Loss

The Bereavement & Loss Worker
My own experiences Not definitive Able to be challenged

The Bereavement & Loss Worker
Your Own Bereavement History Experience Attachment

Your Resources Work Life Personal Life Social Life Balance Support

Organisation Cultural Environment
Management Support / Clinical Supervision Links to other services internal / external

Role What is your role? Is it clear? To you? To Managers? To others?
Has it developed by creeping from another role? Is it recognised?

Protect yourself Bottom Line Thinking
Have you evidenced what you have done? Risk reporting Look after yourself Take breaks Insurance? Accountability? Clinical Responsibility Saving the World

Who is helping Who? Motivation? Altruism? Our agenda?
Two Bereaved people in the room?

Other Workers Assumptions Organisation / Other workers understand your role? Sensitivity – taking over other workers’ roles Status Paid workers / Volunteers

Precious Avoid Similar to other services Be open
Have a sense of humour about counselling ‘peculiarities’

Envious Attack! Your role might be envied You are perceived as: -
Special? Secretive? Doing something nobody else can do?

Contracting Boundaries Space / Room Privacy / Confidentiality

Risk Clarity Who do you report risk to?
Person’s perception of actions around risk

Skills Listening Hearing
Reflecting back – demonstrating you have done the above

Role Model Nurturing, caring, available Tough, Boundaries, limits
Copy what you do / are - Not what you say Be professional person/organisation

“Being with” Trying to be with the person Showing you are trying to be with the person Comments and Interpretations

Beginnings, Breaks, and Endings
Importance? How? – notice, repeat Beginning and ending of contract / sessions

Goals To establish Acceptance Trust Empathy
What happens if you cannot?

Resistance / Avoidance
Respect it - it is there for a good reason Is the person ready to talk Timing – too near bereavement Be available

Hidden Be aware of what might be unknown
To you and the bereaved person Comfortable with not knowing

Actions Is what you are saying precipitating an action?
Is this your role? What message? Separate “being with” / actions

Administration Policies and Procedures Health and Safety Lone working
Forms - attendance, recording, risk

Case Examples

Audio Visual St. Christopher’s Hospice Bereavement Group – 20 minutes
people with terminal illness Tavistock Institute Couple whose son has died 40 minutes poor quality Dr Anthony Crouch minutes

Attachment Statistics Julia Buckroyd Emeritus Professor of Counselling University of Hertfordshire Population: 65% Secure Attachment 20% Ambivalent Attachment 15% Avoidant Attachment 2% Disintegrated Attachment Counsellors / Therapists?

Attachment Exercise You are child in a family environment
Recall an incident when you did something wrong What was the reaction from the primary care giver?

Comment Attachment begins in baby / childhood
Adolescence a good study – Major attachment – separation – attachment period of life

Successfully Attached 12 year old
Independent Separation Work / Study Words to feelings

Tasks of Attached Adolescent
Independent Separation Sexuality Choice Sense of Self Compulsion dodges, delays development

Developing emotional management How ?
Baby cannot regulate emotions alone Implications for brain development Secure attachment – person can self soothe / trust other people Insecure attachment – person needs external substances Deficit in developing sense of self

The Attachment Counsellor Tasks
We all manage feelings with thoughts at 2 Levels: Conscious / Unconscious Cognitive (the behaviour) / Emotional

The Healing Relationship
Active – Interactive Attuned (Daniel Stern) Accepting Reflective Modelling Nurture Sitting in silence doesn’t work!

Sometime later……… Repair by: Teaching Skills Encouraging Experiment
Containing Anxiety Encourage Reporting

Change Internal Dialogue
Restrain Critical Parent Taking Care of Child Develop the Adult …………easy to say!

Attentive and responsive to the client’s needs
See and feel the client’s world through the client’s eyes These points are transferred to the counselling session

Mother and Baby D.W.Winnicott
Studied a lot of mother baby interactions Potential space How does primary relationship enable separation to be tolerated by the baby? Transitional Object Must be allowed to have rights over the object Good enough parenting and mothering Play negotiation between inner psychic reality and outer worldly reality Culture originating in Potential Space as relationship of experience

Case Study: Ethnic Differences – Dealing with Grief and Loss
WASP Culture - psychologies emotional pain Ethnic Groups – somatise emotional pain WASP culture might struggle to support non WASP grief Differences unrecognised until major loss occurs Individuals might lack focus, energy, flexibility to deal with loss 1st major Loss – 1st experience of mortality Existential P.105 Handbook of Bereavement, Cambridge 1993

Edit from here! One person’s grief can seem inappropriate to another
Individuals who attempt to assimilate a different culture’s norms Struggle – self control, Silence, Guilt, Depression, Unable to resolve loss. People in transit between cultures struggle to find an appropriate grieving process.

Case Study: Kibbutz – Children’s Homes
Collective sleeping arrangements Starts a few months after birth Infant mother attachment 59% compared to 75% in Israeli day centres possible environment for insecure attachments Ambivalent attachment experience encouraged by national security environment (P.721 Handbook of Attachment Guildford 1999)

Case Study: Attachment in One Child Families in China
Chinese culture favours Interdependence rather than individuality Comparable to Japan Chinese parents emphasise Harmony and control Western parents emphasise individuality and spontaneity Beijing study evaluated secure attachment (P.719 Handbook of Attachment Guildford 1999) {Goa and Wu (Posada et al. 1995)]

Emotional interdependence did not feature highly.
Valuing interdependence not incompatible with individuality Age of child – attitude towards child changes in adulthood – presume responsibility for themselves.

Assessment Visit Report on Assessment Visit Client: Counsellor:
Address: Session No: Date of Visit: Tel No: Relationship to Deceased: Name of Deceased: Date of Death: Brief History AT TIME OF LOSS Describe the events around the death. PRE-LOSS What kind of relationship did you have to the Deceased. Was it good / bad? SINCE LOSS How are you coping? What are your feelings towards the Deceased? What do you miss. What do you not miss? LIFE EVENTS Do you have any other major/minor bereavements FUTURE Do you see the future still in terms of the Bereaved or are you ready to move on FAMILY NETWORK What support do you have? INTELLECTUAL Do you think you should be getting over it? IDENTITY Have you changed? What identity did the deceased give you if any? EMOTIONAL How did you feel about the deceased. How do you feel now?- Counselling Expectations? HEALTH On Medication SEXUAL Any close relationships to deal with the bereavements PHILOSOPHY Religion: how are they coping with bereavement. LIFESTYLE Any Addictions PRACTICAL Housing, Benefits, Money. COUNSELLING DECISION / CONTRACT: NEXT APPOINTMENT: DATE: DAY: TIME: PLACE:

1. Clinical Boundaries: – Space / Time / Frequency Continuity, Beginning, Endings, Breaks 2. Confidentiality: Counsellor-Client Relationship 3. Listening and Hearing 4. Reflecting and Empathising 5. Creating Acceptance / Trust 6. Focus of the Bereavement 7. Bereavement / Attachment Theory The Client’s Feelings/Our own reaction to the Client’s Feelings / Own Bereavement Hidden / Unknown Feelings

Audio Visual Bereavement TV Programme 35 minutes
Four examples of people talking about Bereavement from different cultures and social backgrounds. Man living in France educated in private system in the UK. Mother died, Father died. Father whose wife died of breast cancer. Description by father and his two sons about their experience of the Hospice system. Young boy whose father died of skin cancer. Supported through bereavement process with counseling. Group of older widowers talking about bereavement. Issues of loss, gender, being alone.

Ted Talk: What I learnt about Loss 17 minutes

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Ted Talk: What I learnt about Loss 17 minutes

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