1. Morning Session 10.40Introduction 10.55 Icebreaker Exercise 11.40Break 12.00Theory and Group Discussion 1pmLunch

2. Afternoon Session 2pm Working with your own Bereavement & Loss 2.45pmBreak 3pmWorking with Bereavement & Loss 3.30 Case Examples – Video 4.10Round Up / administration 4.30End

3. Your Experience & Ideas Case Examples

4. 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 5 minutes

5. Learning Outcomes Icebreaker Exercise - Counselling Skills Understanding Bereavement & Loss Theory Assessment Exercise -Own Experience/ Attachment An Understanding of Working with Bereavement & Loss Case Examples - Video / Suggestions from you!

6. 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

7. 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.

8. 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!

9. 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

10. 10-15 minute Break

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

12. 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 “ 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 surprise 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 Handout

13. Colin Murray Parkes Bereavement: Studies of Grief in Adult Life Paperback: 288 pages Publisher: Penguin Books Ltd; 3New Ed edition (1998) ISBN-10: 0140257543

14. “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

15. 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??

16. Types of Loss Actual loss Death from old age, illness, accidents. Old person more acceptable loss Younger person less acceptable loss Discuss Perceived loss Person’s view of loss Culture, history, family, socialisation? Bereavement Counselling Time-limited Focus solely on bereavement

17. 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?

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

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

20. 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

21. 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

22. Bereavement is like a tide

23. 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

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

25. 3.Mitigation–Lessening Impact of Bereavement Components of grief work Pre-occupation / wish to find the person Repeating, painful recollection of the loss Discuss: patterns, PTSD Making sense of the loss to fit assumptions Discuss: meaning? Dreams Common dream: happy interaction with the dead Pining / Avoidance of Pining Idealised person - forget the negative

26. 4.Anger and Guilt Familiarity Misdirection Blame / Self Blame Family Split Resistance

27. 5.Disorganisation and Despair Period of uncertainty New set of expectations Time / Acceptance? Old model of the world abandoned Other people: support, security, protection. Take on the reality of what has happened Identifying with lost person – method of avoiding the loss of that person

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

31. 6 March 1987 193 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.

32. 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.

33. 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”.

34. 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. Extending the Event- Searching

35. Avoidance Panic Throughout this period he exerted a rigid control and he was still not crying two months later when he was persuaded to seek psychiatric help. At this time he was tense and tremulous, 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. No Interest in himself Suicidal Stuck

36. 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 the 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?” Routine Event re-enacts trauma - moves stuckness

37. Post-Traumatic Stress Disorder The case illustrates the features of 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.

38. Colin Murray-Parkes Conclusions What helped the bereavement process was:- 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

39. This case study poses a question………?? What determines how a Bereavement affects a person?

40. Stressors Stress & Trauma part of Bereavement Wide variations Type of stress Coping strategies Perception Capacity to tolerate strong feelings Self Esteem

41. Key Determinants of the Affect of Bereavement Situation and Environment of the Bereaved Age Gender Personality Proneness to Grief Inhibition of Feelings Expression of grief Socio-economic Status (Social Status) Nationality Religion Cultural Factors of Grief

42. Before the Bereavement Relationship to the Deceased Type of Relationship Strength of Attachment Security of Attachment Degree of reliance InvolvementIntensity of Ambivalence Childhood Experiences Later Bereavement Experiences Previous mental health Life Crises prior to the Bereavement Type of Death

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

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

45. 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:five stages of grief model Personal change model beyond death and dying.

46. 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.

47. 1 - Denial Denial is a conscious or unconscious refusal to accept Natural defence mechanism Can be locked in this stage

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

49. 3. Bargaining Preparatory grieving Dress rehearsal or the practice run for the 'aftermath' People facing death bargain with God /Own beliefs Bargaining in relationships: "Can we still be friends?.." when facing a break-up Bargaining rarely provides a sustainable solution

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

51. 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

52. 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

53. 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

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

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

56. 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

57. 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

58. 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)