1. New Hampshire Psychological Association Meeting – May 6, 2011 Gerald P. Koocher, PhD, ABPP Simmons College www.pedpsych.org

2.  Accepting the reality of the loss  Grieving: experiencing the pain and emotion associated with the loss  Adjusting to the new reality  Commemoration: relocating representation of the deceased in one’s own life

3.  What did we learn from…  our culture?  our family of origin?  our personal loss experiences?  What does this particular loss mean?  to my support system (social and economic)  in light of my quest for meaning (attributions and sense of self)

4. Supported by National Institute of Mental Health Grant No. R01 MH41791 Gerald P. Koocher, Ph.D. and Beth Kemler, Ph.D. Principal Investigator and Co-Principal Investigator

5. Time elapsed since death Perceived social support Mean social support Week 1 Week 6

6.  External social support rises sharply after the loss event and then declines  Intra-familial support can be variable Congruence Complementary Mutual Escape Distancer and Pursuer

7. T1 T1 T2 T2T1 T2 3 months 9 months Group 1 Group 2 Comparison Group

8.  Part I – 90 minutes  Family members tell their stories ▪ Assure that all speak for themselves  Exploration of coping ▪ Circular questioning about perceptions of self and others  Education about grief ▪ Child versus Adult patterns

9.  To assist the telling of the story, the intervener asks specific questions pertaining to  the times of the diagnosis or accident,  the funeral, and the period following the funeral.  The purpose of the questions is to provide some structure for eliciting everyone's story, as well as to make clear each person's conception (or misconception) regarding causality, blame, and cognitive understanding of the death How to do it and why:

10.  Part I – 90 minutes (continued)  Acknowledge pain and discomfort of discussing the loss again  Give parents reading material ▪ The Bereft Parent (Schiff)  Assign Homework for Session II ▪ Each family member to choose memory object for next session, but avoid discussing the choice at home.

11.  The parental subsystem remains critical one in grief affecting the entire family system.  Parents may differ on how to handle discussing death within the family, especially with the surviving siblings.  Another frequent source of tension may result from asynchrony in the style and/or timing of parental grieving.  Parents may disagree on how to deal with behavioral issues in the surviving children.  How open and direct to be around the topic of death, how much autonomy to allow, limit setting, etc.

12.  Part II: parents only- additional 30 minutes  Explore dyadic issues ▪ Sources of tension in the relationship (e.g., sexual disruption, replacement child, etc.)  Discuss losses in family of origin context ▪ How were you taught to deal with loss?  Review personal loss histories ▪ What important losses have you suffered previously?

13.  Part I: parents only - first 30 minutes  Explore interval since first session  Address any recent concerns  Normalize the distress of reawakening grief  Provide encouragement for coping efforts made to date

14.  Part II: family meeting- 90 minutes  Two Exercises: ▪ Remembering the deceased child ▪ Family letter writing

15.  Remembering the deceased child  What reminder has each person brought? ▪ Discuss the meaning of the item.  How is the child remembered. ▪ Where are the reminders at home?  Assess idealization. ▪ Are negative memories tolerated? ▪ What has been done with the child’s room and belongings? ▪ Explore cemetery visits.  Discuss how the family has changed.

16.  Family letter writing activity  May be literal or figurative, written or taped.  Young siblings can draw pictures.  Goal: create emotional object to take home.  Content: ▪ Things left unsaid ▪ Memories shared ▪ Unanswered questions

17.  Anticipating anniversary phenomena.  Which will be most difficult for whom?  Review normal grief and “warning signs.”  Discuss re-involvement in the world for each person.

18.  Explore meaning-making for each person.  Philosophy of life  Hope for the future  Plan family activity outside the home.  Dealing with relatives and friends.  Dealing with PIG (people in general) and their helpful or NOT comments

19.  Staying withdrawn from family and friends  Persistent blame or guilt  Feelings of wanting to die  Persistent anxiety; especially when separating from parents or surviving children  Unusual and persistent performance problems at work or school  New patterns of aggressive behavior  Accident proneness  Acting as though nothing happened, or happier than normal  Persistent physical complaints  Extended use of Rx or non- Rx drugs and alcohol

21.  Five aspects  Physical  Emotional  Behavioral  Interpersonal  Attitudinal

22.  Anger/Hostility  Chronic Frustration  Depression  Apathy  Exhaustion  Emotional and physical  Malice and aversion toward patients  Reduced productivity and effectiveness at work

23.  Role ambiguity  Vague or inconsistent expectations/demands  Conflicts  Discrepancy between real/ideal work functions  Unrealistic pre-employment expectations  Lack of support at work

24.  The Asshole Factor  (temporary and certified status)  Demeaning, bullying, hypercritical…all too common in medicine ▪ Example- medical error reporting  The No Asshole Rule: Building a Civilized Workplace and Surviving One That Isn't -- by Robert I. Sutton

25.  Role clarity  Positive feedback and recognition  Enhanced staff autonomy  Providing for stress recovery at work  Social support at work

26.  Perfectionistic personality  Losses in the family  Chronic helplessness  Permeable boundaries  Substance abuse  Expectations  The Savior Complex  External control orientation (I-E Scale)

27.  Sense of personal accomplishment  Realistic criteria  Including patient outcome expectations  Accurate awareness of personal strengths and weaknesses  Internal control orientation (I-E Scale)

29.  Most important: how do we know that the patient will perceive the news as 'bad'?  A patient may receive definite news--whether or not it is perceived by clinicians as 'bad'--as conferring a degree of certainty and feel grateful for this, particularly if it confirms a long held suspicion or belief.  Equally important: information that the bearer may have thought of as relatively unimportant may have a severe impact on the patient and/or family members. Hart, C., Harrison, A., & Hart, C. (2006). Breaking Bad News. In Mental health care for nurses: Applying mental health skills in the general hospital. (pp. 82-94): Blackwell Publishing: Malden.

30.  Someone who knows the patient/family.  The person who has all the information available, to cover any questions the patient or family may ask.  Who is that? The primary care physician, as the person with overall responsibility for the patient's treatment, a team, a 'specialist' in such matters as breaking bad news?  Communicating bad news is most closely associated with having to tell patients about a terminal prognosis.

31.  Try not to protect yourself with distancing.  Just because you have bad news should not prevent you from offering support. “You have a serious illness of an undisclosed nature.”

32.  Try to understand and respect the perspective of the recipient.

33.  Deliver the bottom line first, then explain.

34.  The "good news/bad news approach does not help if the news is only really bad.

35.  Have a plan or help the recipient to engage in developing one.  When stress is high written information can help.  Set up ongoing support and availability.

36.  Be human, and be present.