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

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

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

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

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

Grief is an individual phenomena!

Lets Chat about these Cases

Kito
Elena Jane Billy

 What loss and grief loss requires the counselor to do:

a. Prioritize uniqueness of our clients and their experiences within the context of their lives b. Recognize normality of grief, empower clients to be actively involved in their adaptation to loss, support clients without attempting to cure or fix them

c. Respect clients as experts on themselves

Lets talk about the last one

Humphrey Chapter 9 pgs. 213 219

Three Roles
Witness Facilitator Collaborator

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:
1. Listen more than we talk 2. Employ respectful silence 3. Fully attend (see what is here) 4. Exhibit comfort 5. Allow grief (dont fix even when clients request rescue) 6. No judgment

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!

Facilitator Medicine:
1 2 Encourage recognition and use clients strengths, resources and abilities 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 Consult with clients regularly as to direction of therapy, and usefulness of various techniques / activities Assist clients where they are - not where the counselor wants them to be

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

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

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

Video Emersion: Practicing The Three Roles

Listening To and Listening For Loss and Grief

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

Lets not Get Ahead of ourselves?

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

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

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

Primary and Secondary Losses

Primary Loss: significant loss event such as death

Secondary Loss: come about as a result of a primary loss

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

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:

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 absent:person 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

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

Historical oppression Racism Residential school

Immigration

Cultural losses

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 Cognitive Behavioral Spiritual (emotional response / regulation) (analysis, reframing, distraction or avoidance (problem solving, activity, behavioral distraction) (prayer, meditation, rituals)

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

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
30

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

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

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

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

Video Emersion: Shattered Assumptive Word

Video II: Disrupted Meaning Structures

Other Psychosocial factors

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

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

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

Complicated Bereavement Grief

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

(Prigerson et al. 1995)

Toward Diagnosis: Four Proposed Criterions

A. Symptoms must last for 6 months B. Symptoms cause marked dysfunction in social, occupations or other important domains C. Yearning, pining, longing for deceased must be experienced at least daily over past month to a distressing or disruptive degree

D. 4 symptoms of 8 must be experienced in the past month as extreme

These are:

 Trouble accepting death Inability to trust others since the death

Excessive bitterness about the death

Feeling uneasy about moving on with ones life Feeling emotionally numb/detached from others since death Feeling life is meaningless without the deceased Feeling the future holds no meaning without the deceased Feeling agitated, jumpy, or on edge since the death

Lets talk about pathologizing grief

Contemporary Models of Loss Adaptation

Martin and Dokas Adaptive Grieving Styles

Dual Process Model of Coping

Adaptive Grieving Model

Model focuses on:

A. Specific patterns of grieving that is natural to the person, and

A. The preferred cognitive, behavioral, affective, and spiritual strategies an individual uses to manage our innate response to loss

Continuum: 3 Basic Grieving Styles

Intuitive

Blended

Through emotion Tend to express emotions intensely

Both intuitively and instrumentally

Usually, however, will have a greater emphasis on one polarity

Instrumental

Respond to loss:

Respond to loss

Respond to loss cognitively Modulate emotion Express grief in terms of thoughts and activity

A Closer Look at The: Intuitive and Instrumental

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

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

Affective Strategies

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?

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

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.

What are we seeing here?

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

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

Dissonance Response: More Instrumental Griever

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

Counseling Implications?