Grief and loss; getting through the tough times
...d as overcoming denial and coming to full face with the reality that the person is dead and will not return. The second task, to work through the pain of grief, has been interpreted as being able to experience the intense pain that is associated with the loss of a loved one. The third task, to adjust to the environment in which the deceased is missing, has been interpreted as being able to function as the bereaved faces living alone, raising children, managing finances, adapting to new roles (widow) and continuing to build self-esteem, self-worth and self efficacy. The fourth task, emotionally relocating the deceased and moving on with life, has been subject to particular discussion. One interpretation of this task is not that the bereaved abandon the memory of the deceased; rather it is that they recognize a different perspective on the deceased and begin to find joy in their life and in relationships with others. Once these four tasks have been completed, grief is assumed to have been resolved. As with all models of grief, criticism has been made of the idea that grief tasks can be resolved and grief can be left behind. Good section. Identifying Grief Complicated or uncomplicated grief Grief is the name given to the reactions we have after the death of someone who has been close to us. Grief can resemble a physical injury, which may be spoken of as a “blow”. A wound gradually heals for the inside out, a process that takes time. Grief a natural reaction is also a time in which a person has to heal from inside out. The grief process is a time for healing and recovery, which can’t be rushed and will vary for each of us . Worden (2002) defines normal grief as a broad range of feelings and behaviors that are common after a loss. Individuals with normal reactions to loss will progress through the four dimensions of grief and will make an adaptation to the loss. This is referred to as uncomplicated grief. The individual was able to process their emotions, find meaning to the death, adjust to live without the deceased, and emotional relocated the deceased and move on with life. This is not to say that the deceased will not be missed or forgotten. There may even be times in the future when the loss or grief may resurface but only for a brief time. In identifying uncomplicated grief, there are no symptoms that would meet the diagnostic criteria for a psychiatric disorder. In uncomplicated grief, there are behaviors that manifest themselves as depression Worden (2002. pg. 22) cites “Freud’s belief that in grief, the world looks poor and empty while in depression, the person feels poor and empty.” However, from time to time, an individual do not cope with the feelings and behaviors associated with grief. There are a number of factors that may complicate the grief process such as the relationship with the deceased, the mode of death, did the survivor have a chance to say good-bye and past losses. Worden (2002) discusses diagnosing complicated grief and states that there are twelve clues to unresolved grief. The first clue states that the individual being interviewed cannot speak about the deceased without becoming upset as if h/she were experiencing intense and fresh grief. This fresh and intense sadness can occur many years after the loss. The second clue states that minor events trigger an intense grief reaction. The third clue states that themes of loss continually come up in the interview process. The fourth clue states the person who suffered the loss will not be able to depart with material possessions that belonged to the deceased or departs with material possessions of the deceased to soon. The fifth clue states the individual with have reported developing the same symptoms the deceased had and the symptoms are problematic around anniversaries. The sixth clue indicates that the individual would have made some radical life changes immediately following the death. Clues seven dates the individual may have a history of clinical depression. Clue eight discusses the individual have an impulse to imitate the deceased. Clue nine discusses the self-destructive impulses that may be triggered by any situation. Clue ten discusses unexplained and accountable depression that only happens at specific times during the year. Clue eleven discuss the individual possibly reporting phobias or illnesses about death and they are related the illness of the deceased. Clue twelve discusses the need for the therapist to discuss circumstances surrounding the death in order to gather additional information that may indicate unresolved grief. Complicated grief can sometimes be difficult to determine due to the signs and symptoms of psychiatric disorders. It appears that clinicians are more comfortable making diagnosis of psychiatric disorders than complicated grief. Some of the common psychiatric disorders seen in complicated grief are depression, anxiety, and phobias. Unfortunately, these disorders end up being treated the grief remains unresolved. In my experience, I have found that a high percent of individuals with psychiatric disorders have underlying unresolved grief. For example, I was treating an individual who had been diagnosed with major depressive disorder who appeared to be a classic case; however, as I continued to assess the individual, it became clear that there was some unresolved grief for the loss of a parent. The parent had been deceased since 1988. Once we dealt with the grief, the individual was able to process the emotion, adjust to changes in life, and emotional relocate the deceased, the depression left and the individual was able to move on with life. As a matter of fact, she is now helping other with their grief. Grief in adults There is evidence that all individual will grieve to some degree at sometime. When we look at adults and the grief process, adults do have manifestation of complicated and uncomplicated grief. Worden (2002) gives some examples of how adults try to express their grief when they are not being strong for someone else. Adults try to hide their emotional state and will make comments “I lost it at the funeral home.” If adults fail to experience the sadness, it can lead to complicated grief. Adults tend to show their anger by blaming others for the death of their loved one and sometimes will blame themselves. The key is to not displace the anger but to work through the anger in order to reach or maintain a healthy self. One of the biggest feelings for adults is guilt. There is always the thought of “What if I had done this or that, may they would still be alive.” Two of the biggest behavioral manifestation of grief in adults is loss of appetite and sleep disturbance. This is especially difficult if you lose a spouse after fifty or sixty years of marriage, there was always someone there to eat with sleep with and now they are gone. This takes a lot of time adjusting to as well as managing the emotional pain. In talking with clients who have lost spouse of long marriages, they have reported that eating and sleeping is just not the same. One stated that the security was gone, what if I choke who will help me, what if I get sick at night; who will come and take care of me? Oftentimes, adults withdraw socially and become isolated from family and friends. When the adult is not able to process the emotions, accept the reality of the death, their grief becomes complicated and that is usually when they will seek help. Osterweis and Townsend (1988) summarized adult bereavement as including the following: The bereavement process is long, much longer than most people consider. In fact, some people find that the second year of grief is more difficult than the first. For many people, the grief process may take several years. The bereavement process does not necessarily progress in an orderly fashion. People do not systematically move through a series of stages as they address and resolve their grief. Individual variation in grief is substantial. People vary in how fast they are able to recover from loss and the issues that are a part of their grief work. They also have different resources to draw on and this affects speed of resolution. Many emotions and behaviors that might be judged abnormal under other circumstances are common following loss. It is inappropriate to judge the bereaved by "normal" standards, as their life is not normal after a loss. Anniversary reactions are common. Grief makes it difficult, if not impossible, to enjoy joyful times. This makes it difficult to experience times that were once joyous. Holidays, anniversaries, important family events, the time the loss occurred all may be experienced as painful rather than joyous now. Another important point to keep in mind about adult grief is this: Although it seems that adult would have a full conceptual understanding of death (e.g., it is final, irreversible, and universal), this is not necessarily so. Writing from a psychotherapeutic perspective, Beverly Raphael (1983) observed that adults engage in the following: magical thinking, the feeling that they may have somehow been responsible for the loss because they wished for it or in some other way caused it. fantasies about the deceased, the belief that one might be reunited with or maintain an active connection with the deceased. She would include here the belief that the deceased is an active (albeit ephemeral) part of one's life after death; the belief that one can be reunited with the deceased through dreams; and that one can reunite with the deceased through the use of spiritual mediums, magical rituals, by performing certain acts, the bereaved maintains a connection with the deceased. This would include a variety of rituals and ceremonies that are both formal and informal; dread of word "death" or anything related to it. This is the superstitious view that you shouldn't tempt fate by using the "forbidden" word. "If you don't talk/think about it, it won't happen." Probably because of the intensity of the loss and its impact on their assumptive world, these activities are far more likely with traumatic losses. Losses that occur out of sequence most often experienced as trauma. You may think of other examples of these; a partial list includes young widowhood, the death of one's child at any age, the death of one's wife at any age). Another factor that has is very much in evidence among adult grievers is guilt. This is particularly true among adult grievers. Miles and Demi (1986) identified six different manifestations of guilt among parents who have lost a child. Their grief seems to come from being helpless unable to protect their child from harm. The guilt they describe for parents often can be seen among other grievers and among those who are grieving losses other than those caused by death: death causation guilt -- the belief that they either contributed to or failed to protect their child from death; illness-related guilt -- these relate to perceived deficiencies in the parent's behavior during child's illness or at time of death; parental role guilt -- in this, the parents feel they failed to live up to their own or societal expectations in their overall performance of the parental role; moral guilt -- the belief that child's death was some type of punishment or retribution for violating a moral or religious standard; survival guilt -- in this, parents struggle with the violation of the standard that a child should outlive his/her parents and, in their case, this was not true; and grief guilt -- relates to the view that they did not grieve "right" at the time of their child's death. Grief in children The questions has been asked of many therapist, doctors and psychologist “Do children grieve?” Yes, children and adolescents do grieve. The grief of children and adolescents is far more complex than many adults assume. Among the factors that contribute to this complexity is the simple fact that children and adolescents go through a grief experience that is limited by their developmental level. Children and adolescents will re-experience the effects of a loss throughout their lives. Attempting to avoid the reality of their grief will not make it "go away." Rather, it will simply be sealed over to be exposed again, possibly with greater intensity, since it has not been dealt with at an earlier time (Gilbert, 1995). Children may experience the following physical, emotional, cognitive, and behavioral symptoms common in the grieving process: The child continually re-tells events about his or her loved one and their death; feels the loved one is present in some way and speaks of him or her in the present tense; dreams about the loved one and longs to be with him or her; experiences nightmares and sleeplessness; cannot concentrate on schoolwork, becomes disorganized, and/or cannot complete homework; finds it difficult to follow directions or becomes overly talkative; appears at times to feel nothing; is pre-occupied with death and worries excessively about health issues; is afraid to be left alone; often cries at unexpected times; wets the bed or loses his or her appetite; shows regressive behaviors (e.g., is clingy or babyish); idealizes or imitates the loved one and assumes his or her mannerisms; creates his or her own spiritual belief system; becomes a class bully or a class clown; shows reckless physical action; has headaches and stomach aches; and rejects old friends, withdraws, or acts out. In addition, children's grief can be complicated, and common signs include withdrawal, sleep disorders, anxiety, difficulty in concentration, and regression. The common signs associated with children's bereavement may become heightened by their intensity, frequency, and duration. The term disenfranchised grief is used by Doka (1989) to refer to losses that cannot be openly acknowledged, socially sanctioned, or publicly mourned. Five categories of situations may create complications for the bereaved child (Goldman, 2001). These categories are: Sudden or traumatic death; Social stigma and shame; Multiple losses; Past relationship with the deceased; and the grief process of the surviving parent or caretaker. Grief in families Families are seen as a supportive resource for bereaved family members; however, grief in families is a complicated thing, because each person must deal with his or her own grief while also dealing with that of others in the family. When the loss affects all family members, the expectation may be that others in our family will be supportive and understanding. After all, they have experienced the same loss, haven't they? In the case of the loss directly affecting only one (or few) family member, do others grieve too? In such a case, how far does grief extend beyond the primary griever(s)? Grief in families is naturally complex, involving disagreements, alliances, and negotiation, reconfiguration of family roles and contradictions in expectations about behaviors. It may be, as Rosenblatt et al. (1991) found, that others in the family are the worst people to turn to at the time of loss, simply because the loss is equally fresh for all of them. The situation is never easy, and the grief of one can set off the grief of others. At the same time, they may also give each other a sense of perspective on the loss that they may not be able to get anywhere else. If they are able to move beyond their relationship "baggage" and do not depend solely on each other, they may find that their relationship is enriched by their mutual loss. Loss in families can be tremendously painful and can contribute to the breakdown of the family system. It can also serve as a catalyst for positive change. With the loss of a family member, the family system will change. Family structure is modified as a result of the loss and the family system must be reorganized to adapt to that change. If the deceased person had played a central role in the functioning of the family and the family is relatively rigid in identifying that specific individual in that role, adaptation to the loss will be made more difficult. If they are more flexible, adaptation will be made easier (Gilbert). Much work in this area focuses on the mutual loss of a family member, but families are indirectly affected by the loss experience of individual or few family members. Impacts of the loss may spread through the family and may not be restricted to the generations who directly experience the loss. Grief has an effect across multiple generations and within the extended family culture. Loss can affect family development into future generations. Transgenerational effects of loss have been explored by Bowen (1991), who found through his practice of therapy that unresolved loss can have long-term implications for the family. His contention is that loss disrupts normal family process and this can extend into future generations if it is not resolved. Grief Counseling and/or Grief Therapy Determining the need for counseling or therapy There is a belief that all individuals, particularly those that experience the death of a parent or child should be offered grief counseling or therapy. The loss of a parent or child has been labeled as a very traumatic event (Worden, 2002). Oftentimes, the individual will determine a need for counseling or therapy when their grief become overwhelming and they can longer maintain a healthy mental state. There are also those that believe if we can predict who will have problems with grief, we can do early intervention to prevent complicated grief. Goals of grief counseling and grief therapy Worden (2002) makes the following distinction between grief counseling and grief therapy. Grief counseling has a goal of facilitating the tasks of mourning in the bereaved in order that the bereavement process comes to a successful end; whereas, grief therapy has the goal of identifying and resolving the conflicts of separation which preclude the completion of mourning tasks when the grief is absent, delayed, excessive, or prolonged. Principles and techniques of grief counseling and therapy One of the simplest principles of counseling is to listen; therefore, grief counselor should be good and patient listener. Along with that, Worden (2002) suggested the following principles as a guideline for counselors to help clients work through their grief and reach a acceptable resolution: help the survivor actualize the lose, help the survivor to identify and experience feelings, assist living without the deceased, help find meaning in the loss, facilitate emotional relocation of the deceased, provide time to grieve, interpret “normal” behavior, allow for individual differences, examine defenses and coping styles, and identify pathology and refer. By following these principles, one will be able to help the bereaved complete the tasks of mourning and move on with life. These principles help the counselor understand the goals of treatment; however, it is the counselor’s theoretical orientation that has the greatest impact on the progress of the counseling process. Worden (2002) also suggests some techniques that are based on theory. Those techniques include evocative language where the counselor uses the words that will evoke a response and not dance around the subject; use of symbols, here the counselor uses photos are other objects that help the bereaved move through the grief process; drawings and writings, sometimes it is easier to write about then talk about it. The counselor can interpret a lot from writing and drawing such as conflicts and feelings. Two of my favorites are role playing and memory book. Role playing help the bereaved deal with situations in which they are uncomfortable, it’s like practicing over and over until they get it right. The memory book has helped the bereaved focus on the positive attributes of the deceased and they are eventually able to emotional relocate the deceased and move on with life. As Worden (2002) stated, the purpose of all these techniques is to encourage he fullest expression of thoughts and feelings regarding the loss, including regrets and disappointments. Assessment tools used in grief counseling and therapy How do we know how to help the people that come to us for assistance in dealing with their problematic situations? Assessment is the process in which we gain pertinent information about the individuals’ situation and their need for treatment. When completing assessments on adults, we obtain information about the differences in the home, at work, and during social activities since the loss. Information is gathered about past losses, medical and mental health. One goal of the assessment process is to rule out medical problems, pathology and to determine whether the individual is experiencing complicated or uncomplicated grief. In children, one can use the tripartite assessment of bereaved children. Worden (2002) discusses the tripartite assessment and the factors that are considered: individual, factors related to death, and family social religious/cultural factors. The individual factors include age, cognitive development, medical information and past experiences with death. This information helps the counselor gain insight into the stage of grief. The factors related to death include the relationship with the deceased, was the bereaved able to say good-bye and the type of death. The information gathered here will help determine which type if grief is being experienced- complicated or uncomplicated. It has been stated earlier that the loss of a parent or child places the bereaved at risk for complicated grief. The family social and religious/cultural factors help gain insight into family functioning, family role, family influences, social influences, school influences and the religious values of the family and the individual. In addition to the tripartite assessment, there should be a psychosocial assessment completed. I’m in favor of the psychosocial assessment because it not only covers the items described above, but it addresses substance use and the mental health status. There are those individual who will use alcohol and drug to self-medicate due to the intense emotional response to the loss. It is important to be aware that the assessment occurs at all phases of treatment and does not end until the case has been closed. Cultural factors faced in grief counseling and therapy Webb (1993) cites McGoldrick, et al, who warns that clinicians should be careful about definitions of normality in assessing families’ response to death, because the manner of, as well as the length of time assumed normal for mourning differs from culture to culture. Being sensitive to culture is important when determining which techniques to use in therapy. One would not want to use any art therapy centered around the funeral if the family’s cultural belief is that children or adolescents do not attend funerals. The counselor needs to be culturally sensitive to the type of relationship between males and females in certain cultures, ability to make eye contact, language, and in family counseling, who should you address and what is the order of addressing other family members. It is my belief that counselor should be cultural competent in order to be an effective counselor with any group of individuals. Counselors should seek training on a regular basis to address questions and concerns for cultural competence as well as to gain insight into different cultural aspects of counseling. Individual counseling with adults and children Grief counseling for both individuals and children is completed most often when they are perceived to be suffering from complicated grief. One of the most important aspects of grief counseling is to work with the individual so that they are no worse off than before they came in for treatment. The assessment process will have help determine if the adult or children are stuck in any process of the tasks of mourning. Some of the interventions that can be completed with adults include one of the techniques of gestalt therapy, the empty chair, when the individual can process “unfinish...