THEORETICAL APPROACHES TO BEREAVEMENT CARE

1. THEORETICAL APPROACHES TO BEREAVEMENT CARE

2. OUTCOMES • To define bereavement, grief and mourning. • To discover the role of attachment in the theory of grief & bereavement • To identify theories of grief and bereavement. • To explore ways of supporting and helping those in a state of grief.

3. DEFINITIONS • Bereavement – the fact of loss, having been left after the death of a loved one • Grief – the process of adjustment to the state of bereavement • Mourning – the varied rituals concerning loss, culturally and socially conditioned

4. FACES OF GRIEF TRANSCENDS AGE GENDER CULTURE NATIONALITY

5. WE FIRST EXPERIENCE GRIEF AS INFANTS – THE URGE TO CRY AND SEARCH (SEPARATION ANXIETY) ATTACHMENT –THE MAINSPRING OF HUMAN SURVIVAL AND DEVELOPMENT – UNDERPINS GROWTH, LOVE AND GRIEF

6. OTHER PRIMATES MUST ATTACH TO CARERS AND GRIEVE THEIR LOSS FLINT THE CHIMP WHO ‘PINED AWAY’ AND DIED AFTER HIS MOTHER’S DEATH

7. ATTACHMENT THEORY • a ‘meta theory’ underpinning human growth and development • Why is attachment important? Our early attachment experiences shape: - neurological development - our emotional intelligence - optimal cognitive development - how we make & sustain relationships - how we give and receive care - our adult behaviour in parenting & loving - how we deal with loss & relinquish relationship

8. Secure attachments in the making – how young minds grow in relationships (Alan Schore) Attachment conditions; How humans make, maintain and relinquish relationships

9. ATTACHMENT • Humans are genetically programmed to form primary attachments: an infant has no more choice in this than in the matter of being hungry for food - this affects us throughout our lifespan. • Loss or separation results in observable ‘Attachment behaviour’ – crying, approaching, clinging – the visible signs of inner distress..... ....each & every behaviour has the predictable outcome of increasing proximity with the carer’ Montuori& Garelli, 1997

10. In summary - Attachment is the basic human survival mechanism • Secure attachments formed in the safety of nurturing relationships ensure basic human survival, growth and optimal emotional and neurological development (Bowlby et al) • Attachment theory underpins several modern approaches to understanding grief

11. THE CHEMISTRY OF ATTACHMENT Chemicals of emotion’, neurotransmitters activated by attachment include: • Oxytocin & opioids (endorphins) – ‘feel good’ chemicals • GABA ( gamma aminobutyric acid) – helps regulate anxiety • Dopamine – feelings of enjoyment, excitement, curiosity & motivation in learning • Serotonin – helps regulate mood, sleep, appetite, arousal • Adrenaline & noradrenaline – in right amounts help clear thinking

12. Stress hormones protect from danger - ‘fight or flight’ - action of adrenaline, cortisol • If hormonal response to stress can’t be switched off, person remains on constant alert • For infants - Impact on foetal brain development • Child not free to learn, explore their environment or grow in relationships For adults, grief is accompanied by an ‘overdose’ of these stress hormones and a depletion of the ‘chemicals of emotion’

13. BEREAVEMENT AND ATTACHMENT • Bereavement, the fact of loss by death - A major crises in life, is shared by all of us • Grief is the process by which the adjustment to loss is made – sometimes called a ‘healing process’ • ‘Grief is the price we pay for love’ ------ attributed to the late Queen Mother: what do we understand by this?

14. We can understand love and loss - joy in relationships and grief at their ending - as two sides of the same coin– the human attachment system. • Love between adults - often defined by psychologists as ‘romantic attachment’ – is often coloured by separation anxiety especially when threatened by illness: • ‘.....the fact that one day we shall lose the ones we love, and they us, draws us closer to them but remains a silent bell that wakes us in the night’ • ---- Colin Murray Parkes 2006

15. Grief prior to death – ‘anticipatory grief’ - can intensify attachment & pre-occupation with the other person • Secure attachment doesn’t ‘insulate against grief’ (Shemmings D) – on the contrary – but can help avoid complex, chronic grief reactions. • Grief after death may be prolonged, but may ‘decline as we learn to live without the physical presence of the one we love’ (Murray Parkes) and may be followed by new attachments . • Grief cannot be avoided – it may be postponed, buried or distorted but, like truth, ‘grief will out’.

16. ADULT GRIEF is highly variable in intensity and duration. WHAT OTHER FACTORS ARE IN PLAY? Personality Genetic endowment Age, health Type of relationship – eg. anxious, secure, ambivalent attachments Spirituality, cultural identity Nature of illness and death Circumstances, eg. Isolation from supports Prior mental illness or major unresolved issues The end-state of adult grief is the result of many inter-related factors. After Zisook and Shear 2009

17. BEREAVEMENT & VULNERABILITY IN ADULTS • Decreased resistance to illness • Apathy, aimlessness • Loss of interest • Restlessness • Loss of confidence • Low self-esteem • Anguish • Confusion, Loneliness

18. Concentration & memory difficulties • Loss of meaning • Loss of faith • Hopelessness • Suicidal ideas • Depression After Relf M, 1999

19. ‘‘No-one ever told me that grief felt so like fear. I am not afraid, but the sensation is like being afraid. The same fluttering in the stomach, the same restlessness..........’’ ‘’At other times it feels like being mildly drunk, or concussed. There is a sort of invisible blanket between the world and me.’’ ‘’ An odd by-product of my loss is that I’m aware of being an embarrassment to everyone I meet.’’

20. ’To some I am worse than an embarrassment. I am a death’s head. When I meet a happily married pair I can feel them both thinking, ‘One or other of us must someday be as he is now’.’’ C.S. Lewis, ‘A Grief Observed’,1961

21. KUBLER-ROSS 1970 • PHASES OF DYING • DENIAL • ANGER • BARGAINING • DEPRESSION • ACCEPTANCE

22. Colin Murray ParkesModel of grief • Numbness – shock and disbelief • Pining – anger, guilt and physical restlessness • Disorganisation and despair – depression, loneliness and anxiety • Re-organisation – recovery and acceptance

23. Worden’s four tasks of mourning Task 1: To accept the reality of the loss Task 2: To experience the pain of grief Task 3: To adjust to an environment in which the deceased is missing Task 4: Emotionally to relocate the deceased and move on with life. W Worden (1987)

24. Phases, stages, tasks – neat ideas, but................................ Why is grief like a roller coaster?

25. Staged models ( Kubler – Ross) & ‘Tasks of grief’ (Worden) attracted some criticism because they failed truly to reflect peoples’ lived experiences or chaotic feelings Current thinking on grief encompasses both the letting go of bonds and holding on to the attachment • Dual process model - Stroebe • Continuing bonds - Nickman, Klas • Narrative approaches - Neimeyer • Range of responses to loss - Machin

26. Dual Process of Bereavement - Stroebe et al (1993) • Loss Oriented • Deep pre-occupation • with grief • Profound sadness and • awareness of • broken bonds • Denial/Avoidance of • Restoration Restoration oriented Attending to Life Changes Doing New Things Distraction from Grief New Roles/Identities New Relationships OSCILLATION

27. Dual Process of Bereavement – This model proposes there are two main stressors in grief – loss and restoration. • Adaptive copinginvolves the person confronting grief at times, avoiding it at others. • The oscillation is a coping mechanism that helps regulate emotional states

28. Difficulties in grief can sometimes come about for a person who is completely dominated by one stressor or the other, or.... • .....for some-one who experiences great tension, guilt or distress at the oscillation between different states – might fear they are ‘losing their mind’ • This model argues the need for a ‘dosage’ of grieving, or the need to take respite from dealing with either of these stressors.

29. Continuing Bonds • Challenges the idea of ‘letting go’ • Death ends a life but it does not end a relationship • The bereaved remain involved with and connected to the dead person • The bereaved actively find a place for the deceased in their sense of their own selves • This can be like a ‘living legacy’ providing: comfort, continuity, a role model, guidance, meaning and support to self-esteem • after Klass & Silverman, 1996

30. The actual, living & breathing relationship has been lost; other aspects remain – imagined, symbolic, remembered. • "I had to learn to have a relationship with someone who wasn't there anymore" Natasha Wagner, whose mother, the actress Natalie Wood, drowned when Natasha was a teenager(1998).

31. People rarely just "get over it," nor do they ever really find "closure." The phrase "continuing bonds" is one contribution to a new language that reflects a new understanding of the grief process. • Phyllis Silverman

32. Continuing Bonds - an everyday understanding in some cultures A Korean Family Wedding – offerings at a Confucian family ancestral shrine

33. Dia de los Muertos DAY OF THE DEAD ALL SAINTS DAY ALL SOULS DAY A holiday for Various countries and religions

34. A Narrative approach Enabling someone to tell their story is a basic aspect of bereavement support. • Use of a narrative is a vehicle for making sense of difficulties / understanding our life • Creating a story provides a safe way of feeling the emotions of grief & finding meaning in painful experiences

35. Telling & re-telling can restore a sense of control over frightening events • Language can shape events into narratives of hope

36. RANGE OF RESPONSE TO LOSS MODEL (L Machin 2001) OVERWHELMED CONTROLLED BALANCED / RESILIENT

37. WHAT IS BEING CONTROLLED? • I believe that I must be brave in the face of loss. • For me it is important to keep my grief under control. • I think it is best just to get on with life after loss.

38. WHAT IS BEING OVERWHELMED? • For me it is difficult to switch off thoughts of the person I have lost. • I feel that I will always carry the pain of grief with me. • Life has less meaning for me after this loss.

39. WHAT IS RESILIENCE? • I feel able to face the pain which comes with grief. • I feel very aware of my inner strength when faced with grief. • It may not always feel like it but I do believe that I will come through this experience of grief.

40. RRL TWO DIMENSIONAL MODEL (Debilitating) VULNERABLE Denial or struggle with the reality of loss Grief dominates OVERWHELMED CONTROLLED Effective engagement with the reality of loss Strong emotions RESILIENT (Enabling) Overwhelmed & Controlled are core grief reactions Resilient & Vulnerable are coping responses

41. Range of responses to loss In Summary : This approach discards traditional ideas about ‘risk’ in favour of understanding how people cope in grief and their coping ‘style’ or response to loss. Does their coping style and their resilience or vulnerability suggest the bereavement support they might need? Can debilitation be reduced or enabling factors enhanced?

42. What helps? TALKING WITH BEREAVED PEOPLE ‘Don’t just do something, stand there!’ (Colin Murray Parkes)

43. Three key components in supporting people with grief: • 1. Understanding our personal relationship with loss • 2. Knowledge and understanding of grief as a universal human process • 3. The confidence and resilience to be alongside and to listen to a person in deep distress

44. WHAT HELPS WHEN TALKING WITH BEREAVED PEOPLE? • There is a story --- Listen to it and help them construct a bigger picture • There is a relationship --- Explore it to bring out meaning • There is a life to celebrate --- Identify the reasons for celebration and validate them

45. There is a legacy left behind --- discover it and encourage them in giving worth to the life 5. There is a strategy for coping --- understand it and affirm it .... or challenge • There is a journey undertaken --- think about their pathway and accompany them on their journey. (after Graves, D. 2009)

46. In talking to bereaved people, what is less helpful? • Avoid the subject • Change the subject • Avoid mentioning the deceased • Say “I know how you feel” • Tell what they should feel or should do • Give advice unless it is asked for • Think you can soothe away the pain • Make offers you cannot keep • Assume people recover in a certain time

47. Complicated Grief • Affects about 10% of all bereaved people, especially where trauma accompanies death • Vulnerability – eg. history of difficult early relationships, strongly inter-dependent relationships, includes history of depressive illness, bipolar disorder, substance misuse, anxiety disorder, poor health, low social support.

48. Acute grief is prolonged, can be of indefinite duration with intense preoccupation and separation distress. • ‘A repetitive loop of intense yearning and longing that becomes the major focus of their lives’. Relationship to depressive illness, (Zisook and Shear). • Debate in the literature about whether bereavement counselling creates dependency– if grief is a natural process, won’t people ‘just get over it’?

49. Grief per se isn’t a ‘sickness’ but c.16% are likely to have major depression after 1 year, 7% being chronically depressed (in Zisook and Shear, 2009) • Take-up rates of hospice bereavement services = tend to be from 10% to 20% of the bereaved population known to them. • Take-up rates in the community, eg. CRUSE = about 9% of the bereaved population in West Suffolk.

50. WHAT WORKS WITHIN A HELPING RELATIONSHIP? Helper’s techniques 15% Placebo 15%