Morning Session - PowerPoint Presentation

Slide1

Morning Session

10.30 Introduction OBSERVATION10.45 Icebreaker Exercise Break12.00 Theory and Group Discussion1pm LunchSlide2

Afternoon Session

1.45pm Exercise - Reflecting on Bereavement Break2.30 pm Attachment / Counselling Session3pm Case Examples - Video3.30 Round Up / Feedback Forms Administration4pm EndSlide3

Your Experience & IdeasCase ExamplesSlide4

Learning Outcomes

Icebreaker Exercise - Counselling

Skills

Listening, Hearing, Reflecting back

Understanding Bereavement & Loss Theory

Models and Attachment

Assessment

Exercise

- Own Experience/ Attachment

Personal Experience – Own Therapy

Understanding of Bereavement CounsellingCriteria MethodsVideo Case ExamplesSeeing others peoples’ reaction to Bereavement and LossSlide5

The Day

Wide range of skills in the roomHope you all get something out of itI am not an expert on Bereavement

Encourage you to have your own viewSlide6

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.Slide7

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!Slide8

Icebreaker Exercise Learning Outcomes

Basic

Counselling

Skills

Listening

Hearing

Reflecting backSlide9

What do you want

from the Day?Are there any Topics, Issues, that you would like to focus or discuss today?

Write on flip chartSlide10

Break Slide11

Preamble before

Bereavement TheoryGeneral Principles of Counselling?

Training in Bereavement

Counselling

– last bastion of old volunteer model? –

Discuss

A way to reflect on feelings

Learn

about relationship with ourselves

Generic

Counselling Approach Slide12

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

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 a surprise to 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-ParkesSlide13

Link to Counselling

“ in order to avoid thinking about something we have to think about it”. Slide14

Colin Murray

ParkesBereavement: Studies of Grief in Adult LifePaperback: 288 pagesPublisher: Penguin Books Ltd; 3New Ed edition (1998)

ISBN-10

: 0140257543Slide15

“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 CareSlide16

A

Theory of BereavementFor 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 houseDays, weeks, yearsWe cope with major / minor bereavements in the same way??Slide17

Types of Loss

Actual lossDeath from old age, illness, accidents.  Old person more acceptable lossYounger person less acceptable

loss Discuss

Perceived loss

Person’s

view of loss

Culture

, history,

family,

socialisation?Bereavement Counselling Time-limited Focus solely on bereavement  Slide18

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? Slide19

The

Cost Of CommitmentGain Investment

in relationships: emotional,

physical

, financial.

Lives enriched but there is a

……….

Cost

Risk of losing Gain Slide20

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 Slide21

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 1993Slide22

Bereavement is like a tideSlide23

Bereavement Summary

“

in

order to avoid thinking about something we have to think about it”.

Link to Counselling

Bereavement is a process of grieving

Loss

is the person or object this is lostThe Cost Of CommitmentBereavement is Individual and PersonalThe stages to do not occur in orderBereavement is like a tideSlide24

Stages of Bereavement

Theory1. Alarm 

2. Searching

3. Mitigation – Lessening the Impact

4. Anger & Guilt

5.

Disorganisation

& Despair6. Gaining a New Identity Theory is theory - feel able to agree or contradict it!Discuss Colin Murray-Parkes Slide25

1.Alarm

Tension, Shock, Panic, Disbelief RestlessnessNumbness – 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 feelingsSlide26

2.Searching

Calling for the lost personSobbing, tearfulness,

Feeling of loss / lost Discuss

Visit places of experience

Aimless searching – irrational?

Find lost person

 Slide27

3.Mitigation–Trying to

Lessen the Impact of Bereavement

Components

of grief work

Pre-occupation / wish to find the person

Repeating, painful recollection of the loss

P

atterns

,

Obsessive thoughts, PTSD

Making sense of the loss to fit assumptions - meaningDreams - common dream - happy interaction with the dead Pining / Avoidance of PiningIdealised person - forget the negative Slide28

4.Anger and Guilt

Familiarity - loved ones, family members  Misdirection - Hospital staff / GPsBlame / Self

Blame

Anger guilt becomes irreconcilable - leading to family splits

Resistance to sadness, grief under the anger and guiltSlide29

5.Disorganisation and

DespairPeriod of uncertainty 

Take on the reality of what has happened

Identifying with lost person – method of avoiding the loss of that person

Old

model of the world abandoned

New set of

expectations created - with time and acceptance

Other people become a support

, security,

& protection.Slide30

6.Gaining

a New IdentityTaking on role/interest that lost person hadNew versions of old relationships

New relationships

New interests

New updated view of the

world

Less repressed / more flexible Slide31
Slide32

6 March 1987 193 people

killedThe British ferry Herald Of Free Enterprise capsized off the coast of BelgiumThe ferry overturned without warning only a mile outside Belgian port ZeebruggeDespite the best efforts of rescue crews, it became the worst ferry disaster in British history.Slide33

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

.

 Slide34

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”.Slide35

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. Henry - Extending the Event- Searching Slide36

Avoidance Panic

Throughout this period he exerted a rigid control on himself and he was still not crying two months later when he was persuaded to seek psychiatric help. At this time he was

tense,

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

.

Henry - no

i

nterest

in himself Suicidal Stuck Slide37

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 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?”

Henry - Routine

Event re-enacts trauma

- moves

stuckness

Slide38

Post-Traumatic Stress

DisorderThe case illustrates the features of Post Traumatic StressDisorder (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.

 Slide39

Summary

Stages of Bereavement Theory

1

. Alarm

2. Searching

3. Mitigation – Lessening the Impact

4. Anger & Guilt

5.

Disorganisation

& Despair

6. Gaining a New Identity Slide40

Summary - Henry

Saved himself – anger guilt Stayed on the boat - maintained alarm Avoidance Panic - isolated himself to copeTrigger – overwhelmed by feelings Re-enacted trauma with counsellorSlide41

What

facilitated the Bereavement process? CMP

Traditional family

Good

family support

Predictability of

death

Practical tasks of funeral arrangements

Supportive people making few demands

Social

NetworksMutual Self Help GroupsBereavement CounsellingSupport Groups – Group CounsellingSlide42

What determines

how a Bereavement affects a person?Stressors

The Trauma

Stress

& Trauma

of the Bereavement

Type of

stress - multiple deaths, violence, age of deceased

The Person

Coping strategies - avoidance /drink /drugs /isolation

Perception – world view /core values / emotional intelligenceCapacity to tolerate strong feelings Processing feelingsSelf Esteem High /LowSlide43

Who is the Bereaved?

Situation and Environment of the Bereaved Age /Gender Personality Proneness to Grief

Inhibition of Feelings

Expression of grief

Socio-economic Status (Social

Status /Class)

Nationality Cultural Factors of

Grief UK?

Religion Community /Over arching belief Slide44

Before the Bereavement

Relationship to the Deceased Good /BadType of Relationship Fixed Role /FlexibleStrength of

Attachment Dependence / Independence

Security of

Attachment

Secure/ Ambivalent / Involved

Degree of reliance

  Reason to liveChildhood Experiences  Other Bereavement Experiences   Coping? Previous mental health  Life Crises prior to the Bereavement  Type of Death  Slide45

After the Bereavement

Social Support Prevention of IsolationSecondary Stresses: financial

Life Opportunities – Options open to

BereavedSlide46

Summary

Facilitates the Bereavement – Situation and support of bereavedType of Trauma Type of person – ability to cope – backgroundBefore the Bereavement - relationships After the Bereavement – support / resilienceSlide47

Dr Elisabeth Kübler

-Ross Pioneer of personal trauma, grief and grieving, associated with death and dyingImproved the understanding of

bereavement

in hospice care

Her

five stages of grief model

:

Personal

change

model beyond death

and dying. Slide48

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

. Slide49

1 - Denial

Denial is a conscious or unconscious refusal to accept  Natural defence mechanism Can be locked in this stage Slide50

2.

AngerAngry with themselves and Others, Especially those close to them.

 Slide51

3.

BargainingBargaining for people facing death can involve attempting to bargain with whatever God the person believes in.  Bargaining in relationships: "Can we still be friends?.." when facing a break-up. Bargaining rarely provides a sustainable solution 

Also

preparatory grieving

Dress rehearsal or the practice run for the 'aftermath'

Means different things depending on whom it involves. It's a sort of acceptance with emotional attachment. Slide52

4. Depression

Natural to feel sadness and regret, fear, uncertainty Shows person beginning to accept the realitySlide53

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 Slide54

Kübler-Ross Summary

Some similarities to CMP model1. Denial – refusal to accept2. Anger with anger loved ones3. Bargaining 4. Depression 5.

Acceptance

Slide55

Attachment

Theory John BowlbyWhat 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 motherSlide56

A Good AttachmentPrimary

care givers are available & responsive to infant's needs creating a sense of security.  The infant knows that the caregiver is dependableCreates a secure base for the child to explore the worldSlide57

Experiment

with rhesus monkeysMonkeys offered two objects to attach

to

Soft

mother dummy without food

Hard

mother dummy with food Slide58

Monkeys preferred soft dummy without food

Discuss – reaction against Freud’s Instincts TheorySlide59

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

lifeSlide60

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 ContainingSlide61

Different Perspective

The Other Side of Sadness. What the New Science of Bereavement Tells Us About Life After Loss George Bonanno Basic Authors 2009Review in Weekly blog 21st September 2012Slide62

Different Perspective

George Bonanno PsychologistFocusing on behaviours Statistics CBT Cognitive Behavioural TherapyIAPT Improving Access to Psychological TherapiesSlide63

How Humans Cope with Bereavement

Equipped - hard wired In-born psychological processes that help us do the job Optimistic, flexible, resilientS

elf-serving

bias telling us we are stronger than we are.

Positive experienceSlide64

Evidence Gathering

Freud’s work based on interviews with no basis for theoryKubler- Ross studied people who were dying- not bereaved people Bowlby studied attachment issues of children and parents not bereaved people. Slide65

Sadness

Grief not overwhelming but partly intense sadnessNormal and naturalSadness makes people more reflective: a forced time out. Oscillation between pain and sadness important:

Bereaved

temporarily

reconnects

with

others

Then continues

the process of mourning. Slide66

Resilient People

In Western Culture Normal not exceptional. Expectation for bereaved people to feel constant sadness and griefIndividualistic cultures based on peoples’ feelingsSlide67

No trauma

Majority of people in Nagasaki no trauma symptomsNew York residents after 9/11 had no trauma symptoms.Slide68

Coping Strategy

Resilient people do not use avoidance as a coping strategyThink a lot about the loss or avoid the pain - Positive emotions and memories keep them stable Is there a resilient type? Evidence shows that some people cope with adversity better: but not specifically grief work.

No

clear pattern emerges in the way bereaved people describe their past that might account for their resilience.

No general

rule to the type or quality of the relationship to the lost person that promoted the healthiest forms of grieving.

Relationships

to others do not determine whether people cope with their

loss Slide69

Memory

Comfort from memoryResilient people find comfort from the memory of the relationship. The relationship is not completely goneShare relationship experience with others In traditional theory comfort from memories is not dealing with the reality of loss. Comforting memories are just a fantasy substitution Resilient

people are confident, more flexible with a broader repertoire of behaviours.

Resilient

people express emotion, but can also keep their feelings to themselves when appropriate. Slide70

10-15% of people

Do not fare do well with Bereavement The bereaved feels as if everything is missing, they are unable to hold onto positive relationships. Pain of grief can block all memories of the good. Prolonged grief is dominated by yearning for the lost person. Depression is global and has no object. All thoughts circle back to the lost person. Safety and happiness turn to fear and dread.

link

between prolonged grief and emotional

dependency Slide71

Other Cultures

Other cultures think more about the interactions between people and what they doIndividual and their feelings are not so importantSlide72

Chinese Culture

In research Chinese people better at getting over grief that US. More grief work Memoires, feelings, thoughts about the deceased searched for meaning and how to make sense of the loss. In Chinese not related to suffering: grief work not related to level of distress. Slide73

Chinese Culture

Chinese mourning rites focused on deceased is on the imagined experience of the deceased: to help them to the land of the dead and find a good life. Crying at Chinese funerals is more deliberate: tightly orchestrated so that it occurs at the right moment of the ritual. Professional mourners and musicians hired to help. Crying sends a message to the deceased loved one. Focusing on the deceased rather than the bereaved apes the continued bond. For the Chinese the continued bond was more common with Chinese and more healthy. The more early bond made to the deceased the less distress they felt.Slide74

Chinese Culture In Asia continuing bond is sewn into the culture.

Many towns have ancestral temples to honour the dead, and commune with them Chinese ceremony – about honouring loved ones and particularly family and connection.Slide75

US Culture

In the West for some this bond is healthy and for others not.If you are anxious about engaging in rituals that might not be accepted they lose their powerCrying in the West when we cannot hold back the pain.The more Americans experienced grief work early on: the more difficult it was for them.Slide76

US Culture

In US continued bond caused more distress for some and less distress for othersContinuing bond is more adaptive in an culturally supported environment Slide77

Bonanno Conclusions

Past evidence poorly collected 85% of bereaved recover wellHard-wiredMost people are resilientCulturally resistant to Bereavement