Working with Bereavement
across the Life Cycle
Arlene Vetere
[email protected]
The Plan
• Introductions – why are we interested in this
work? Expected/unexpected resonances
• Hopes for this session?
• Theory: Kubler Ross, Worden, Murray Parkes,
Neimeyer, attachment
• Disability and families
• Children and families
• Intervention and Protective Factors
• Traumatic bereavement – sudden death
Dynamic Systems
“Many of the most intense emotions arise during the
formation, the maintenance, the disruption and the renewal of
attachment relationships. The formation of a bond is described
as falling in love, maintaining a bond as loving someone, and
losing a partner as grieving over someone. Similarly, threat of
loss arouses anxiety, and actual loss gives rise to sorrow;
whilst each of these situations is likely to arouse anger. The
unchallenged maintenance of a bond is experienced as a
source of security and the renewal of a bond as a source of
joy.”
(Bowlby, 1980)
Some Useful Definitions
• Bereavement – the objective situation of
having lost someone significant (death,
divorce...)
• Grief – the usual reaction to bereavement –
primarily emotional response to loss
• Mourning – the social expression or acts
expressive of grief that are shaped by the
practices of a given society or cultural group
Activity: Reflective Questions
• When you think of bereavement across the
individual and family life cycle, what comes to
mind for you?
• Do you notice any themes or particular issues?
• Where have they come from – family of origin,
education, faith and spirituality, culture, personal
experiences
• What are your hopes for the day?
Spiritual and Cultural Issues
• Wide variation in cultural and spiritual beliefs
about what happens after death
• Wide variation in beliefs about appropriate ways
of expressing grief
• Wide variation in rituals/ways of mourning
• Need to take account of the past and present
experience and needs of individuals and families
• Need understanding of particular family/culture
• Might there be a cultural/personal desire to
minimise our perceptions of others’ grieving?
Bereavement Research
• Grieving is normal......’masked’ grief
• Attempts made to understand grief in terms of
stages/phases, tasks and process
• Bereavement can affect physical and mental health,
and be more difficult for some of us
• Research limited by focus on small sections of world
population
• Dual process of grieving alongside normal functioning
can give false sense of coping and hide grief
• Responses to disaster
Grief: supporting/complicating factors
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Quality and significance of the relationship
The kind of death
Developmental stages
Nature and quality of family and community
support and resources
• Concurrent crises
• Attitudes of community and culture
• Disenfranchised grief
Theories of grief, loss and
bereavement: Kubler Ross
• Historically significant as one of the early providers of grief
and bereavement model
• Five stages:
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
• Misunderstood or misinterpreted?
Theories of grief, loss and
bereavement: Worden
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Grief conceptualised as a process with tasks
Accepting reality of loss
Experiencing the pain of grief
Getting used to living without the person who
has died
• ‘Picking up the pieces’ of life
• Life function: shock, protest, disorganisation,
re-organisation
Theories of grief, loss and
bereavement: Murray Parkes
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Murray Parkes prefers to think of phases rather than stages
Four phases are:
Numbness occurring close to the time of loss
A phase of yearning: for lost one to return - a denial of the
permanence
• Disorganization/despair - bereaved person finds it difficult to
function in their environment
• Reorganized behaviour...beginning to pull life back together
• Research suggests 2 – 5 years is to be expected..….
Theories of grief, loss and
bereavement: Neimeyer
• Individual differences in grief experience require individualised
approaches: dual process theory (meaning making and continuing
bonds)
• ‘complicated grief’ marked by broad changes to all personal
relationships, sense of meaninglessness, prolonged yearning or
searching, and a sense of rupture in personal beliefs (more likely
associated with sudden, unexpected and traumatic death)
• Challenge the widely held assumption that grief is ‘letting go’
• Foster a constructive continuing bond with person who has died:
remembering the good times, internal dialogue with lost loved one,
continuing to think of them on regular basis, imagining their
reactions to current life events and problems
• Expression of positive emotion and ability to find meaning in loss
Theories of grief, loss and
bereavement: Attachment
• Bowlby: sorrow and joy different sides of same
attachment coin; grief is embodied, representational,
relational and developmental
• CS Lewis: ‘it’s part of the deal’ ‘no one told me grief is
like fear’
• Bion: like trauma, the only way out is through
• Protest: anger of hope and anger of despair – a wish
for connection
• Secure/insecure attachment styles and grieving
• Processing is key: changes in representational systems integration and reflection
ATTACHMENT ALWAYS TWO SIDED
Attachment always has TWO sides. Responses to non-availability
of our attachment figures:
PROTEST - anger…..(of hope, of despair)
and
VULNERABILITY – sadness
One may be shown more than the other, or shown in rapid alternation.
Internal conversation – potential ‘Strange Loops’
ATTACHMENT REPRESENTATIONS:
The layers of attachment
PROCEDURAL MEMORY: memory for how we do things (R)
SENSORY MEMORY: visual images, smell, touch, auditory (R)
SEMANTIC MEMORY: cognition, beliefs, attitudes (L)
EPISODIC MEMORY: narratives, stories, inter-connected
experiences (L and R )
INTEGRATIVE MEMORY: reflection, meta-cognition, on-going monitoring of
our speech and thought.. (L and R)
Right Brain – Implicit
Left Brain - Explicit
Activity: Reflective Questions
• How are you responding to these models of
grief?
• What resonances do they create?
• Are they useful? ..….Do they help you make sense
of your clients’ experiences? …....How does your
personal understanding of death and
bereavement influence your practice…..…and
when might it be different from that of your
clients?
Working with Children and Families
• Infants: non-specific distress; protest, despair,
detachment
• Grief: actions and somatic states (language and
symbolic representation)
• Death permanence: projection in play – comfort and
soothing
• Meaning and making sense of death, tolerate
questions and yearning, straightforward
communication, clear and realistic information –
transitional objects, involve children in rituals
• Child’s view of self as worthy and deserving of care
• Children’s social networks
Continued
• Use of words and symbols to organise experience – our
responsibility for helping a child to understand – use of
second guessing to introduce possible worries – talking while
drawing
• Denial as a defence/adaptive; fears that own behaviour
caused death; gender socialisation (a problem for boys??)
• Regressed patterns of behaviour, withdrawal, intrusive
thoughts, sleep disturbance, somatisation
• Idealisation and identification – trying to recover lost person?
(a wish to die to be with dead person?)
• Inhibit grief and strong need to be cared for – compulsive care
giving?
Continued
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Pre-teens: understand what the loss means in the future
Magical thinking may persist
General irritability mislabelled?
Quiet and withdrawn responses may not attract adult
attention? Mutual protectiveness may mask grieving
• Biological and logical understanding of death – search for
philosophical meaning/spirituality
• May still hold on to earlier worries
• Adolescence: stronger gender effects; ‘antisocial’ behaviour
masking sadness; stepping into ‘vacated’ roles; suicidal
ideation; substance use; risk-taking?
Intervention and Protective Factors
• Child: internal representations; maintain memory links;
emotional expression – what have they been told and
how do they understand it?
• Parental: replacement figure; practical and emotional
needs; not overwhelmed by own grief?
• Family: flexibility in roles; open communication;
concurrent crises?
• Friends: contact with other children at home and at
school; adolescent support network
• School: open discussions about life and death;
individual support and access to group support
• Community: culturally appropriate role models; rituals
Cont’d
• Open and straight forward communication –
explanation and reduce confusion – avoid
euphemisms
• Give time for ‘cognitive mastery’ – support
questions, conversations and children’s play,
photos, visiting grave, resemblances
• Making the loss real – rituals, reminders, not
hiding feelings – anticipate anniversaries
• Support emotional coping – avoid unnecessary
separations, talk about guilt feelings/anxiety that
something will happen to them/parents
Rituals and Funerals
• Important for children to say goodbye
• Including children in family rituals promotes
closeness at a time of sadness
• Not pressured to attend funeral, but offered
choice – a special person to look after the child
during the funeral
• Children need preparation and be allowed to ask
questions
• Children’s participation: letter/picture/flower in
coffin; help choose readings/poems/music; light
candle; blow bubbles; decorate coffin, and so on
Communication and Memory
• Special times, special places and special things
• Experiencing the presence of someone who has
died
• Talking and communicating with the dead person
• Keeping special things as a link to the dead
person
• At first, clothes and items preserving smell may
be important
• Young children may need prompts (photos etc) to
help them remember
Children’s Fears, Worries and Need for
Reassurance
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The death is not their fault
They will be looked after even though parent/s are grieving
Their parent/s’ intense grief is normal
They are still loved and wanted
Anger, guilt and sadness are part of grieving
Important to carry on with activities like school and hobbies
It is still alright to enjoy some things
Other family members are alright and not likely to die until
they are much older
• If appropriate, no one can ‘catch’ the illness that caused
death
Support for Families
• Immediate additional help to provide and care for
family members
• Processing: listening, acknowledgement and
acceptance, reassurance and information,
tolerating silence, ‘being there’, talking about
own experience of loss, not taking anger
personally, support for family’s beliefs
• Participation in rituals of mourning
• Familiar with own feelings about death and
bereavement
Reflective Practice
• What seemed helpful to the child/family?
• What seemed unhelpful to the
child/family…….and how might I know?
• How might I have communicated things
differently?
• How was I affected personally by this
particular conversation about death and loss?
• What have I gained from this experience that
will help me in my future practice?
DECONSTRUCTING TRAUMA and LOSS
Loss and danger an inevitable part of life
“The function of resolution is to enable the individual
to take forward into the future information that is
relevant to future protection and comfort and keep
in the past that which was unique to the specific
event. ‘Unresolved’ individuals are unable to
differentiate these two classes of information.”
Crittenden, 2009
TRAUMA and LOSS
• Loss and danger inevitable part of life
• What information from dangerous events we carry forward or dismiss
• Information held in different representational systems
• Resolved balance
• Unresolved
– Dismiss too much – remain unsafe - dismissed
– Carry to much forward – anxious pre-occupied
• May intrude into our primary attachment strategies and disrupt coping –
need a balance of pre-occupied and dismissing strategies for effective
coping
TRAUMA and LOSS
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Resolution balance :
– able to both carry forward relevant and also to discard irrelevant information
– able to connect information from different representational system
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Dismissing
– Discard too much information – remain unsafe - ignore relevant cues to
potential future danger
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Pre –occupied
– Overwhelmed by carrying too much forward – remain anxious, hyper-vigilant,
over – aroused
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INTRUSIONS:
– Memories, e.g. visions, smells, feelings may intrude into our primary attachment
strategies and disrupt coping
UNRESOLVED STATES – TRAUMAS and LOSSES
Pre-occupying - continual arousal
Vicarious - events occurred to others
Imagined - fantasised
Anticipated - real concern but extent exaggerated
Dismissed - severity of events minimised
Blocked - no event remembered or claimed
Displaced - effects on other source of concern
Disorganised - multiple and complex
Depressed - events beyond control
RELATIONAL APPROACH
• Development of unresolved states shaped by reactions of
others – family, friends, communities
• Social support network, attachment figures, etc., centrally
assist in processing dangerous, extreme events:
• Validate, acknowledge our experience
• Assist in developing coping strategies for future safety
KEY UNRESOLVED MARKERS
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Pre-occupying
– Intrusions of negative affect
– Intense animated imagery
– Confusions of self and others
– Confusions of time and place
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Dismissing
– Minimization of the importance of the event/s
– Absence of expected emotions
– Extreme brevity
– Erroneous beliefs of having caused the events
Some Useful Approaches when Working
Therapeutically with People with Intellectual
Disabilities
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Family Trees (photographs)
Art work
Life story work
Pictures
Videos
Drama
Poetry
Memory books/boxes
Some References
Bowlby J (1980) Attachment and Loss. Vol 3. New York: Basic Books
Lewis CS (1966) A Grief Observed. London: Faber
Melvin D & Lukeman D (2000) Bereavement: A framework for those
working with children. Clinical Child Psychology and Psychiatry, 5,
521-540
Murray Parkes C (2006) Love and Loss: The roots of grief and its
complications. London: Routledge
Neimeyer R, Baldwin S & Gillies J (2006) Continuing bonds and
reconstructing meaning: mitigating complications in bereavement.
Death Studies, 13, 715-738
Wertheimer A (2001) A Special Scar: The experiences of people
bereaved by suicide. 2nd Edition. London: Routledge
Worden JW (2003) Grief Counselling and Grief Therapy. 3rd Edition.
London: Routledge
Some References
• Glenda Fredman (2003) Death Talk: Conversations with
Children and Families. London: Karnac
• Rachel Hare-Mustin (1972) Family therapy following the
death of a child. Journal of Family Therapy
• Lorna Bowlby-West (1983) The impact of death on the
family system. Journal of Family Therapy
• Mary Ann Sedney, John Baker and Esther Gross (1984)
‘The story’ of a Death: Therapeutic considerations with
bereaved families. Journal of Marital and Family Therapy
Sudden death
• Resources for those supporting people who
have experienced a traumatic response to
bereavement. Download from the
bereavement page on Belfast Health and
Social Care Trust website:
www.belfasttrust.hscni.net
And finally…
“People are much greater and much stronger than we imagine, and
when unexpected tragedy comes . . . we see them so often grow to
a stature that is far beyond anything we imagined. We must
remember that people are capable of greatness, of courage, but not
in isolation. . . . They need the conditions of a solidly linked human
unit in which everyone is prepared to bear the burden of others”.
(Bloom, 1969).