Grief & Bereavement

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Grief & Bereavement Workshop

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Grief & Bereavement

  1. 1. Grief and Bereavement Workshop By December 14-15, 2013 Hospis Malaysia Amy Y. M. CHOW, Ph.D., R.S.W., FT., Associate Professor, Department of Social Work & Social Administration, The University of Hong Kong, Hong Kong Assisted by: Gilbert FAN, DProf, RSW, RC, FAPA Head, Department of Psychosocial Oncology Co-Chair, Patient Support, National Cancer Centre Singapore
  2. 2. Content • Challenges of working in the area of Grief and Bereavement • Bereavement Care as part of the Palliative Care • Anticipatory Grief Work (Before death) • Assessment of Bereaved Persons • McKissock Model of Bereavement Intervention • ADAPTS Targeted Intervention • Dual Process Model Group Work for Bereaved Older Adults
  3. 3. A Relational Frame for Technical Proficiency in Grief Therapy (Neimeyer, 2012)
  4. 4. Integrated Model of Death Anxiety (Chow, 2011, p.102)
  5. 5. Death Anxiety “…a cluster of death attitudes characterized by fear, threat, unease, discomfort and similar negative emotional reactions, as well as anxiety in the psychodynamic sense as a kind of diffuse fear that has no clear object.” (Neimeyer, Moser, & Wittkowski, 2003).
  6. 6. Exercise: The Life Journey Gains Losses
  7. 7. Exercise: Unpredictable Life (Letter to my beloved) Dear___________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________
  8. 8. An ancient Chinese character for “Death” depicting a person weeping besides the body of the decease.
  9. 9. Remembering that I'll be dead soon is the most important tool I've ever encountered to help me make the big choices in life. Because almost everything — all external expectations, all pride, all fear of embarrassment or failure - these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.
  10. 10. Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary. (Commencement address delivered by Steve Jobs, CEO of Apple Computer and of Pixar Animation Studios, on June 12, 2005)
  11. 11. NICE Guidance and Bereavement (NICE,2004) • Bereavement can give rise to a wide range of needs – practical, financial, social, emotional and spiritual. • There might be needs for information about loss and grief, needs to pursue particular cultural practices, needs for additional support to deal with the emotional and psychological impact of loss by death or, in a small number of circumstances, specific needs for mental health service intervention to cope with a mental health problem related to loss by death. (p.156)
  12. 12. A three-component model of bereavement support (NICE,2004) Component 1 Grief is normal after bereavement and most people manage without professional intervention. Many people, however, lack understanding of grief after immediate bereavement. All bereaved people should be offered information about the experience of bereavement and how to access other forms of support. Family and friends will provide much of this support, with information being supplied by health and social care professionals providing day-to-day care to families. Component 2 Some people may require a more formal opportunity to review and reflect on their loss experience, but this does not necessarily have to involve professionals. Volunteer bereavement support workers/befrienders, self-help groups, faith groups and community groups will provide much of the support at this level. Those working in Component 2 must establish a process to ensure that when cases involving more complex needs emerge, referral is made to appropriate health and social care professionals with the ability to deliver Component 3 interventions. Component 3 A minority of people will require specialist interventions. This will involve mental health services, psychological support services, specialist counselling/psychotherapy services, specialist palliative care services and general bereavement services, and will include provision for meeting the specialist needs of bereaved children and young people (being developed as part of the Nation Service Framework on children and not covered here). (p.160)
  13. 13. 12.34 Providers should ensure that a leaflet is made available to families and carers around the time of the bereavement. Ideally, this should be developed locally, agreed by those involved in the provision of bereavement services, and include information on anticipated feelings and how to access local and national services.
  14. 14. 12.38 Those who offer bereavement services that include volunteer support workers should ensure mechanisms for recruiting, training, supervising and managing volunteers are in place. It is desirable that the workforce reflects the gender, age distribution and ethnicity of the clients they serve.
  15. 15. ANTICIPATORY GRIEF WORK
  16. 16. Common Themes raised by Bereaved Clients • Unfinished business (unexpressed apology, forgiveness, appreciation love) with the deceased • Uncertainties about decisions • Flashbacks of Memories in the final days • Loneliness
  17. 17. Definition of Anticipatory Grief (Costello and Hangreaves, 1998) • Emotional experiences some people have before the loss of a significant other person • Affects both the dying persons and the family • Begins with the diagnosis of a life-threatening illness and ends with the death • Emotional intensity increases as death approaches
  18. 18. We Believe…… • Care from the family members are the things that patients longed for • Precious opportunity for communications • Events happened will be reviewed for a life time
  19. 19. Guiding Beliefs: Source of sufferings: -Inability to live in present moment Life Review: Ego Integrity Vs Despair (Erikson, 1959) - To integrate the experiences of earlier stages - To realize that one’s life has had meaning - To develop a sense of connectedness with younger generations
  20. 20. Finishing of Relational Unfinished businesses : - Guilt & Unexpressed Apology - Unexpressed Forgiveness - Unexpressed Gratitude - Unexpressed Emotional Statements
  21. 21. Concepts of Bereavement • Definitions of terms • Bereavement Vs Grief Vs Mourning
  22. 22. Manifestations of Grief (Stroebe, Schut, & Stroebe, 2007, p.1964)
  23. 23. Health Consequences of Bereavement (Stroebe, Schut, & Stroebe, 2007) • Increased Risk of Mortality • Higher Physical Morbidity • Higher Psychiatric Morbidity
  24. 24. Stage Model (Kubler-Ross, 1993)
  25. 25. • Bowlby (Numbing – Yearning & Searching – Disorganization – Reorganization) (Bowlby, 1971) • Parkes (Alarm & Alarm Reaction – Searching – Searching – Mitigation – Gaining New Identity)(Parkes, 1986)
  26. 26. Empirical Testing of Theories of Stages of grief (Maciejewski, Zhang, Block, & Prigerson, 2007)
  27. 27. Dual Process Model (Stroebe and Schut, 1999, 2010) Loss-Oriented Coping - Concentrating on, dealing with, appraising, processing of some aspect of the loss experience - Focusing on the relationship, ties or bond with the deceased - Involving a painful dwelling on, even searching for the lost person - Yearning for the deceased
  28. 28. Restoration-oriented Coping - Restoration of the secondary stressors arisen from the loss - Dealing with the new roles, reorganization of life, mastery of tasks carried out by the deceased - Reflecting a struggle to reorient oneself in a changed world without the deceased person - Rethinking and re-planning one’s life in the face of bereavement Oscillation - Alternation between loss- and restoration oriented coping, as a dynamic coping process - Back and forth process of juxtaposition of approach and avoidance
  29. 29. Depathologizing grief
  30. 30. Assessment in Bereavement High Risk GroupNormal Group Risk Factor Assessment
  31. 31. Based on your observations, what are the risk factors of bereavement?
  32. 32. Risk Factors Six Risk Factors (Rando, 1993) • Suddenness and lack of anticipation • Violence, mutilation, and destruction • Preventability and/or randomness • Loss of a child • Multiple deaths • Person encounter with death secondary to threat of personal survival/ massive confrontation with the death
  33. 33. Twelve Risk Factors (Mckissock & Mckissock, 1998) • Suddenness • Death of a child • Traumatic witness • Centrality • Perceived • Preventability • Ambivalence • Decreased role diversity • Decreased social support • Pre-existing factors (Alcoholism) • Concurrent crisis • Overly prolonged dying process • Lack of reality (Missing persons)
  34. 34. Integrative Risk Factor Model (Stroebe, Folkman, Hasson, & Schut, 2006)
  35. 35. Risk and Protective Factors (Stroebe, Schut, & Stroebe, 2007, p.1966)
  36. 36. Risk factors identified in Hong Kong • Dependency on the deceased • Loneliness (emotional and social loneliness) • Perceived Traumatic effect of the death
  37. 37. Assessment of Outcomes: • Psychiatric Assessment (DSM5) • ADAPTS Assessment
  38. 38. ADAPTS Assessment • Anxious Mood • Depressed Mood • Adjustment • Physical Symptoms • Traumatization • Separation Distress
  39. 39. Story-telling Approach Bereavement Counseling (McKissock & McKissock, 1998) • Engagement • Contracting • Exploration • Facilitation • Review • Closure
  40. 40. a. Engagement - Social ritual - Meeting and greeting - Setting the scene - Making the client’s familiarity with the environment - Testing the climate
  41. 41. b. Contracting - A passage from social chat to counselling - Explore gently about previous experience of counselling - Explanation of the purpose and structure of this interview - Define the time frame - Increase mutual understanding
  42. 42. c. Exploration - Getting to the story through the structure of chronological sequence
  43. 43. Death - How & where death occurred - Whether client was present - If not, who told them Effect - e.g. “Tell me about the day X died/tell me about the time around x’s death”
  44. 44. Viewing - When and where - How was it - E.g. “Did you have an opportunity to spend time with X after s/he died?” Funeral - Assess whether the client was involved on a ‘them-centred way’ - Assess whether the funeral was emotionally/spirituality satisfying Time Since - E.g. “And how has life been since the funeral?”
  45. 45. d. Facilitation - Facilitation of expression of feelings involved - Also can be focused around bringing the deceased back to life and continuing the relationship with the deceased. e. Review - Leave around 10 mins for reviewing what has been brought up, accomplished and unfinished business - Re-contract about the tasks of coming sessions
  46. 46. f. Closure - Exit version of engagement, also involved with social ritual - One question can be asked is “what do you imagine you’ll be doing when you leave here today?”
  47. 47. ADAPTS Targeted Intervention Traumatization - Debriefing model - Minimizing Technique - Anchoring Technique - Emotional Freedom Techniques Physical Symptoms - Linkage physical symptoms with emotions - Gestalt Approach: dialogue with the symptom
  48. 48. Depressed Mood - Cognitive Therapy - Exercise and movement - Sunshine Separation Distress - Continuing Bond - Gestalt Empty-chair technique - Letter writing
  49. 49. Anxious Mood - Mindfulness Exercise - Breathing Exercise - Physical Exercise - Emotional Freedom Technique Adjustment - Psychosocial Education - Resources referral - Dual Process Model Intrvention
  50. 50. Dual Process Model-based Bereavement Intervention
  51. 51. • an 8-session revised intervention model for Chinese widowed persons (Chow, 2012)
  52. 52. • Thank you!

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