Winds of Change: Grief and Bereavement For I&R

1. Winds of Change: Grief and Bereavement For I&R The 37th Annual I&R Training And Education Conference Dallas, Texas Thursday May 28, 2015 10:00 – 11:30 AM This posting to the AIRS Networker provides 14 additional slides not included in the Conference presentation. The additional slides were not used as a result of time constraints but allow for a fuller view of the Grief Response and Bereavement Process. Thank you for your interest. John Plonski Developer - Helping Empathically As Responders Training (HEART) Training Development Director IMAlive Hicksville, New York jpnysairs@gmail.com Paper-free Workshop

2. When great souls die, the air around us becomes light, rare, sterile. We breathe, briefly. Our eyes, briefly, see with a hurtful clarity. Our memory, suddenly sharpened, examines, gnaws on kind words unsaid, promised walks never taken. Great souls die and our reality, bound to them, takes leave of us. Our souls, dependent upon their nurture, now shrink, wizened. Our minds, formed and informed by their radiance, fall away. We are not so much maddened as reduced to the unutterable ignorance of dark, cold caves. And when great souls die, after a period peace blooms, slowly and always irregularly. Spaces fill with a kind of soothing electric vibration. Our senses, restored, never to be the same, whisper to us. They existed. They existed. We can be. Be and be better. For they existed. Adapted from When Great Trees Fall - Maya Angelou

4. Let’s Begin By Taking About Loss Losses can be actual, anticipated or perceived. The experience of loss is not limited to individuals

5. Loss Takes Many Forms • Losses due to death - terminal illness, sudden death, suicide, or violence • Relationship Losses – Romantic, divorce, empty-nests • Life Cycle Losses resulting - Aging, physiological changes, disability, job loss or retirement • Losses experienced from geographically relocating • Public tragedies - Natural or man-made disasters, terrorism • Vicarious Loss – Losses affecting the person but not experienced by them • Pet Loss – Loss of a beloved pet from death or circumstance

6. Concept Of Primary And Secondary Losses • Primary Losses represent the immediate change confronting the individual. • Secondary Losses are those precipitated by the Primary Loss that negatively affect the autonomy of the individual. • You can recognize secondary losses by asking: • How has the loss changed the person’s life? • What have they given up? • How has it affected their relationships with others?

7. Secondary Loss • Losses occurring as a result of a primary loss - Example, loss of income when the bread winner dies • Can result from loss or change in status caused by the primary loss • The bereaved frequently do not anticipate secondary losses • Secondary losses can complicate the Bereavement Process as they do not occur all at once - they can cause a chain reaction of losses

8. Key Factors To Consider In Processing Secondary Losses • All secondary losses should be viewed as a part of the Grief Response and Bereavement Process. • Some secondary losses may not show up for extended periods of time. • The person or their caregivers may not be aware of secondary losses. • Do not address all the secondary losses all at once, take them one at a time.

9. Examples Of Secondary Losses? • Loss of primary relationship and family structure • Loss of the familiar way of relating to family and friends • Loss of support systems • Loss of a chosen lifestyle • Loss of financial security • Loss of the past and future - loss of dreams • Loss of identity and self

10. Additional Examples Of Secondary Losses • Loss of self-confidence • Loss of ability to make decisions or see choices • Loss of trust • Loss of security • Loss of a sense of humor • Loss of patience • Loss of ability to focus and function • Loss of health

11. Let’s Begin By Making Some Distinctions • While we may equate grief and bereavement, for our purposes, we will make the following distinctions - • Grief is the stress reaction to an actual or perceived loss • Bereavement is the process individuals engage in to relieve the stress reaction and achieve homeostasis (normalcy) • Mourning is a cultural, ritualized response to the stress of grief.

12. Additional Thoughts About Grief, Bereavement and Mourning • Grief is a process of Emotional, Cognitive, Social, Physical, Behavioral and Spiritual responses to a loss.  • Bereavement is a state of suffering a loss - it is cyclical and natural and encompasses grief reactions and the mourning practices of the culture.  • All three are a response to death or loss (actual or perceived).

13. The Grief Response • As it relates to our discussion grief is a stress reaction over which we have no control. As such it is all about changes that trigger the Stress Response. • Grief is not a disease or mental health disorder. It is an inherently healthy, natural process of coping with a death or a loss of something we care about. • Grief is the result of the Primal Coping as well as the Autonomic Coping Defenses . • As it is a physiological response it can not be ignored.

14. Primal Coping Defenses Stressor Induces One Of Four Responses Fight Flight Fawn Freeze

15. Autonomic Coping Defenses • Avoidance • Delusions • Denial • Displacement • Dissociation • Hallucinations • Intellectualization • Isolation • Projection • Rationalization • Reaction Formation • Repression • Somatization • Splitting • Suppression

16. Grief Is A Natural Response Impacting Several Levels • Emotional – Sadness, anxiety, anger • Cognitive - Confusion • Social – Withdrawal, avoidance • Physical – Inability to sleep, restlessness, loss of appetite • Behavioral – Avoidance of friends, substance abuse • Spiritual – Questioning of core beliefs

17. Emotional Responses

18. Cognitive Responses

19. Social Responses

20. Physical (Somatic) Responses

21. Physical (Somatic) Responses

22. Behavioral Responses

23. Spiritual Responses • Spiritual or core assumptive beliefs are challenged • The question “why” is asked without answer • Where was God? • If God is all powerful, why allow this? • If God loves me, how could this be? • Prayers weren’t answered • Sense of good, right and just are called into question (the Golden Rule) • Sense of betrayal by that which has provided strength in the past

24. The Grief Response Manifests Itself In Many Ways • A feeling of "going crazy" • Difficulty concentrating • Feelings of inconsolable sadness or depression • Irritability or anger toward the deceased, the situation, oneself, others or higher powers • Feelings of frustration or misunderstanding • Anxiety, nervousness, or fearfulness • Uncharacteristic calmness

25. The Grief Response Manifests Itself In Many Ways • Feelings of guilt or remorse • Ambivalence • Numbness • Lack energy and motivation • Experiencing a need to escape or get away • The “Roller Coaster Effect” • A loss of sense of self

26. Types of Grief

27. Uncomplicated Grief • Normal Grief is marked by movement towards acceptance of the loss and a gradual alleviation of the symptoms, as well as the ability to continue to engage in basic daily activities. • Anticipatory Grief is the reaction to a death a person is able to anticipate as when an individual dies from a long term illness. As soon as the person accepts and understands someone they love is going to die, they begin grieving. The grief response occurs upon realizing that death may be imminent and before the post loss bereavement and mourning processes occur.

28. Complicated Grief • Complicated Grief or Prolonged Grief Disorder refers to grief reactions and feelings of loss that are debilitating, long lasting and impair the individual’s ability to engage in daily activities and block the return of the homeostatic balance. Other types of grief such as Chronic Grief, Delayed Grief, Exaggerated Grief and Disenfranchised Grief all fall under the blanket of Complicated Grief. • We should also be aware of the concept of Ambiguous Loss which can lead to Complicated Grief.

29. Chronic Grief • Chronic Grief (sometimes termed Pathological Grief) applies to people who are unable to work through their grief despite the passage of time. • The grief process can be considered to be a form of traumatic stress injury. • As a traumatic stress the grief reaction can become Acute Stress Disorder and Post-traumatic Stress Disorder. • It may be diagnosed after a protracted time has passed indicating that resolution is delayed and professional help is needed.

30. Delayed Grief • Delayed grief (sometimes referred to as Unresolved or Inhibited Grief) refers to any reaction that occurs later than usual, as a delayed onset of symptoms. • The reaction to the loss is postponed until a later time, even years later. • It is generally triggered by a seemingly unrelated event, such as a recent divorce or the death of a pet, but with reactions excessive to the current situation.

31. Exaggerated Grief • An overwhelming intensification of normal grief reactions that may worsen over time. It is characterized by • Extreme and excessive grief reactions • Self-destructive or life threatening behaviors • Substance abuse • Panic and abnormal fears • Emergence or exacerbation of psychiatric disorders

32. Disenfranchised Grief • Disenfranchised Grief occurs when culture or society deems the loss to be invalidated or insignificant • When the death is stigmatized - suicide, overdose, HIV/AIDS, drunk driving • The death is seen as insignificant - ex-spouse, co-worker, miscarriage, pet • The relationship is stigmatized by society - same-sex partner, gang member, partner from an affair • The loss is not a physical death - dementia, Traumatic Brain Injury, coma, mental illness, substance abuse

33. Thoughts About The Bereavement Process • Bereavement is the process of experiencing a loss and learning to cope with it by bringing thoughts, feelings and behaviors into a homeostatic balance • As such it is a third level coping strategy and can either be adaptive or maladaptive • It is a cyclical process that encompasses grief reactions and the mourning practices of the culture. • Helping a person can be counter-intuitive – For example, we may want to cheer the person up but that may not be their wish or ability

34. Myth-information About Grief, Bereavement and Mourning

35. General Myths About Grief, Bereavement And Mourning In Youth • The death of a loved one is the only major loss children and adolescents experience. • Children get over loss quickly. • There are no interventions to help children grieve. • Children should be shielded from loss. • Helping children and adolescents deal with loss is the family’s responsibility.

36. General Myths About Grief, Bereavement and Mourning • People all over the world view grief in a very similar way. • There is a proper way to honor the dead and to grieve. • People who are grieving appropriately usually get over their grief within six months to a year. • People who don’t cry following a death are avoiding dealing with their grief.

37. General Myths About Grief, Bereavement and Mourning • It is more helpful to the bereaved person if the loss is not mentioned. • The goal of grief interventions is to help people get over their grief. • Grief is so personal that it is difficult to provide assistance to the bereaved. • It is best to hide your sadness from the dying person.

38. General Myths About Grief, Bereavement and Mourning • If one grieves prior to the death of a loved one then there is less grief work to do later. • Grieving prior to the death of a loved one means that you have given up. • For family and friends of a person with a terminal illness, grieving begins at the death of a loved one.

39. General Myths About Grief, Bereavement And Mourning In Youth • Children do not grieve. • Children should not go to funerals or other death-related rituals. • Children should always attend funerals or other death-related rituals. • Children should be protected from exposure to death, dying loss and grief or they may be permanently scarred.

40. Understanding The Bereavement Process • Bereavement is a complex individualized process • The length and expression of grief may vary by individual • Grief responses may be different depending on the age of the person experiencing the grief • Cultural and community practices and norms impact Bereavement Process – Mourning • The response of family, friends, community or society can help or hinder the Bereavement Process

41. During The Bereavement Process • During the Bereavement Process the individual attempts to re-establish a new reality and perspective. They will: • Become aware of their own mortality • Develop an awareness of the preciousness of time • Change and adapt their priorities and values • Modify their “world view” and their relationship to family, friends, community or society

42. What Helps The Bereavement Process? • Acknowledgment and acceptance of positive and negative feelings • Time to experience thoughts and feelings • Ability to confide in others about the loss • Open expression of feelings • Finding bereavement or support groups • Realizing that crying can provide a release - So can humor. • Professional help if feelings are overwhelming or of an extended duration

43. Things To Remember During The Bereavement Process? • Recognize that the person’s natural resilience is the main component of Bereavement Process and it can be helpful to point out that which has helped before can help now • Intensification of grief may occur around anniversaries, milestone events and holidays • Frustration can occur months later as the bereaved expects things to be better but they have not improved • As supports wane over time, autonomic defenses may kick in and may retrigger the initial Grief Response

44. Individual Needs During the Bereavement Process

45. Needs Of The Individual During the Bereavement Process

46. Each Person Will Follow A Different Path Through The Bereavement Process • To complete the process certain tasks need to be accomplished. • Accepting the reality of the loss • Permission to experience the pain of the loss • Adjustment to a new reality in which the deceased or object lost is no longer present • Realigning prior relationships and creating new ones • The order and timing of these phases will vary from person to person

47. Kübler-Ross: Grief and Loss • Denial: “It didn’t happen; this can’t be real.” • Anger and Resentment: “Why did this happen to me?” • Bargaining: “I would give anything to have her back.”“It should have been me.” • Depression: Deep feelings of sadness and despair. • Acceptance: “I will find a way through this.”

48. The Grief Response Is A Temporary Response To A Life Event • There is no concrete timeline for the completion of the Bereavement Process but there are guideposts to be aware of. • First year is a series of losses – Primary and secondary • Special occasions and holidays can re-trigger the initial grief response • Uncomplicated Grief is usually a 2-3 year process • Complicated Grief may be a 5-7 year process. • However, the process continues for a lifetime through major life milestones and anniversaries

49. Grief-speak: Helping A Bereaved Person • Express your concern empathically by talking about observed emotional states • Be genuine and don’t hide your feelings - “I’m not sure what to say, but I want you to know I care and I want to help.” • Offer your support proactively – “I am going to do <task> for you”. • Don’t assume you know how the person will feel on any given day.

50. Grief-speak • Recognize that our need to say something is our need and may not be the need of the grieving person – Silence can be golden! • Be empathic – avoid sympathy - skip the clichés and platitudes • Don’t deny that the person who died is dead, the bereaved is in emotional pain or that the death or loss will change the person’s lives • Use the deceased’s name