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B. Juen , E. Mohr, Siller, H ., Gmeiner, V. University of Innsbruck

Crisis Intervention in the acute Phase after Trauma, the client´s subjective needs Acute Interventions after sudden loss: the families´ subjective view. B. Juen , E. Mohr, Siller, H ., Gmeiner, V. University of Innsbruck. Stage or phase models of grief.

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B. Juen , E. Mohr, Siller, H ., Gmeiner, V. University of Innsbruck

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  1. Crisis Intervention in the acute Phase after Trauma, the client´s subjective needsAcute Interventions after sudden loss: the families´ subjective view B. Juen, E. Mohr, Siller, H., Gmeiner, V. University of Innsbruck

  2. Stage orphasemodelsofgrief • Stage modelsassume a detmerminedcourseofgrieflike: disbelief, intensive emotions, acceptance • In workingmodelsofgrief, thetasksthathavetobeaccomplishedare also conceptualized in phaseslike: realization, workingthroughemotionsandreuptakeof emotional life • Phase orstagemodels do not have an empiricalbasis • Research exampleMaciejewski et al analysed a groupof 233 grievingpersonsandfoundthatdisbelief was not the dominant response in thebeginning, acceptance was most dominant in all phasesandyearning was themost prominent negative griefindicator in thefirstmonths. • Over time, disbeliefandyearningdecreasedandacceptanceincreased

  3. Copingmodelsofgrief • Today most reseachers prefer coping models of grief to phase or stage models • Grieving persons have to cope with new and overwhelming emotions as well as with new life circumstances (Znoj, 2007) • Research example, Berne study on parental grief: If this process is completed in a positive way, persons may be more able to cope with extreme negative emotions than others (Znoj, 2006)

  4. Grief therapy • Loss is a life-event thathas a specific, evenbiologicallydeterminedreactioncourseandtakes time. AccordingtoZnoj (2004,2006) therapeutichelpis not alwaysneededanddoes not shortenthereaction. Itmayevenhinderthenaturalhealingprocess (“toomuchgrief”) • Psychotherapyonlyworkswhenthebereavementhasbecomecomplicated (e.g. Shear et al., 2001, Wagner et al. 2005) • “Thus it must bestated ...thattherecanbenojustificationforroutineinterventionforbereavedpersons in termsoftherapeuticmodalities -- eitherpsychotherapeuticorpharmacological -- becausegriefis not a disease.” (Raphael, Minkov & Dobson, 2001) • Therapymeansinterventionsthatshallhelptoconfrontoneselfwiththedifficultaspectsoftheloss. This maybeuseful in complicatedgrief but tooconfrontativeifgriefis normal. • But whatkindofsupportiseffective in theacutephaseif not therapy?

  5. AcutePsychosocialInterventionsforgrievingfamilies • In lower Austria twosupportsystemsareactiveforfamilies after thesuddendeathof a familymember. • Crisis Intervention teamsconsistingofspeciallytrainedemergencypersonnelcometothesiteimmediately after theevent (ifthefamilywantsit) andsupportthefamilythroughtheveryfirsthours (thisispaidbytheredcrossandother NGOs whichprovidetheservice) • In themoreseverecasestheAcuteteamconsistingofpsychologistsandpsychotherapistscancomeintothefamilyuptofivetimes after theeventtogive immediate psychologicalandpsychosocialsupport (thisserviceispaidbythegovernment)

  6. The Study abouttheworkoftheAcute Team • In a studyusing a mixedmethodapproachthefollowingquestionswereanalysed • Quantitative dataanalysis • WhichRiskfactorscanbeidentified in thefamilies? • Whichresourcescanbeidentified? • Whichinterventionsareusedbytheteamandhowaretheyperceivedbytheaffectedfamilies? • Whichriskfactorscanpredictproblematicacutereactions? • Whichinterventionscanpredictsatisfaction?

  7. The Study abouttheworkoftheAcute Team • In a studyusing a mixedmethodapproachthefollowingquestionswereanalysed Qualitative dataanalysis • Whichresourcesaresubjectivelyseenasimportantbytheaffectedfamilies? • Whichinterventionsareseenasimportant? • Whichindicators do theaffectedseefor positive and negative change?

  8. AcuteTeam Cases Analysed • 426 casesofsuddendeathwereanalysedin a quantitative manner • 376 casesweredocumentedby narrative protocolsandanalysedby qualitative contentanalysis, 15 ofwhichwereanalysed in a detailledmanner. • In thesecases 1194 individual personsweresupported. In thesecasesitis not possibletocollectdataaboutindividualsbecausefamilies/groupsare in thefocusoftheinterventions. The eventswere in mostcasessuddendeathof a familymemberbysuicide, Illnessoraccident • The families/groupsreceived a onetothree time acutecrisisinterventionattheirhomebypsychologists/psychotherapistsoftheAcuteTeam in Lower Austria

  9. Quantitative Results(seepostersession) • Riskfactorsstemfromthesituation, theperson, previoustraumaordisorder • Problematicacutereactionslikeseveredissociation, panicattacks, severeformsofhelplessness etc. canbeseenratheroften in thefamilessupported • Oftheresourcesthemost prominent arethesocialresources • The teamusesinterventionsaccordingtotheHobfollprinciples (safety, connectedness, calm, self/colelctiveefficacyandhope) • Most prominent aretheinterventionspromotingself (colllective) efficacyandcalminginterventions • Onlythesituationalfactorscanpredictproblematicreactions in theacutephase (especiallyviolenteventsandaccidentswithneardeathsituations) • Satisfactioncanbestbepredictedbycalminginterventions

  10. Qualitative resultsSubjectivelyperceivedresources • Beingabletotalktosomebodyfrom outside • Connectednesswithfamilyandfriends • Socialintegration (tohave a networkoffriends, school, broadersocialnetwork) • Tobeabletotakeresponsibilityforthefamily • Personal resources (creativityandrituals)

  11. Beingabletotalktosomeonefrom outside • Totalkaboutthedeathcan bring stress reduction • Itcan also enhancethefeelingofselfefficacyandsaftetyifthepersontowhomyoutalkcanbetrustedandisabletogivepsychoeducation • Safetycanbeenhancedifthepersonrealisesthatthehorribleeventwhichcannotbefullyputintowordscanbesharedwithanotherpersonwhobearswitnesstoit (especially in violenttraumathisis an importantfactor)

  12. In thewordsoftheaffectedpersons • Tobeabletotalkaboutdifficultemotionslikeguiltfeelingsandfears • Tohave a personlisteningwhoisobjectiveandcomesfrom outside thefamily • Totalktofamilyandfreiendsisoftenonlydone in smallpieceswhereasheretheyfeeltheycantaketheir time andtalkaboutthewholestory in detail • They find itimportantthattheyaregiven time andspacetothinkabouttheeventand „summmarize“ thethingsthathavehappened • Theyfeeltheycan bring orderintotheirthoughtsandfeellesslonely

  13. Connectednessandsocialsupport • Tofeelconnectedtoothersespeicallyfamilyandfriendsisoneofthemostimportantresources in thesesituations • Also thefeelingtobepartof a broadersocialnetworkisperceivedasveryimportant • Tobeabletotakeresponsibilityforthefamilyis an importantfactor in selfandcollectiveefficacyandhelpstheaffectedpersonstobe not only on thereceiving end ofsocialsupport. This includes not talkingaboutcertainaspectsoftheeventwiththefamily in ordertoprotectthem (especially after violence, see also Yehuda et al 1998)

  14. Personal resources • Creativityisseenasimportantbytheaffectedpersons. Theywritelettersandpoems, theydrawpictures • Theyengage in a varietyof individual andcollectiveritualsthathelptoworkthroughthefeelingsoflossandtokeepcontacttothedeceased (see also Schwaiger, 2011, Duffek, 2012)

  15. Functionsofrituals(Schwaiger 2011) • Rituals canhelptofulfillneedsthatcannotbefulfilledbythesocialenvironment • tofeelproximitytothedeceased, togivethedeceasedpersonspace in everydaylife, to express ambivalent emorions, tocreateorderandcontrol…. • Personal ritualsare not donewhenothersarepresent but only in private • Rituals canberealizedbyactions but soemaredoneonlybyimagination • Rituals can but do not havetocontain spiritual elements

  16. Qualitative results: SubjectivelyimportantInterventions • Tohave an externalpersonwhoonecantrust • Tohavethepossibilityto express emotionsandenhanceunderstandingbytalkingabouttheevent • Tobecoachedthroughnextsteps • Tohavecontinuityand a certainlengthofsupport • Somebodywhoisreallypresent, interestedandattentive • Tohaveenough time (morethanonecontact) • Support in activatingresources • Listening • Gettinginformationaboutwheretogetfurtherhelpandhowtocopewithsymptoms

  17. In thewordsoftheaffected • Tobeabletotalkaboutguiltfeelingsandbeunconditionallyaccepted • Gettinginformationaboutwhatto do nextandhowtogetfurtherhelp • Tobeabletoaskquestionsaboutanyaspectsoftheeventthatisimportantlike, howhas he died, did he suffer etc. • The affectedpersonsfeelthattheybecomemoreactivebygettinginformationandadviceabouthowtocopewiththenewlifecircumstances • Theyappreciatepsychoeducationbecausetheylearnabouttheirsymptomsandhowtocope, theyfellmoresecure • Theysaythatit was especiallyhelpfultoagaintalkabouteverything after someweeksandtohave a continuity in supportfromtheaccidentuntilfourweeksafterwards. Theywouldwishevenmorecontacts. • Tobepresent, interestedandattentive: The feelingthatsomebodycares

  18. Qualitative results: Indicatorsof positive change • Uncontrollablethoughtsaboutthedeceased/theeventhavedecreased • Activeandcontolledworkingthroughbecomespossible: deathis a realitynowandacceptanceisenhanced, ritualsaredonetounderstandandmarkthenextstep • Moodandclimatewithinthefamilyarebetternow, tensionhasbeenreduced • Moodofthepersonhasbecomebetter, he/shefeelsstronger, ismorecalm • Totalkaboutlossandguiltfeelingsbecomespossible • Fear isdiminished • Normal everydaylifecanbestartedagain • „Old“ ritualslikehowtocelebratechristmasorbirthdaysarerearranged

  19. Qualitative results: Indicatorsof negative change These stemmostlyfromthegrievingprocess but also fromthenecessityofrolechange in thefamily after a lossaswellasfromdifficultreactions in thesocialenvironment (negative socialsupport) orfrompreviousfamilyconflicts • New conflicts in thefamily • Misunderstandingsand lack ofunderstandingfromthe outside world • Old conflictsfromthepastintervenewiththeacutetrauma • Mooddecreasesandgriefgetsworse (oftenas a normal phase in thegrievingprocess)

  20. In thewordsoftheaffected • Thereis not such a bigtensionanymore • Grandmacannowtalkabout her lossandguiltfeelings • I am feelingstrongerandbetternow • Old conflictsbetweenourfamilyandthefamilyofourunclebecomemixedupwithourpresentstory • Westarttogo on withourlives (wemeetfriendsagain, wego out again…)

  21. In thewordsoftheaffected • Griefisbecomingworsewhenyourealizethat he isnevercoming back • Youhavetolethimgo • Especiallychristmasis a verydifficult time

  22. Conclusions: Supportingthe normal processofcopingbythefollowinginterventions • Listen tothegrievingpersonandsupportthenaturalgrievingprocess • Forthegrievingfamilytobeabletotalkto an outsiderwhoispresentinterestedandattentiveisveryimportantespeciallywhendealingwithdifficultemotions • Giveinformationandpsychodeducation • Togetinformationandpsychoeducationisveryimportant in ordertobeactiveandfeelcompetentandabletocopewiththe extreme negative emotions • Accompanyandsupportunderstanding in a nonintrusivemanner • Tobeabletorepeatedlytalkabouteventanddeceasedperson in ordertocometo a betterunderstandingisseenasthemostimportantaspectoftalk • Promote connectedness • Tobeconnectedtofamilyandfriends but also to a broadersocialnetworkisseenascrucial • Encourage personal resourcesandrituals • But also personal resourceslikecreativityandritualsareseenashelpful in thegrievingprocessandcansupportthecopingprocess

  23. Conclusions • Positive changesaredescribedbytheaffectedpersonsas a changefromtheuncontrollableruminationtowards a morecontrolledthinkingaboutthedeceasedandtheevent. This processisverysimilartowhatTedeschiandCallhoundescribeasthepathwaytoPosstraumatic Growth

  24. References • Duffek, P. (2012) KollektiveRitualezurTraumebewältigungnachKatastrophen (unveröffentlichte Diplomarbeit, Institut für Psychologie, Universität Innsbruck) • Neimeyer,R.A. & Currier M. (2009): Grief Therapy. Evidence of Efficacy and Emerging Directions. In: CurrentDirections in Psychological Science 18 (6), S. 352–356 • Raphael B, Minkov C, Dobson M (2001)Psychotherapeuticandpharmacologicalinterventionforbereavedpersons. Death Studies 24: 603–610 • Schwaiger, E. (2011) Die Funktion von Ritualen nach traumatischen Ereignissen (unveröffentlichte Diplomarbeit, Institut für Psychologie, Universität Innsbruck) • Tedeschi, R.S., & Calhoun, L.G. (2006). The foundationsofPosttraumatic Growth: an expandedframework. In: Calhoun, L.G. & Tedeschi, R.G. (eds) Handbook ofPosttraumatic Growth: Research and Practice, New Jersey: Lawrence Erlbaum • Wagner, B., Knaevelsrudb, Ch,  Maercker, A. (2006) Internet-BasedCognitive-BehavioralTherapyforComplicatedGrief: A RandomizedControlled Trial, Death Studies, 30 (5) Pages 429 – 453 • Shear, M.K., Frank, E., Foa, E., Cherry, C, Reynolds, C.F.., VanderBilt, J. & and Masters, S. (2001) TraumaticGrief Treatment: A Pilot Study, Am J Psychiatry 158:1506-1508 • Yehuda, R., McFarlane, A.C., Shalev, A.Y. (1998). Predicting the Development of Posttraumatic Stress Disorder from the Acute Response to a Traumatic Event. Society of Biological Psychiatry, Vol. 44, pp. 1305–1313. • Znoj, H.J. & Maercker, A. (2004). Trauerarbeit und Therapie der komplizierten Trauer. In M. Linden & M. Hautzinger (Hrsg.). Verhaltenstherapiemanual (5. Aufl.). Berlin: Springer

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