Welcome to Life’s Levels Of Grief

Welcome to Life’s Levels Of Grief Presented by Dr. Susan R. Rose March 2, 2011

Introductions • Your name • Your title and your school/organization • Educational Goals • What brought you to this session? To the conference? • Something of interest about yourself that you haven’t already mentioned • Favorite vacation • Hobbies • Foreign languages

Purpose of Grief • …this is not a process which can be rushed. • It is about integrating the changed circumstances into the survivor’s ongoing life. Related Quotes & Thoughts While I thought I was learning how to live, I was learning how to die. - Leonardo da Vinci Life is measured not by its length, but by its depth. – Mary Fisher

Level 1: Defining the Loss Experiences That Generate Grief Reactions Grief knits two hearts in closer bonds than happiness ever can; and common sufferings are far stronger links than common joys. Alphonse de Lamartine (French writer, poet, and politician, 1790-1869) School Counseling Program

The Experience of Loss • Bereavement: The objective event of loss • Disrupts survivor’s life • “Shorn off or torn up” / “Being robbed” • A normal event in human experience • Grief: The Reaction to Loss • Thoughts (mental distress) • Feelings (emotions) • Physical responses • Behavioral responses • Spiritual responses • Mourning • Process by which a bereaved person integrates a loss into his or her ongoing life • Determined partly by social and cultural norms for expressing grief

Basic Facts about Loss and Grief • Every year, two million people die in the U. S. • If each of these deaths affects just five people, at least ten million people are affected each year. • Chronic illnesses such as cancer, heart disease, and diabetes account for two of every three deaths. These illnesses create many losses before death is anticipated. • Accidents are the leading cause of death children under age eighteen. Accidents are also the cause of many disabling injuries, creating loss of mobility, fine motor skills, and cognitive functions. • In 1999, the most recent year for which statistics are published by the U.S. Dept. of Health and Human Services, 568,000 children were removed from their biological families to live in foster care. These children, their biological and foster parents, siblings, teachers, and counselors/social workers are all affected by loss and grief. School Counseling Program

Basic Facts about Loss and Grief cont. • According to predictions based on the U.S. census, approximately 43% of marriages in the U.S. will end in divorce. • Some parents and children who experience divorce consider adjusting to the losses associated with it to be as challenging as the losses associated with death. • The tragic events of September 11, 2001 immediately affected people all over the world. • Traumatic losses associated with these terrorist attacks, along with other tragedies such as the Columbine High School shootings, have an impact on individuals and communities far beyond what can currently be understood. School Counseling Program

If you’re wondering what you should gain from this workshop, you should ask yourself: How comfortable and confident am I in my own ability to deal with grief and loss? How well do I understand the impact of death on people of different ages, genders, cultures and spiritual orientations? How familiar am I with other life events and losses that can cause grief reactions? Am I confident that I can identify when an individual or family is expressing normal grief or when their grief may be complicated? How prepared am I to respond effectively to those around me who are grieving? Do I know how to acknowledge grief and make a referral to an appropriate resource when necessary? School Counseling Program

More Insight into the Purpose of this Workshop The Keeper http://www.counselingtoday.com/FreeStuff.html School Counseling Program

Symbolic (Psychological) Loss • Divorce/The end of a relationship without one of the partners dying • Foster care placement • Children leaving home for independent living (The “empty nest”) • Unemployment or Job demotion • Changes in health status • Moving, Selling a childhood home, etc. • Parents whose children have been diagnosed with a disabling medical or mental condition • Moving parents into a nursing home • Loss of independence • Miscarriage/Infertility • Death of a pet School Counseling Program

Loss and Grief in Different Contexts • Crisis Counseling • We can’t “cure” grief, but we can offer help and care. • Trauma Therapy/Counseling • Becoming attuned to grief issues helps identify and assist with loss and grief associated with these problems. • Unacknowledged Grief – For example: • Losing a parent symbolically due to substance abuse • Refugees fleeing their homeland • Empty Nest (High School Counseling) • Loss of Health School Counseling Program

Loss and Grief in Different Contexts cont. • The “Tough” Kid • 14-year-old girl place in therapeutic home for adolescents • Mother died in a car accident when she was a toddler • Father was incarcerated at the time, so she and her sister were moved from family member to family member as well as to foster homes where she was sexually and physically abused. • Frequent expression of anger and poor behavior resulted in residential placement, outside of the city in which she has spent her childhood and separate from her sister. What do you think happened next? School Counseling Program

Small Group Exercise (3 – 4 members) Divide a sheet of paper into two columns. In the first column, write down the types of losses, both actual and symbolic, that students are likely to experience. In the second column, write the emotions someone experiencing each loss is likely to experience. Discuss your thoughts about how you might observe these losses and the feelings related to them. (For example, a school counselor leading a group for children whose parents are divorcing might observe academic problems with some of the children.) School Counseling Program

Share out in Large Group Although the world is full of suffering, it is full also of the overcoming of it. - Helen Keller School Counseling Program

Level 2: Self-Preparation - Preparing Yourself to Help Others Encountering Loss and Grief What is of greatest importance in a person’s life is not just the nature and extent of his or her experiences but what has been learned from them. -Norman Cousins Everything that happens to you is your teacher. The secret is to sit at the feet of your own life and be taught by it. • Polly B. Berends (Author & Editor of Children’s book) School Counseling Program

Reviewing Our Own Experiences and Attitudes Related to Grief • Experiences with death or loss significantly influence the way we react to the losses of other, both consciously and unconsciously. • Take a few moments now to think about the following questions. • What was your earliest experience with death or loss? How old were you when it occurred? Where were you when you learned of the loss? Who did it involve? • What were the physical, emotional, and cognitive reactions you were aware of in yourself following the loss? • How did the people around you respond to the loss? How did they respond to your reactions? • How did your cultural and/or spiritual background influence your responses? • What about the loss makes you feel vulnerable now? • Based on what you have learned since, what do you think can help you to cope more easily with death or loss now and in the future? • How do you think your own feelings and reactions to loss may impact your work with others who are experiencing loss or trauma? School Counseling Program

Assessing and Enhancing Readiness to Address Grief in Our Work • How do we know if we are ready to help others with their grief? • Self-Assessment/Self-Awareness • Working with individuals and families facing loss inevitably brings up emotions and memories for every professional. • Establishing competence in providing care to those who are grieving. • Support clients in their expression of emotional needs • Actively listen • Refer to support groups, peer support programs, and professional experts • Ask open-ended questions such as, “How are you doing?” School Counseling Program

Supervision, Consultation, and Collaboration with other Professionals • Especially important when exposure to distress of others is prolonged, frequent, or intense. • Vicarious/Secondary trauma: a common reaction in professionals who work closely with individuals or groups who directly experienced trauma. • Supervisors, peers and consultants can help us to recognize when our own reactions may be distressed. • Interdisciplinary/Multidisciplinary Team • Counselors • Teachers • Attendance Specialists/Clerks • Disciplinary Staff • Administrative Personnel School Counseling Program

Questions, Comments, Concerns

Level 3: Experiencing Loss and Grief Across the Lifespan School Counseling Program

Factors that influence a child’s a child’ cognitive, emotional, and behavioral reactions to death: Childhood Chronological age Earlier experiences with death Reactions of adults and other children around them Child’s own unique personality and coping style School Counseling Program

Infants • Key developmental issues for infants are dependency and attachment. • Developmental Factors • Dependence on caregivers for all basic needs • Limited object constancy – the understanding that person or object exists, even if not physically present. • Limited ability to verbalize. • Few coping strategies to regulate tension. • Understanding of death • Do not recognize • Experience feelings of loss in reaction to separation that are part of developing an awareness of death • Reactions to loss • Emotional: Sluggish, quiet, unresponsive to a smile or a coo; may also cry and appear inconsolable • Physical: Weight loss, less active, sleep less • What can help? • Maintaining normal routines of care giving and familiar surroundings • Providing a consistent caregiver who can give frequent and lengthy periods of love and attention, including holding and hugging • Providing consistent, gentle, physical and verbal reassurance and comfort • Expressing confidence in the child and the world School Counseling Program

Ages 2 – 3 (Toddlers) • Like infants, key developmental issues for toddlers are dependency and attachment. • Great variation in cognitive and emotional development • Developmental Factors • Ambivalence about independence • Increasing comprehension and articulation of language • Learning by mimicking and following the examples of others • Understanding of death • Generally cannot cognitively understand death • Cannot differentiate absence for a short time from a long time • Can sense loss of change but often cannot verbally explain or discuss it • Reactions to loss • Emotional: Express discomfort or insecurity through frequent crying or protest; Express distress or sadness through withdrawal, loss of interest in usual activities, and changes in eating and sleeping patterns. • Physical: May show regression through clinging or screaming when a caregiver tries to leave; May express distress through regression, often giving up previously acquired skills such as speaking clearly, toileting, and self-soothing at bedtime • What can help? • Same as infant + • Providing simple, understandable verbal explanations for changes • Naming feelings expressed by the child and those the child observes being expressed by others, such as, “Daddy feels sad; that is why he is crying.” School Counseling Program

Ages 3 - 6 • Children at this stage are still thinking concretely and may perceive death as a kind of sleep • Concept of death may involve magical thinking • Developmental Factors • Developing a fuller mastery of language • Learning to read • Expressing feelings through art and play • Acquiring social skills through interactions and observing others • Understanding of death • Cannot quite comprehend the difference between life and death • Reactions to loss • Emotional: May be very anxious that something could happen to them or someone else upon whom they are dependent; May exhibit searching behaviors • Physical: May have trouble eating, sleeping, and controlling bladder and bowel functions • What can help? • Explaining death in simple and direct terms, including only as much detail as the child is able to understand. • Answering a child’s questions honestly and directly, making sure that the child understands the explanations provided. • Reassuring children about their own security and explaining that they will continue to be loved and cared for (They often worry that their surviving parent or caregiver will go away) • Encouraging master of age appropriate skills while allowing for regression • Expressing confidence in the child and the world. School Counseling Program

Ages 6 – 9 • Children in this age are commonly curious about death and may ask questions about what happens to one’s body when a person dies. • Children beginning in this age benefit from being invited to contribute to memorial ceremonies or activities. • Developmental Factors • Relationships with peers and adults are important • Striving for mastery of information and tasks • Superego and a sense of responsibility are developing • Cognitively, they are still thinking concretely. • Understanding of death • Children’s questions often indicate their efforts to understand death fully. • Reactions to loss • Can become afraid of going to school or have difficulty concentrating, may behave aggressively, become overly concerned about their own health, or withdraw from others. • What can help? • Discussions of death that include proper words, such as ‘died” and ‘death” • Providing opportunities for children to ask questions freely and to express their feelings directly or through creative activities • Providing reassurances that the child’s thoughts, feelings, and behavior did not cause death • Reading aloud stories or books that deal with death and allowing the child to share their reactions or questions • Inviting children to share memories and participate in ceremonies or remembrance activities School Counseling Program

The Sandpiper http://www.counselingtoday.com/FreeStuff.html School Counseling Program

What is your Joy? School Counseling Program

Ages 9 – 12 • Child is developing an increasing grasp of abstract concepts • By the time a child is 12, death is seen as final and something that happens to everyone • Developmental Factors • Interest in and capacity to understand biological processes • Heightened sensitivity to others’ emotions • Increased awareness of vulnerability • Regressive and impulsive behaviors indicate stress • Understanding of death • Death is usually known to be unavoidable and is not seen as punishment • Reactions to loss • Greater risk for symptoms of depression, withdrawal, anxiety, conduct problems, changes in school performance, and low self-esteem • Capable of empathy • What can help? • Talking about death can help children learn effective ways to cope with loss • Providing an opportunity to explore and discuss spiritual and cultural beliefs related to loss • Providing physical outlets for strong emotions • Encouraging expression of feelings through different media including art, music, dance, and writing. • Letting children know they are not alone and that others experience loss and the feelings related to it. • Modeling direct and constructive expression of feelings naturally associated with loss such as anger and sadness. School Counseling Program

Adolescence • Adolescents may view death in the family as making them appear different from their peers • May perceive death has placed greater demands on their own development • Developmental Factors • Searching for identity • Peer relationships are very important • Exposure to maladaptive responses to stress • Abstract thinking • Understanding of death • Adolescents comprehend that death is permanent, irreversible, and affects everyone. • Reactions to loss • At risk for exposure to maladaptive coping strategies; May also be at risk for parentification • What can help? • Talking openly about death, indicating that the subject is not off-limits • Verbal or written explanations that tears, sadness, anger, guilt, and confusion are all part of normal grief • Providing opportunities for adolescents to hear from and talk with peers who have also experience loss • Inviting the adolescent to help plan or participate in memorial or remembrance activities in the way that feels most comfortable to them • Connecting adolescents to peers who have similar experiences to reduce isolation • Encouraging journal writing or using other methods to express thoughts and feelings • Constructing memorials, memory books, boxes, or quilts, or providing other tangible ways to memorialize significant relationships School Counseling Program

Young Adulthood • Multiple demands of life may deter ability to devote time and energy to grief. • Developmental Factors • Expected to be self-sufficient (economically, if not emotionally) • Developing career and life plans • Expanding their range of roles and coping strategies • Understanding of death • Fully comprehend and are also capable of comprehending the complex range of responses of different people to different types of losses • Reactions to loss • Vulnerable to the emergence of anxiety, depression, and other disorders that stress related to loss can exacerbate • What can help? • Acknowledge the multiple impacts of loss and the normalcy of grief reactions • Encouraging individuals to take time to attend to their own feelings as well as those of others • Acknowledging or providing opportunities for expression and discussion of conflicting feelings • Promoting social connections through peer support and group activities • Referring young adults to credible Internet sources for information and peer support School Counseling Program

Middle Adulthood • “Sandwich” generation • Developmental Factors • Re-examination, renewal, and /or reintegration of identity • Multiple roles and responsibilities • Long-established patterns may be difficult to change • Increased vulnerability to physical disorders • Reactions to loss • “Pile-up” of losses • Maladaptive patterns may make the process of grieving complicated • What can help? • Empathic listening and support • Release time from work or school to meet family obligations and process grief • Bereavement support groups • Tangible expressions of support or caring • Pastoral care or connection with a religious or spiritual community • Identification of risk factors and offering intervention for complicated grief • Opportunities for respite and renewal • Opportunities to assist others School Counseling Program

Late Adulthood • Textbooks define this as 65 and older  • Developmental Factors • Poor health or disabling medical conditions may have significant impact as biological aging progresses • Serenity and wisdom may be sought • Changes in identity related to work and family occur • Adaptation to changes in information processing and memory is required to maintain maximum functioning • Reactions to loss • Multiple losses require continuing adaptation; May be difficult to differentiate between grief and depression • What can help? • Acknowledgement of symbolic losses as well as losses through death • Maintaining or augmenting social supports • Provision of income supports or economic assistance, when needed • Identifying new activities, roles, and relationships to augment or replace those that have been lost • Conducting informal and formal life review, with emphasis on strengths and contributions School Counseling Program

Conducting informal and formal life review, with emphasis on strengths and contributions http://www.counselingtoday.com/FreeStuff.html A Life Well-Lived School Counseling Program

Advanced Age • Textbooks define this as 80 and older • Developmental Factors • Vulnerability to social isolation, disabling medical conditions, and memory loss • Adaptation to multiple losses, both symbolic and through deaths • Change in sense of time • A sense of consummation and conclusion in life • Reactions to loss • Anticipate own death; Reminiscence is common and often brings a positive sense of closure and fulfillment School Counseling Program

Advanced Age cont. • What can help? • Reminiscence through sharing of memories, with individuals and groups • “Make memories, Little Buddy, because when you get older, that’s all you’ll have.” Thank You for Your Time , http://www.counselingtoday.com/FreeStuff.html School Counseling Program

Advanced Age – What can help? cont. • What can help? • Reminiscence through sharing of memories, with individuals and groups • Providing concrete supports to allow expenditures of time and energy on satisfying activities and relationship (helping with household maintenance or bill paying) • Acknowledging losses as well as strengths and coping capacities • Encouraging completion of advance directives • Providing opportunities to open discuss ideas, values, feelings, and fear related to dying and death • Just Be There School Counseling Program

Just Be There http://www.counselingtoday.com/FreeStuff.html School Counseling Program

Questions, Comments, Concerns

Level 4: Normal and Complicated Grief Reactions School Counseling Program

And can it be that in a world so full and busy the loss of one creature makes a void in any heart so wide and deep that nothing but the width and depth of eternity can fill it up! - Charles Dickens School Counseling Program

Theories That Inform Our Understanding of Grief • Sigmund Freud’s Mourning and Melancholia (1917) • Every human infant develops attachments to significant people (whom he referred to as “objects”) through the process of Cathexis. • Cathexis: process of attaching emotionally • Decathexis: process of letting go of an attachment as an adaptive response to loss of a significant “object” • John Bowlby elaborated on Freud’s ideas (1973) • Proposed that attachment behavior helps infants establish an maintain a sense of security throughout their life. • According to Bowlby’s theory, grief reaction of the bereaved to the loss of a significant other is a similar process. • Bereaved must cease investing their emotional energy (referred to as libido in both Freud and Bowlby) in the deceased in order to reinvest it in other relatioship • Both believed that with the passage of time grieving individuals could achieve decathexis • Failure to do this results in depression School Counseling Program

Theories That Inform Our Understanding of Grief • Eric Lindemann became interested in grief reactions after a major tragedy in Boston, the Coconut Grove nightclub fire, took the lives of 492 people in November 1942. • Lindeman studied the grieving survivors and found common reactions of: • Physical or Bodily Distress • Preoccupations with the image of the person who had died • Anger or hostility • Guilt • Impaired functioning in work or family roles • He also identified task that grievers completed that resulted in a diminishment of these symptoms. • Acknowledging the reality of the death • Adjusting to life without the deceased person • Forming new relationships School Counseling Program

Theories That Inform Our Understanding of Grief • Elizabeth Kubler-Ross, a physician who worked with dying patients, made major contributions to our understanding of Anticipatory Grief. • Pioneering Publications in the 1960’s and 1970’s described her stage model • Denial and Isolation • Bargaining • Anger • Sadness/Depression • Acceptance • Parkes (1998) identified related stages in the grieving process • Shock or numbness • Yearning and pining (anger & guilt) • Disorganisation • Beginning to pull life back together School Counseling Program

Theories That Inform Our Understanding of Grief • More recently, grief counselors Therese Rando and William Worden have expanded on earlier theories • Worden (2005) concentrates on tasks of grieving that have to be worked through (‘grief work’) if resolution of grief is to take place: • To accept the reality of the loss • To work through or experience the pain of grief • To adjust to a changed environment in which the deceased is missing • To emotionally relocate the deceased and move on with life and capacity to love others. • Rando’s 6 R’s/ The Tasks of Mourning • Recognize the loss • React to the separation • Recollect the deceased and the relationship • Relinquish old attachments to the deceased • Readjust adaptively into a new world without forgetting the old • Reinvest

Common Reactions in Normal Grief • Highly variable and individualistic • Grief reactions vary across a wide spectrum according to: • Cultural Backgrounds • Social Support Networks • Gender • Socioeconomic Status • Psychological Health • Circumstances of Loss • Complex, evolving process • Multiple dimensions • Signs of grief may appear immediately after the death or may be delayed or even absent • No predetermined timetable for “completion” • Most often, the social and emotional support provided by family and friends is enough School Counseling Program

Normal Grieving Behaviors • Thoughts (Mental Distress) • Confusion, inability to concentrate or remember details, disbelief, anxiety; Sense of disorganization; Depression; Sensory responses undependable and erratic; and auditory or visual experiences that mimic hallucinations – such as seeing an image of the deceased person or hearing their voice – are not uncommon following a loss • Feelings (Emotions) • Sadness, Longing, Loneliness, Sorrow and Anguish, Guilt, Frustration at being unable to control events, Anger and outrage at injustice of the loss, Anxiety, Fatigue, Helplessness, Numbness, Shock, and even Relief • Physical (Somatic) Sensations • Tightness in the chest or throat, choking, shortness of breath; Lack of energy; Feeling of emptiness in the abdomen and stomach; Frequent sighing; Sleep disruptions (e.g., insomnia); Changes in appetite; Chills, tremors, hyperactivity • Behavioral Responses • Crying; Searching for the deceased; Incessant talk about the deceased and circumstances of death; Avoidance of talk about the deceased; Restlessness, irritability, hostility School Counseling Program

Expressions of Mourning • The bereaved are “different” for a time • Abstaining from social occasions • Visual Symbols • Black armbands • National flag at half-mast • Seclusion • Cutting long hair short (Native Americans)

The Course of Grief (Summarizing Normal Grief) • Initial phase: Shock, numbness, disbelief, denial • Middle phase: Anxiety, despair, volatile emotions, yearning for deceased, feelings of abandonment • Last phase: Sense of resolution, reintegration, and transformation; turmoil subsides; balance regained

Complicated Grief • Complicated Grief/Complicated Mourning: difficulty coping with loss; prolonged distress long after the loss has occurred. • Failure to complete the tasks of grief/mourning results in several types of complicated mourning: • Delayed grief: when a loss is insufficiently mourned • Masked grief: when grief is absent immediately after a loss but appears later in the form of a medical or psychiatric problem • Exaggerated grief: when a normal grief reaction, such as depressed mood or anxiousness, goes beyond normal grief to a clinical level of depression or anxiety • Chronic grief: when the mourner is stuck, sometimes for many years, in the grief process • Anomic grief: where there is an absence of standards or guidance on how to grieve. The person does not know what to do, doesn’t know how to deal with the loss, change in circumstances. • Forbidden grief: when others deny the person has suffered any loss. • Time-limited grief: the idea is that you should get back to normal, especially emotional normality, as soon as possible. School Counseling Program

Who is at risk for complicated grief? • Perceived lack of social support • Examples: Suicide, older adults who have already sustained the loss of many members of their primary support network, Children placed in foster care • High Profile Losses • Lack of privacy; frequent inquiries about and exposure to the details of the loss make it difficult to obtain respite • Multiple Stressors • Reduced income or unexpected financial debt • Loss of important roles • Loss of a job or health insurance • Disenfranchised loss: losses accompanied by stigma resulting in loss of support or acknowledgment for grieving survivors • Examples: Execution of a prisoner, loss associated with AIDS, death of a drunk driver, suicide • Unique losses that produce intense grief reactions for a long time • Examples: Loss of a child, Parents whose children have been removed by CPS or how have relinquished the role of parent through adoption • Sudden, unanticipated loss (especially when traumatic, violent, mutilating, or random) • Bereaved’s perception that the death was preventable • Death from overly lengthy illness • Relationship that was markedly angry, ambivalent, or dependent • Mental health problems or unaccommodated losses School Counseling Program

Welcome to Life’s Levels Of Grief