Module 5: Grief Counseling Lindsey Parrish, L.M.S.W. Licensed Master Social Worker Palliative Care Team-Saint Joseph’s Hospital, Atlanta, GA Unit 9: End of Life Care

Objectives: Provide overview of theories of grief counseling Review Worden’s 7 Mediators of Mourning and 10 General Grief Counseling Principles Describe “complicated grief” Identify, by developmental age, ways in which children both understand death and grieve Unit 9: End of Life Care

Introduction to Grief Counseling “Grief,” derived from Latin gravis Multidimensional response to loss Emotional (“Feelings”) Physical Cognitive Behavioral Unit 9: End of Life Care

Theories of Grief Counseling Stages model: Kubler-Ross (1968) Phases: Bowlby (1980), Parkes (1972), Rando (1988) Tasks: Worden (1982) Dual-Process Model : Stroebe and Schut (1999) Unit 9: End of Life Care

The Mediators of Mourning Grief Counseling The Mediators of Mourning (Worden, 2002) Unit 9: End of Life Care

Mediator 1: Who the Person Was Grief Counseling Mediator 1: Who the Person Was Mediator 2: The Nature of the Attachment Strength of the attachment Security of the attachment Ambivalence in the relationship Conflicts with the deceased Level of dependence Mediator 3: Mode of Death Unit 9: End of Life Care

Mediator 4: Historical Antecedents Grief Counseling Mediator 4: Historical Antecedents Grief baggage from previous losses? Mental health hx? Mediator 5: Personality Variables Age and gender Coping style Attachment style Cognitive style Unit 9: End of Life Care

Mediator 7: Concurrent Stresses Grief Counseling Mediator 6: Social, Cultural, Religious Factors Social network Cultural expectations? Religious rituals Mediator 7: Concurrent Stresses Unit 9: End of Life Care

10 Grief Counseling Principles and Procedures for Acute Grief (Worden, 2002) Unit 9: End of Life Care

Help the Survivor Actualize the Loss Grief Counseling Help the Survivor Actualize the Loss Help the Survivor to Identify and Experience Feelings Assist Living Without the Deceased Help Find Meaning in the Loss Facilitate Emotional Relocation of the Deceased Unit 9: End of Life Care

Interpret “Normal” Behavior Allow for Individual Differences Grief Counseling Provide Time to Grieve Interpret “Normal” Behavior Allow for Individual Differences Examine Defenses and Coping Styles Identify Pathology and Refer Unit 9: End of Life Care

When is grief “finished? “ Grief Counseling When is grief “finished? “ Stages Phases Tasks Dual-Process Model Importance of education of pts / families during grief counseling re: expectations (i.e. return to pre- grief state?) Unit 9: End of Life Care

Grief Counseling “Complicated grief” Unit 9: End of Life Care

Worden’s classifications (2002) Grief Counseling Overview 3 categories of distinguishing symptoms (Hooyman & Kramer, 2006) Worden’s classifications (2002) Chronic grief reactions Delayed grief reactions Exaggerated grief reactions Masked grief reactions Unit 9: End of Life Care

Prolonged Grief Disorder (aka Complicated Grief, Complicated Bereavement) Criterion A: Yearning, pining, longing for the deceased. Yearning must be experienced at least daily over the past month or to a distressing or disruptive degree. Criteria B: In the past month, the person must experience four of these eight symptoms as marked, overwhelming, or extreme. 1. Trouble accepting the death 2. Inability trusting others since the death 3. Excessive bitterness or anger about the death 4. Feeling uneasy about moving on with one’s life (e.g., difficulty forming new relationships) 5. Feeling emotionally numb or detached from others since the death 6. Feeling life is empty or meaningless without the deceased 7. Feeling the future holds no meaning or prospect for fulfillment without the deceased 8. Feeling agitated, jumpy or on edge since the death Criterion C: The above symptom disturbance causes marked dysfunction in social, occupational, or other important domains. Criterion D: The above symptom disturbance must last at least 6 months. J Pall Med 2006;9:1188-203 Unit 9: End of Life Care

Newly Recognized Disorder: Detect, Refer and Stay Up to Date! Prolonged Grief Disorder (aka Complicated Grief, Complicated Bereavement) Newly Recognized Disorder: Detect, Refer and Stay Up to Date! Unit 9: End of Life Care

Special Considerations: Grief and Children “How adults respond when someone loved dies has a major effect on the way children react to the death. Sometimes, adults don’t want to talk about the death, assuming that by doing so children will be spared some of the pain and sadness. However, the reality is very simple: children will grieve, anyway.” --Dr. Alan D. Wolfelt Director, Center for Loss and Life Transition Fort Collins, Colorado Unit 9: End of Life Care

Special Considerations: Children & Grief How Children Understand Death: Newborn to 10 months (Infant): Security linked to touch, warmth, scent, and manner; will have to adjust to new faces & voices in environment; cannot comprehend meaning but will perceive changes and negative stimuli as routines changed and interrupted 10 months to 2 years (Babies): Can recognize adults; major growths in memory, language, socialization; cannot conceptualize or understand death, but will experience loss of attachment to primary caregiver 2 to 5 years: (Children): Egocentric, curious, very literal interpretation of their world; use facts and reality, not vague or indirect language, death perceived as temporary state (“sleeping”) and deceased will awaken at some point. Use words: totally, not, very, very…., 6 to 9 years: (Children): Significant cognitive and developmental progress, socially involved, aware of roles, can conceptualize the fact of death, can distinguish fantasy vs. reality, can experience guilt, being able to understand factually does not mean can cope well 10 to 12 years (Preadolescent):Know that death is permanent, grasp significance of rituals, understand how the death occurred, grasp impact of death on them and the family, strong sense of own mortality, may deny the death will change their lives or “don’t care, don’t feel anything” 12 years +: (Adolescent): Sense of themselves and their place in society, death is the complete opposite of everything currently impt. to them , understanding comparable to adult but emotional state full of turmoil and change, reactions vary widely and change abruptly Unit 9: End of Life Care

Special Considerations: Children & Grief How Children Grieve: Newborn to 10 months (Infant): Difficult to assess how much infants grieve; do know infants react with distress to loss of primary caregiver; can also sense the distress of those around them; may become cranky, cry often for no apparent reason, and alter eating / sleeping patterns 10 months to 2 years (Babies): May respond to loss and changes with temper tantrums and anger outbursts to express despair / frustration; may search rooms and familiar spots for the lost loved one; decreased interest in toys and food; may revert to infantile thumb-sucking, fetal position 2 to 5 years: (Children): Grief expressed through bewilderment, regressive behavior, ambivalence (“I can’t find my doll”), may be expressed through play in which loss and death themes occur, separation anxiety, forming attachments to other adults who resemble the deceased 6 to 9 years: (Children):Denial the death happened; idealization of the deceased; guilt they caused the death; fearing for survival of remaining caregivers / parents; caretaking of younger siblings 10 to 12 years (Preadolescent): May hold off on any outward signs of grief so as not to be perceived as “different” by their peers; may assume caretaking; uncharacteristic displays of anger; fear may be expressed as physical complaints, moodiness, disinterest in school; may try to collect memories / bond of the deceased (photos, mannerisms, wearing clothing, perfume of deceased) 12 years +: (Adolescent): May band together with friends; might shut down emotions; magnified feelings of cynicism or depression; self-destructive coping mechanisms (poor grades, alcohol); caretaking and increased responsibility, previous teen-parent conflicts with deceased cause guilt Unit 9: End of Life Care

Conclusion and Resources “Just as there is no one way to mourn, there is not one kind of help that makes grief come to an end. Help is not a matter of providing the bereaved with a clear formula for what to do. The goals of help will vary depending on what mourners feel they need at a particular time and where they are in their grieving process.” -Phyllis Silverman in Living With Dying (2004) Remember to meet your patients and families “where they are” in their grief journey. Stay away from cliches: Your patients and families deserve unbiased assessment and skilled grief intervention, not the cliches they are hearing from everyone else in their lives. Remember professional self-care: set boundaries, resolve your own grief tasks (possibly therapy), & nurture yourself. Be able to identify professional Compassion Fatigue and seek support. Unit 9: End of Life Care

Resources Unit 9: End of Life Care The Compassionate Friends: www.compassionatefriends.org The Good Grief Program, Boston Medical Center: (http://www.bmc.org/pediatrics-goodgrief/tipsforadults.htm) Hospice Foundation of America (www.hospicefoundation.org) CancerCare, Inc.: (http://www.cancercare.org) Family Caregiver Alliance: (http://www.caregiver.org/caregiver/jsp/home.jsp) Unit 9: End of Life Care

References Unit 9: End of Life Care Baohui, Z, El-Jawahri, A., & Prigerson, H. Update on bereavement research: evidence-based guidelines for the diagnosis and treatment of complicated bereavement. Journal of Palliative Medicine. October 2006, 9(5): 1188-1203. Berzoff, J. & Silverman, P. (2004). Living With Dying: A Handbook for End-of-Life Healthcare Practitioners. New York: Columbia University Press. EndLink: An Internet-based End of Life Care Education Program: Social and Psychological Considerations. (http://endlink.lurie.northwestern.edu). Hooyman, N. & Kramer, B. (Eds.) (2006). Living Through Loss: Interventions Across the Life Span. New York: Columbia University Press. Kroen, W. (1996). Helping Children Cope with the Loss of a Loved One. Minneapolis: Free Spirit Publishing, Inc. Wolfelt, A. (1995). Helping Children Cope with Grief. [Brochure]. Wolfelt, A. (1995). Helping Teenagers Cope with Grief. [Brochure]. Worden, J. William. (2002). Grief Counseling and Grief Therapy. New York: Springer. Unit 9: End of Life Care