2. Working with Bereavement & Loss
Saturday 11th November 2017 pm

3. Administration The Building

4. Health & Safety
At the start of the course, please ensure that students understand what to do in the event of a fire. The assembly point for any evacuation is in KEAN STREET Take the laminated room number sign from the classroom wall and instruct students to assemble with you, using the room number as your ‘flag’. If students have mobility problems, direct them to the student lounge on that floor and someone should wait with them until a Fire Marshal arrives to assist them to safety (via the fire-fighting lift)
There is a full set of guidelines in each room

5. First Aid
Telephone 2801 to contact a first-aider via the internal telephones in the student lounges or in room 218
Second Floor rooms 206 and 210
have First Aid Boxes.

6. Ladies: floors G,1,3,4,6 Gents: floors G, 2, 5 Disabled: Each level
Toilets
Ladies: floors G,1,3,4,6
Gents: floors G, 2, 5
Disabled: Each level

7. Student Administration
Completing the online register
Completing Feedback Forms at the end of the Day

8. Adrian Scott MSc Senior MBACP Accredited www.counsellingme.co.uk

9. Paper Free! pdf files on website www.counsellingme.co.uk
Background Menu

10. My Experience MBACP Senior Accredited Counsellor
MBACP Senior Accredited Supervisor for Individuals and Groups
Managed Counselling services in Voluntary Sector
Bereaved, Homeless, Mental health, Carers

11. My Work 2015
Assessor / Group Supervisor at Mind in Enfield Group Supervisor at Mind in Haringey
Group Supervisor at Family Action, Angel
Group Facilitator at College of North East London
Group Facilitator at Southwark Day Centre for Refugees and Asylum Seekers
Private Practice in Haringey North London Individuals, Couples, Individual Supervision

12. Expert Not a guru or Bereavement expert Do not know everything
Ideas to be Debated / Challenged

13. Other City Literary Courses
Day Courses:
Introduction to Psychodynamic Counselling
Introduction to the Unconscious
Living through Bereavement
6 Week Course: 3hrs a week
Psychology of Attachment

14. My First Working Bereavement Working Experience
Bereavement Counsellor at the
London Hospital in 1989
Led by Dr. Colin Murray Parkes
Theory / Case Study

15. Morning Session 10.40 Introduction 10.55 Icebreaker Exercise
12.00 Theory and Group Discussion
1pm Lunch

16. Afternoon Session 2pm Working with your own Bereavement & Loss
2.45pm Break
3pm Working with Bereavement & Loss
Case Examples – Video
4.10 Round Up / administration
4.30 End

17. Your Experience & Ideas Case Examples

18. Audio Visual
Various Clips from Youtube
Bereavement TV Programmes

19. Learning Outcomes Icebreaker Exercise - Counselling Skills
Listening, Hearing, Reflecting back
Understanding Bereavement & Loss Theory Models and Attachment
Assessment Exercise - Own Experience/ Attachment Personal Experience – Own Therapy
Understanding of Bereavement Counselling Criteria Methods
Video Case Examples Seeing others peoples’ reaction to Bereavement and Loss

20. The Day Wide range of skills in the room
Hope you all get something out of it
I am not an expert on Bereavement
Encourage you to have your own view

21. Boundaries
Look after yourselves Bereavement can be a difficult and emotive subject
Do not say anything you do not want to say. This is not a therapy group!
Confidentiality Agreement -
All information should be kept to this room
and with this group of people.

22. Icebreaker Exercise Ask Your Colleague: 1. What brought you here?
2. What is your interest and experience of the
subject?
3. What do you want from the day?
You will be asked to briefly and concisely to report back what
your colleague has told you to the group, and check with your
colleague how you did!

23. Icebreaker Exercise Learning Outcomes
Basic Counselling Skills
Listening
Hearing
Reflecting back

24. What do you want from the Day?
Are there any Topics, Issues, that you would like to focus or discuss today?
Write on flip chart

25. 10-15 minute Break

26. Theory

27. Our Relationship to Theory

28. The Theory
Tool
Guide

29. Preamble before Bereavement Theory
General Principles of Counselling?
Training in Bereavement Counselling – last bastion of old model? - Discuss
Generic Approach
Learn about relationship with ourselves
A way to reflect on feelings

30. The Intelligent Human adult……...
…..knows that it fruitless to dwell on painful memories and the intrusive images of traumatic events are sometimes so painful that we will go to great lengths to avoid them.
We may do this by shutting ourselves up in a safe place (usually our home), and avoiding people and situations that will remind us of the trauma and deliberately filling our minds with thoughts and activities that will distract us from the horror. But it is a paradox that in
“ in order to avoid thinking about something we have to think about it”.
That is to say, at some level we remain aware of the danger that we are trying to avoid. Hence it should not be surprise us if our attempts at avoidance commonly fail. In sleep and a time of relaxed attention painful memories tend to float back into our minds and we find ourselves reliving the trauma yet again.
Colin Murray-Parkes

31. Link to Counselling
“ in order to avoid thinking about something we have to think about it”.

32. Buddhism teaches that we should not shrink from the fact of death but squarely confront it. Our contemporary culture has been described as one that seeks to avoid and deny the fundamental question of our mortality. It is the awareness of death, however, that compels us to examine our lives and to seek to live meaningfully.
Death enables us to treasure life; it awakens us to the preciousness of each shared moment. In the struggle to navigate the sorrow of death, we can forge a radiant treasure of fortitude in the depths of our being. Through that struggle, we become more aware of the dignity of life and more readily able to empathize with the suffering of others.

33. Counselling is a craft, technique, or practice of
Link to Counselling
Counselling is a craft, technique, or practice of
thinking and being with feelings
which we want to avoid

34. Colin Murray Parkes Bereavement: Studies of Grief in Adult Life
Paperback: 288 pages
Publisher: Penguin Books Ltd; 3New Ed edition (1998)
ISBN-10:

35. “Bereavement Expert”
Since 1966, Parkes has worked at St. Christopher’s Hospice in Sydenham, where he set up the first hospice-based bereavement service and carried out some of the earliest systematic evaluations of hospice care.
Parkes has also edited books on the nature of human attachments, and Bereavement
Parkes is a former chairman and now life president of the charity Cruse Bereavement Care

36. A Theory of Bereavement
For this course today:
Bereavement is a process of grieving
Loss is the person or object
Life is bereavement
Minor bereavements all the time
Beginnings and endings: relationships, friendships, jobs, work projects, holidays, moving house
Days, weeks, years
We cope with major / minor bereavements in the same way??

37. Types of Loss Actual loss Death from old age, illness, accidents.
Old person more acceptable loss
Younger person less acceptable loss Discuss
Perceived loss
Person’s view of loss
Culture, history, family, socialisation?
Bereavement Counselling Time-limited
Focus solely on bereavement

38. Bereavement Study  
Colin Murray Parkes Psychiatrist at Royal London Hospital
Effect of the loss of husbands on group of widows in London’s East End
Discuss: limitations?
1987 Case study of Henry who survived capsized ferry in Zubbregge, Holland
Discuss: accidents/ terrorism /wartime/peacetime? 

39. The Cost Of Commitment Gain Investment in relationships: emotional,
physical, financial.
Lives enriched but there is a ……….
Cost
Risk of losing Gain

40. Process of Bereavement
Start after loss?
Fade away?
Remain repressed not allowed to begin?
Part of the process begins / Other parts held back.
Bereavement is like a tide: it flows back and forth through the stages
Individual / Personal

41. BEWARE! Comment on Bereavement Stages:
“the stages might lead people to expect the bereaved to proceed from one clearly identifiable reaction to another in a more orderly fashion than usually occurs. It might also result in … hasty assessments of where individuals are or ought to be in the grieving process”
P.351
Handbook of Bereavement, Cambridge 1993

42. Bereavement is like a tide

43. Bereavement Summary
“ in order to avoid thinking about something we have to think about it”. Link to Counselling
Bereavement is a process of grieving
Loss is the person or object this is lost
The Cost Of Commitment Bereavement is Individual and Personal The stages to do not occur in order
Bereavement is like a tide

44. Stages of Bereavement Theory
1. Alarm
2. Searching
3. Mitigation – Lessening the Impact
4. Anger & Guilt
5. Disorganisation & Despair
6. Gaining a New Identity
(Theory is theory - feel able to agree or contradict it! Discuss)
Colin Murray-Parkes

45. 1.Alarm Tension, Shock, Panic, Disbelief Restlessness
Numbness – some emotions break through
Preoccupation / obsessiveness with thoughts of the lost person.
Self-care neglected  
Breakdown of customs / behaviour
Sensitive to noise, conflict, administration
Shut down to avoid feelings

46. 2.Searching Calling for the lost person Sobbing, tearfulness,
Feeling of loss / lost Discuss
Visit places of experience
Aimless searching – irrational?
Find lost person

47. 3.Mitigation–Lessening Impact of Bereavement
Components of grief work
Pre-occupation / wish to find the person
Repeating, painful recollection of the loss
Discuss: patterns, PTSD
Making sense of the loss to fit assumptions Discuss: meaning?
Dreams
Common dream: happy interaction with the dead
Pining / Avoidance of Pining
Idealised person - forget the negative aspects of the person

48. 4.Anger and Guilt Familiarity Misdirection Blame / Self Blame
Misdirection
Blame / Self Blame
Family Split
Resistance

49. 5.Disorganisation and Despair
Period of uncertainty 
New set of expectations Time / Acceptance?
Old model of the world abandoned
Other people: support, security, protection.
Take on the reality of what has happened
Identifying with lost person – method of avoiding the loss of that person

50. 6.Gaining a New Identity
Taking on role / interest that lost person had
New relationships
New versions of old relationships
New interests 
New updated view of the world
Less repressed

51. Colin Murray-Parkes Case Example
Henry

52. Exercise: Be Aware of Your Reaction! Write down your reaction!
Feelings
Images
Perceptions
Thoughts

54. 6 March people killed
The British ferry Herald Of Free Enterprise capsized off the coast of Belgium
The ferry overturned without warning only a mile outside Belgian port Zeebrugge
Despite the best efforts of rescue crews, it became the worst ferry disaster in British history.

55. Be Aware of Your Reaction!
Feelings
Images
Perceptions
Thoughts

56. Colin Murray Parkes – Case Study
Henry - An Extreme Example
The case of Henry who consulted me two months after several members of his family had been killed in the Herald of Free Enterprise, illustrates these bereavement stages. 

57. Be Aware of Your Reaction!
Feelings
Images
Perceptions
Thoughts

58. The Event - Alarm
He recalled how he had left his family below and was smoking a cigarette on the top deck of the Herald of Free Enterprise when the boat suddenly keeled over and then capsized outside Zeebrugge harbour.
His immediate reaction was to save his own life.

59. The Event - Alarm
He managed to smash a window and escaped onto the outside of the boat that was now lying on its side and half submerged.
Only now did he realise that his family were still below. In his alarm, he tried to climb back into the ship but was deterred by a fellow survivor who warned him “You’d never get out of there alive”.

60. Be Aware of Your Reaction!
Feelings
Images
Perceptions
Thoughts

61. Maintaining alarm
Henry stayed on board for five hours, helping with the rescue operation and checking anxiously as each new survivor emerged from the ship.
But none of his own family came out alive and, in the course of the next two weeks he identified the bodies of four of them as, one by one, they were recovered from the wreck.
Extending the Event- Searching 

62. Be Aware of Your Reaction!
Feelings
Images
Perceptions
Thoughts

63. Avoidance Panic
Throughout this period he exerted a rigid control and he was still not crying two months later when he was persuaded to seek psychiatric help.
At this time he was tense and tremulous, chain smoking to control his nerves and feeling numb and depressed.

64. Avoidance Panic
He was easily upset by loud noises and was particularly sensitive to the sound of rushing water. He had shut himself up at home and never went out. His surviving daughters feared that he might kill himself.
No Interest in himself Suicidal Stuck 

65. Be Aware of Your Reaction!
Feelings
Images
Perceptions
Thoughts

66. Re-Enactment
Three months after the disaster a heavy thunder storm took place and, when I saw him the following day, Henry appeared haggard and exhausted.
“It was the thunder,” he said, “it was the same noise that the boat made as it turned over. I heard the children screaming”. He then related, in great detail and with the tears pouring down his cheeks, his memories of the disaster.

67. Re-Enactment
The experience was so vivid that I too felt caught up in the situation. After a while Parkes said, “You’re still waiting for them to come out aren’t you?”
Routine Event re-enacts trauma - moves stuckness

68. Be Aware of Your Reaction! REVIEW
Feelings
Images
Perceptions
Thoughts

69. Post-Traumatic Stress Disorder
The case illustrates some features of PTSD
As long as Henry succeeded in avoiding the thoughts of what had happened he could not escape from the memories that were constantly threatening to emerge.
The thunderstorm acted as a trigger to his memories and allowed him to begin the process of grieving.

70. Colin Murray-Parkes Conclusions
What helped the bereavement process was:-
Good family support
Predictability of death
Practical tasks of funeral arrangements
Supportive people making few demands
Social Networks
Mutual Self Help Groups
Bereavement Counselling
Support Groups – Group Counselling

71. This case study poses a question………??
What determines how a Bereavement affects a person?

72. Stressors Stress & Trauma are part of Bereavement
Wide variations of types of stress
Coping strategies
Perception
Capacity to tolerate strong feelings
Self Esteem

73. Key Determinants of the Affect of Bereavement
Situation and Environment of the Bereaved
Age Gender
Personality Proneness to Grief
Inhibition of Feelings Expression of grief
Socio-economic Status
Nationality Cultural Factors of Grief
Religion

74. Before the Bereavement
Relationship to the Deceased
Type of Relationship
Strength of Attachment  
Security of Attachment  
Degree of reliance  
Involvement Intensity of Ambivalence   
Childhood Experiences  
Later Bereavement Experiences  
Previous mental health  
Life Crises prior to the Bereavement  
Type of Death  

75. After the Bereavement Social Support Prevention of Isolation
Secondary Stresses: Financial?
Life Opportunities – Options open to Bereaved

76. Theory and Counselling Skills Link
The way we react to bereavement is linked to the way we have dealt with or been taught how to deal with bereavements in the past

77. Early Attachment Patterns
Young children need to develop a relationship with at least one primary caregiver in order for their social and emotional development
Still Face Experiment

78. Early Attachment Patterns
During the first two years, how the parents or caregivers respond to their infants, particularly during times of distress, establishes the types of patterns of attachment their children form. 
These patterns will go on to guide the child’s feelings, thoughts and expectations as an adult in future relationships.

79. Secure Attachment
Ideally, from the time infants are six months to two years of age, they form an emotional attachment to an adult who is attuned to them, that is, who is sensitive and responsive in their interactions with them.

80. Secure Attachment
It is vital that this attachment figure remain a consistent caregiver throughout this period in a child’s life. During the second year, children begin to use the adult as a secure base from which to explore the world and become more independent. A child in this type of relationship is securely attached.
In order for a child to feel securely attached to their parents or care-givers, the child must feel safe, seen and soothed.

81. Avoidant Attachment
Adults who are emotionally can be insensitive & unaware of the needs of their children. They have little or no response when a child is hurting or distressed.

82. Avoidant Attachment
These parents discourage crying and encourage independence. Often their children quickly develop into “little adults” who take care of themselves. These children pull away from needing anything from anyone else and are self-contained. They have formed an avoidant attachment with a mis-attuned parent.

83. Ambivalent/Anxious Attachment
Some adults are inconsistently attuned to their children. At times their responses are appropriate and nurturing but at other times they are intrusive and insensitive.

84. Ambivalent/Anxious Attachment
Children with this kind of parenting are confused and insecure, not knowing what type of treatment to expect.
They often feel suspicious and distrustful of their parent but at the same time they act clingy and desperate. These children have an ambivalent/anxious attachment with their unpredictable parent.

85. Disorganized Attachment
When a parent or caregiver is abusive to a child, the child experiences the physical and emotional cruelty and frightening behavior as being life-threatening.

86. Disorganized Attachment
This child is caught in a terrible dilemma: her survival instincts are telling her to flee to safety but safety is the very person who is terrifying her.  The attachment figure is the source of the child’s distress.

87. Disorganized Attachment
In these situations, children typically disassociate from their selves. They detach from what is happening to them and what they are experiencing is blocked from their consciousness. Children in this conflicted state have disorganised attachments with their fearsome parental figures

88. Attachment Personality Types

89. Secure Personality
People who formed secure attachments in childhood have secure attachment patterns in adulthood.
They have a strong sense of themselves and they desire close associations with others. They basically have a positive view of themselves, their partners and their relationships.
Their lives are balanced: they are both secure in their independence and in their close relationships.

90. Dismissive Personality
Those who had avoidant attachments in childhood most likely have dismissive attachment patterns as adults. These people tend to be loners; they regard relationships and emotions as being relatively unimportant. They are cerebral and suppress their feelings.
Their typical response to conflict and stressful situations is to avoid them by distancing themselves. These people’s lives are not balanced: they are inward and isolated, and emotionally removed from themselves and others.

91. Preoccupied Personality
Children who have an ambivalent/anxious attachment often grow up to have preoccupied attachment patterns. As adults, they are self-critical and insecure.
They seek approval and reassurance from others, yet this never relieves their self-doubt.
In their relationships, deep-seated feelings that they are going to be rejected make them worried and not trusting. This drives them to act clingy and overly dependent with their partner. These people’s lives are not balanced: their insecurity leaves them turned against themselves and emotionally desperate in their relationships.

92. Fearful-Avoidant Personality
People who grew up with disorganized attachments often develop fearful-avoidant patterns of attachment. Since, as children, they detached from their feelings during times of trauma, as adults, they continue to be somewhat detached from themselves. They desire relationships and are comfortable in them until they develop emotionally close. At this point, the feelings that were repressed in childhood begin to resurface and, with no awareness of them being from the past, they are experienced in the present.
The person is no longer in life today but rather, is suddenly re-living an old trauma. These people’s lives are not balanced: they do not have a coherent sense of themselves nor do they have a clear connection with others. Monkeys