The City Lit: Bereavement & Loss
Saturday 8th October 2011
10.30 - 4.30pm
10.40Introduction
10.55 Icebreaker Exercise
11.40Break
12.00Theory and Group Discussion
1pmLunch
2pm Assessment Exercise
- Counselling Session
2.45pmBreak
3pmAttachment / Counselling Session
3.30 Case Examples - Video
4.10Round Up / administration
4.30End
Adrian Scott MSc Snr. MBACP Accred
07956 292 740
Bereavement & Loss
Learning Outcomes
Icebreaker Exercise -
Counselling Skills
Bereavement Theory -
Understanding Stages
Assessment Exercise -
Own Experience
Attachment / Counselling Session -
How its done!
Case Examples -
Video / Suggestions from you!
Work History
Adrian Scott
Mental health background
First counselling experience
Bereavement Counsellor at the London Hospital under Dr. Colin Murray Parkes Case Study
MIND in Haringey Volunteer : assessed clients off the street.
In 1990’s started working in the voluntary sector in counselling services.
Homeless client group: working on the streets / cold weather shelters
Homeless Day Centre – of Brick Lane
Brent MIND – deprived area – generic counselling service funded by the PCT.
Southwark Carers Counselling Service
Now setting up a counselling service in Tottenham.
MBACP Snr. Accredited Counsellor
BACP Accredited Supervisor Groups / Individuals
Private Practice in North London, Turnpike Lane N8
Seeing individuals 1:1 / Couples / Groups & Supervision
City Lit Day seminars Bereavement
Psychodynamic counselling
10 week course on the discovery of the Ucs called “The UCS Revealed”
Group Facilitator in Further Education Colleges
Boundaries of the Day
Wide range of skills in the room
Hope you all get something out of it
Not an expert on Bereavement and loss
Look after yourselves
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 this group of people.
What areas, themes issues topics do you want to cover today?
Write on the flip chart
Icebreaking Exercise
Split up into pairs & ask the person
1. What brought you here?
2.What is their interest or experience of the subject?
3. What do they want from the day?
You will be asked to briefly and concisely to:
Report back what your colleague has said
Check with your colleague how you did!
Preamble before Bereavement Theory
General Principles of Counselling
Forget particular approaches
What are they?
How? why?
What’s the point?
A way to reflect on feelings
Being with feelings
Containing feelings
What is it about our feelings?
Why are feelings so important in counselling?
Learn about relationship with ourselves
What motivates us?
Why do the things we do?
Meaning?
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
“ inorder 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
Top of Form
Bereavement: Studies of Grief in Adult Life (Paperback)
Product details
Paperback: 288 pages
Publisher: Penguin Books Ltd; 3New Ed edition (1998)
Language English
ISBN-10: 0140257543
A Theory of Bereavement Counselling
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 the same ??
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
Discuss: culture, history, socialisation?
Bereavement Counselling
Time-limited
Focus solely on bereavement
Colin Murray- Parkes Psychiatrist at RoyalLondonHospital
1983 Bereavement Study
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
193 people died
Discuss: accident /wartime/peacetime?
The Cost Of Commitment
Gain
Investment in relationships: emotional, physical, financial.
Lives enriched
But a ……….
Cost
Risk of losing Gain
CMP’s 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
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
BEWARE!
Comment on Bereavement Stages:
“might lead people to expect the bereaved to proceed from one clearly indentifiable 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)
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, adminstration
Shut down to avoid feelings
Discuss
2. Searching
Calling for the lost person
Sobbing, tearfulness,
Feeling of loss / lost Discuss
Visit places of experience
Aimless searching – irrational?
Find lost person
3. Mitigation – Lessening the Impact of the 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 negative
4. Anger and Guilt
Familiarity. Discuss
Misdirection. Discuss
Resistance
Blame / Self Blame
Family Split
Resistance. Discuss
5. Disorganisation and Despair
Period of uncertainty
New set of expectations
Time / Acceptance?
Old model of the world abandoned
Other people: support, security, protection. Discuss
Take on the reality of what has happened
Identifying with lost person – method of avoiding the loss of that person
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. Discuss
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.
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 heeled over and then capsized outside Zeebrugge harbour. His immediate reaction was to save his own life. 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”.
The Event – Alarm
Henry remained on board for five hours, helping with the rescue operation and watching 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 was to identify the bodies of four of them as, one by one, they were recovered from the wreck.
Maintaining alarm
Extending the Event- Searching -
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. 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 seldom went out. His surviving daughters feared that he might kill himself.
Avoidance Panic No Interest in himself Suicidal Stuck
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. The experience was so vivid that I too felt caught up in the situation. After a while I said, “You’re still waiting for them to come out aren’t you?”
Routine Event re-enacts trauma -
moves stuckness
The case illustrates well the features of PTSD (Post-Traumatic Stress Disorder). 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.
Colin Murray Parkes’ Conclusions
What helped the bereavement process was:-
Traditional family Discuss
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
This case study poses some questions………??
Question: What determines how the Bereavement affects a person?
Stress & Trauma part of Bereavement
Wide variations
Type of stress
Coping strategies
Perception
Capacity to tolerate strong feelings
Self Esteem
CMP’s 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 (Social Status)
Nationality
Religion
Cultural Factors of Grief
Before the Bereavement
Relationship to the Deceased
Type of Relationship
Strength of Attachment
Security of Attachment
Degree of reliance
InvolvementIntensity of Ambivalence
Childhood Experiences
Later Bereavement Experiences
Previous mental health
Life Crises prior to the Bereavement
Type of Death
After the Bereavement
Social Support
Prevention of Isolation
Secondary Stresses: financial
Life Opportunities – Options open to Bereaved.
Theory and Counselling Link
It would seem that the way we react to bereavement has a lot to do with the way we have dealt with or been taught how to deal with bereavements in the past.
1
Dr Elisabeth Kübler-Ross
Pioneered counselling of personal trauma, grief and grieving, associated with death and dying.
Improved the understanding and practices in relation to bereavement and hospice care.
Her five stages of grief model:
transferable to personal change and emotional upset resulting from factors other than death and dying.
grief model works in people confronted with far less serious traumas than death and bereavement, such as by work redundancy, enforced relocation, crime and punishment, disability and injury, relationship break-up, financial despair and bankruptcy, etc.
This makes the model worthy of study far outside of death and bereavement.
The 'grief cycle' is actually a 'change model' for helping to understand and deal with (and counsel) personal reaction to trauma. It's not just for death and dying.
Five stages of grief - Elisabeth Kübler Ross
1 - Denial
Denial is a conscious or unconscious refusal to accept
Natural defence mechanism
Can be locked in this stage
2 - Anger
Angry with themselves
and/or with others, especially those close to them.
Knowing this helps keep detached and non-judgemental when experiencing the anger of someone who is very upset.
3 - Bargaining
Bargaining for people facing death can involve attempting to bargain with whatever God the person believes in.
Bargaining in relationships: "Can we still be friends?.." when facing a break-up.
Bargaining rarely provides a sustainable solution
Also preparatory grieving
Dress rehearsal or the practice run for the 'aftermath'
Means different things depending on whom it involves. It's a sort of acceptance with emotional attachment.
4 - Depression
Natural to feel sadness and regret, fear, uncertainty, etc.
Shows person beginning to accept the reality.
5 - Acceptance
Varies according to the person's situation,
Broadly an indication that there is some emotional detachment and objectivity.
People dying can enter this stage a long time before the people they leave behind
(Based on the Grief Cycle model first published in On Death & Dying, Elisabeth Kübler-Ross, 1969. Interpretation by Alan Chapman 2006-2009.)
Attachment Theory - A Secure Base - John Bowlby
What is Attachment?
Attachment is an emotional bond to another person.
Bowlby believed that the earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life.
Attachment keeps the infant close to the mother, thus improving the child's chances of survival.
The central theme of attachment theory is that primary care givers who are available and responsive to their infant's needs establish a sense of security.
The infant knows that the caregiver is dependable, which creates a secure base for the child to then explore the world.
Experiment with rhesus monkeys
Monkeys offered two objects to attach to:
1. Soft mother dummy without food
2. Hard mother dummy with food
Monkeys preferred soft dummy without food
Discuss
Attachment Statistics
Julia Buckleroyd 2010
Population:
65%- Secure Attachment
20% - Ambivalent Attachment
15%- Avoidant Attachment
2%- Disintegrated Attachment
Counsellors / Therapists?Discuss
Attachment Exercise
You are with your family, and you are 12 years old or younger.
Recall an incident when you did something wrong.
What was the reaction from the primary care giver?
Bereavement is an extreme broken attachment
Violent separation from a loved one
First experience of this between primary care giver and child
Main Carer / Mother emotional state before and after the birth of the baby critical
Main Carer / Mother and baby relationship influence infant right into adult life
Discuss
Successfully Attached 12 year old
Independent
Separation
Work / Study
Words for feelings
Tasks of Attached Adolescent
Independent
Separation
Sexuality Choice
Sense of Self
Compulsion dodges, delays developmentDiscuss
Developing emotional management
How?
Baby cannot regulate emotions alone
Implications for brain development
Secure attachment – person can self soothe / trust other people
Insecure attachment – person needs external substances
Deficit in developing sense of self
Discuss
The Attachment Counsellor Tasks
We all manage feelings with thoughts
Two Levels:
Conscious / Unconscious
Cognitive (the behaviour) / Emotional
The Remedial Relationship
Active – Interactive
Attuned (Daniel Stern)
Accepting
Reflective
Modelling Nurture
Sitting in silence doesn’t work!
Sometime later………
Deficit Repair by:
Teaching Skills
Encouraging Experiment
Containing Anxiety
Encourage Reporting
Change Internal Dialogue
Restrain Critical Parent
Taking Care of Child
Develop the Adult
…………easy to say. Discuss.
Attachment Theory Conclusions: John Bowlby
Counselling explores attachment figures
Secure Base of time, place, frequency
Explore early attachment relationships
Notice relationship between the counsellor and client
Expectations and perceptions of attachment figures
Reflect on the accuracy of self images.
Holding and Containing.
Attentive and responsive to the client’s needs
See and feel the client’s world through the client’s eyes.
These points are transferred to the counselling session
Mother and Baby - D.W.Winnicott
Studied a lot of mother baby interactions
Potential space
How does primary relationship enable separation to be tolerated by the baby?
Transitional Object
Must be allowed to have rights over the object
Good enough parenting and mothering
Play negotiation between inner psychic reality and outer worldly reality.
Culture originating in Potential Space as
relationship of experience to tradition and separateness to union.
Face studies conducted by Brazelton & Cramer
Case Study: Ethnic Differences – Dealing with Grief and Loss
(P.105 Handbook of Bereavement, Cambridge 1993)
WASP Culture - psychologies emotional pain
Ethnic Groups – somatise emotional pain
WASP culture might struggle to support non WASP grief
Differences unrecognised until major loss occurs
Individuals might lack focus, energy, flexibility to deal with loss
1st major Loss – 1st experience of mortality Discuss – Existential
One person’s grief can make another person reaction to grief bizarre to the other person.
Couple – Discuss
Individuals who attempt to assimilate a different culture’s norms
Struggle – self control, Silence, Guilt, Depression, Unable to resolve loss.
People in transit between cultures struggle to find an appropriate grieving process.
Case Study: Kibbutz – Children’s Homes
(P.721 Handbook of Attachment Guildford 1999)
Collective sleeping arrangements
Starts a few months after birth
Infant mother attachment
59% compared to 75% in Israeli day centres
possible environment for insecure attachments
Ambivalent attachment experience encouraged by national security environment
Discuss Bereavement / ambivalence
Case Study: Attachment in the only Child - China