Complicated Mourning: Competent Caring

Baylor University School of Social Work

2008

Death and Grief Happen

Among our peers at workIn our familiesIn our countryIn our friends In our neighborhoodsIn our churches

Sometimes, it happens badly

When we judge When we prescribe When we

“celebrate”only When we excuse When we abandon When we think we

know just how someone feels

The Known

Death is universal; it comes to us all Grief is universal; we will all experience it

many times.

While the average life expectancy in the United States continues to grow, the mortality rate is still the same. One out of one will die.

Definitions:

Loss: Change that includes being without someone or something; physical loss of something tangible like a person, a car, a house, a breast; psychosocial loss of something intangible like a divorce, an illness, a job, a dream, a hope.

Bereavement: comes from the same Latin root word as “to have been robbed….” i.e. to have experienced loss. Rando, Complicated Mourning, p. 20.

More definitions:

Secondary loss: other losses as a result of a primary loss. Example, loss of income when bread winner dies.

Grief: reaction or response to loss; includes physical, social, emotional, intellectual and spiritual dimensions.

Mourning: rituals or behaviors associated with grief; i.e. courses of action in response to loss. Rando, Complicated Mourning, p. 22.

Grief Takes Time

Whole first year is one loss after another Beware of special occasions and holidays all

year Uncomplicated mourning is normally 2-3 years Complicated mourning may be a 5-7 year

process. Grief continues for a lifetime through major life

milestones.

Grief impacts us holistically…

These five needs overlap.Social, Physical, Cognitive, Emotional, Spiritual

Physical responses:

Appetite (eating) disturbances Energy, fatigue, lethargy Sleep disturbance Cold (especially for children) Anxiety (sweating, trembling, etc.) Gastrointestinal disturbance Compromised immune response; increased

illness

Intellectual

Confusion; “What is real?” Difficulty concentrating; ex. Read the same

page several times Short attention span; ex. Can’t finish a 30

minute TV program Difficulty learning new material; short term

memory loss; ex. Income taxes Difficulty making decisions

Social…

Withdrawal Isolation Searching Avoidance Irritability Self absorption Clinging/dependence

Emotional…

Angry Depressed Sad Crying Irritable Afraid Lonely Relieved/Guilty/Regretful

Spiritual…assumptive beliefs are challenged…

The question “Why” reverberates

Where was God? If God is all powerful,

why allow this? If God loves me, how

could this be? Prayers weren’t

answered…

Common and Unique…

Death and grief are unique. Each person’s experience is his or hers

alone. Each experience is unlike any other. So, I can never know exactly how someone

else feels.

Grief Takes Time

Whole first year is one loss after another Beware of special occasions and holidays all

year Uncomplicated mourning is normally 2-3 years Complicated mourning may be a 5-7 year

process. Grief continues for a lifetime through major life

milestones.

Complicated Mourning…

The term complicated mourning as used by Therese Rando, Junietta Baker McCall, Kenneth Doka and others has to do with grief that does not follow the “normal course” or process to successful completion.

Terms seen in the literature:

Absent grief (prolonged)

Delayed grief Inhibited grief Pathological mourning Chronic Mourning Dysfunctional grief

Unanticipated grief Conflicted grief Distorted grief Unresolved grief Grief with mental

disorders Grief with physical

disorders

Theorists you should know…

Freud: Mourning and Melancholia (anniversaries, attachment and relinquishment)

Erich Lindemann: Grief Work (emancipation, readjustment and formation; morbid reactions)

More Theory…..

Charles Anderson (1949): research on pathological grief with particular emphasis on World War II. Rando, 1993

John Bowlby (1950s and 1960s): Attachment and Loss; four phases: numbing, yearning and searching, disorganization and despair, and reorganization; chronic mourning Rando, 1993

Don’t give up yet…

George Krupp (1972): family systems perspective of death and loss. Rando, 1993

Mardi Horowitz (1977): The stress response syndrome (outcry, denial and numbing, intrusion, working through and completion) Rando, 1993

Alan Keith-Lucas: children and grief-shock and denial, protest, mastery or detachment.

The One We All Know…

Elisabeth Kubler- Ross: Anticipatory GriefShock and denialAngerBargainingDespairAcceptance

Disciplines that deal with grief…

Chaplain/pastor Social

Workers/Counselors Nurse/Physician Other medical

professionals (PT….) Teachers/Coaches Lawyers/Accountants Everyone

Social work and grief

ContextCrisisShort term Long termTangential

Social Work and Grief

Normal Grief: Case Management; Peer Support Groups; Counseling/guidance for journaling, etc.

Complicated Mourning: Individual therapy; Group Therapy; Family therapy; Advanced Case Management

Models for Normal Grief

Elisabeth Kubler-Ross (Anticipatory Grief)

Alan Keith-Lucas (Children & Separation)

William Worden (4 Tasks)Alan Wolfelt (Bereavement Needs)Therese Rando (The Six “R”s)

Grief is Work:Worden’s Four Tasks

Experience the reality of the loss Experience the pain of the loss Adjust to an environment without the

deceased Withdraw emotional energy from the

deceased and invest it in new relationship(s) (William Worden, Grieving)

Alan Wolfelt’s 6 Reconciliation Tasks:

Acknowledge the reality of the death. Move toward the pain of the loss while being

nurtured physically, emotionally, and spiritually. Convert the relationship with the person who has

died from one of presence to one of memory. Develop a new self identity based on a life without

that person. Relate the experience of the death to a context of

meaning. Experience a continued supportive presence in

future years. (Alan Wolfelt, Healing the Bereaved Child)

Rando’s 3 Phases and 6 Processes

Avoidance Phase– Recognize the Loss

Confrontation Phase– React to the Separation

Recollect and reexperience the deceased and the relationshipRelinquish the old attachments to the deceased and the old assumptive world

Accommodation Phase– Readjust to move adaptively into the new world without forgetting the old– Reinvest Rando, 1993

AVOIDANCE

RECOGNIZE THE LOSS– Acknowledge the death

– Understand the death

(Rando, 1993, Complicated Mourning)

CONFRONTATION

REACT TO THE SEPARATION– Experience the pain– Feel, identify accept, and give some form of

expression to all the psychological reactions to the loss

– Identify and mourn secondary losses

(Rando, 1993, Complicated

Mourning)

CONFRONTATION

Recollect and re-experience the deceased and the relationship– Review and remember realistically– Revive and re-experience the feelings

Relinquish the old attachments to the deceased and the old assumptive world

(Rando, 1993, Complicated Mourning)

ACCOMMODATION

Readjust to move adaptively into the new world without forgetting the old– Revise the assumptive world– Develop a new relationship with the deceased– Adopt new ways of being in the world– Form a new identity

Reinvest (Rando, 1993, Complicated Mourning)

Risk Factors for Complicated Mourning

Risk Factors for Complicated Mourning McCall, 2004 & Rando, 1993

General Factors

Nature of the relationship

Nature of the Loss

Physical, psychological, sociological, and spiritual condition of the survivor

Resources available

Multiple losses Severe trauma Violent death Concurrent mental illness Axis 2 traits Isolation Guilt Life Skill Deficits Parents who lose children

Extrapolation for Assessment: Example 1

Nature of the relationship– Length/duration– Importance– Culture/Roles– Quality– Dependence– Hopes and Dreams– Amount of Daily Change

Extrapolation for Assessment: Example 2

Physical condition of the survivorAge (Erikson, Freud, Piaget)Physical Health

Independence/DependencePainCaregiving

Mental HealthFinances/Access to services/

Assessment

For Complicated Mourning: Use Rando’s Grief and Mourning Status Interview and Inventory (GAMS II) From Treatment of Complicated Mourning by T.A. Rando, 1993, Champaign, IL: Research Press. Copyright 1993 by T. A. Rando. Reprinted by permission.

For Dysfunctional Grieving: Use McCall’s “Symptoms and Behavior that Can Indicate Dysfunctional Grieving

McCall, 2004.

TREATMENT PRINCIPLES

All social work treatment is based on an assessment.

All social work treatment is based on a contract for work with the client.

Treatment is based on theory and research that validates particular interventions for particular issues.

Treatment Principles: Complicated and Dysfunctional Grief

Most clients of social workers will be clients for some reason other than their grief experience.

Most clients of social workers will be clients for some reason than the issue that makes their grief complex or complicated.

That makes assessment and contracting more important, not less important.

Treatment Principles: Practical

If there is a physical or mental health complication, the treatment plan or contract must address the treatment for that complication.

If the complication includes family or other relationships, the treatment plan or contract must address systems work.

Reimbursement for treatment must be addressed.

Rando’s Treatment Approach

Assess around the six “R”s and determine where the mourner is “stuck” and not making progress.

Base treatment on interventions that address that “R.”

“Explore with the caregiver the identity and roles with the lost loved one and the meaning of the relationship.” Rando, 1993, p. 181

Rando: Treatment Tips

Secondary victimization occurs when support systems isolate, blame, and stigmatize.

Multiple losses require multiple adaptations over time and make intervention very complex.

Homogenity in support groups helps normalize experience.

(Rando, 1993, Complicated Mourning)

Rando therapeutic techniques

Gestalt therapeutic exercises (empty chair, role play)

Bereavement rituals Psychodrama Writing/journaling Creative works; music, art, scultping

Rando, 1993, p. 595

Specifics for our time together…….

Crisis intervention is one of the most important ways to prevent complicated mourning. Crisis includes tragedy, murder, suicide, war death, etc.

The death of a child is particularly difficult. Parent and sibling grief is explored.

Suicide is a serious complicating factor in mourning.

Dealing with Crisis

Sudden, unexpected death/loss is a major complicating factor in grief.

Much complicated mourning could be averted with good crisis management at the time of the crisis.

Crisis work and grief work are NOT the same.

Effective crisis work requires SKILL.

Crisis material is taken from:

Coping with Public Tragedy ( 2002 Hospice Foundation of America) Edited by Marcia Lattanzi-Licht and Kenneth Doka

The National Center for PTSD, Special Edition, Disaster Assistance (2001)

Growing through Grief after Sudden Loss (1999 Hospice Foundation of America) Edited by Kenneth Doka

What exactly are we talking about?

The first and most pressing question in a crisis is: What just happened?

Immediately following is the question: How can I manage right now?

Finally, the larger questions of grief and meaning are formulated.

What Happened?

How will I Manage

It?

How do I Go on?

What is your first memory of public disaster or tragedy?

The assassination of President Kennedy?

MLK Jr? Robert Kennedy?

Mount Carmel? Columbine? Oklahoma City? 9/11? A natural disaster?

Public Tragedies in our Living Rooms

We live in an increasingly small world Major events have global impact, including

impact on our lives The media brings distant events into our living

rooms Live and constant coverage immerse people

in the details of tragedy Most of us have some connection with others

who are touched by the event

Layers of stress and concern:

Fear and anxiety with uncertainty Sense of helplessness and feeling out of

control Normal life stressors of job and family

continue Exacerbation of grief that comes with

losses…death, moves, relationships… Multiple funerals and images of the grief of

others

Understanding the phases of tragedies:

The initial event, early aftermath…i.e. Crisis Phase

The short-term aftermath…i.e. Processing Phase

The long-term aftermath…i.e. Adaptation Phase Licht and Doka

Crisis Management means:

First focusing on basic needs: Shelter, safety, sustenance, information, protection

Second, allowing those affected to begin to figure out what happened…tell their story, process the event and its meaning for them.

Always validate and normalize the responses ….listen carefully…reflect the language

Assessment is essential

Hearing the story will help you assess the needs and the strengths of each person

Listen each time as though it is the first time you heard the story

Assess strengths…support system available to the survivor

Assess spiritual beliefs/source of strength Be careful of trite, glib religiousity

Adaptation Phase

Part of your assessment will include awareness of how long you will be available to help

Contract for work and for referral Remember that crisis work eventually leads

to grief work which is LONG term Encourage the use of ritual and the arts to

personalize the experience and provide formal, structured support. Lattanzi-Licht and Doka

Critical Incident Stress Management…

Mitchell model, Follows a traumatic event Coping skills are

overwhelmed Goal, to prevent or limit

development of PTSD Provide distance Demobilize or debrief Lattanzi-Licht and Doka

Debriefing includes…

Explain process and ground rules (not psychotherapy…not operational critique)

Allow description of what happened and respective roles

Explore “first thoughts” and event processing Facilitate ventilation: What was worst? Identify symptoms of distress Normal crisis reactions Teach stress management and coping skills Summarize, provide follow up as needed Doka

Other options:

Defusing….small group discussion of traumatic event

Informal Held immediately after an incident Designed to reduce tension Focus on facts of the crisis and reactions Offer family/organizational consultation Offer follow/up and referral Lattanzi-Licht and doka

Families of Dying and Grieving Children Need

Resources….financial, transportation, errand, chores, helping with well siblings

Permission to feel what they feel without our judgment or condemnation

Hope without fantasy Presence Care for well siblings Time with each other

Grieving Parents Need….

Permission to feel Awareness that grief

lasts a lifetime Help with marital

differences in grief Help with remaining

children Concrete help with

finances, tasks, etc.

Grieving Children Need:

Information at their age level

Preparation Inclusion in caregiving Inclusion in family ritual Presence of a trusted

adult Long term attention

Remember the five areas of focus

Physical Needs: warm foods and clothing; increased susceptibility to illness

Emotional Needs: Grief bursts of emotion Social Needs: Few peers can relate. Consider a

group experience. Cognitive: Difficulty with concentration, learning new

material, attention span. Be sure the teacher knows. Spiritual: Beware of the trite phrases that confuse

and frighten…asleep in Jesus; God took her; God needed an angel.

And then there are teens….

Listen, listen, listen Provide contact with

peers Affirm feelings; model

seeking support Give them something

positive to DO Encourage activities

they enjoy with others National Centger for PTSD

When is it time for referral?

Consider grief complications…ie suddenness of the death, troubled relationship, violence, arousal of fear

Consider support available Consider coping skills and other stressors Consider length of difficulty…i.e. duration of

distress Always assess for suicidal ideation.

Sudden Death

Acute Natural Causes Accidental Death Disaster Deaths War Deaths Murder Suicide

Suicide

Shneidman (1972) “I believe that the person who commits suicide puts his psychological skeleton in the survivor’s emotional closet.

Rando, 1993, p. 523

Suicide and complications

Feelings of responsibility Cultural responses leading to guilt and

shame Anger at the deceased Fear re becoming suicidal No opportunity for closure

Interventions after suicide

Support groups of others whose loved ones have committed suicide

Permission to explore the “why” and to recognize there may never be an answer

Support to avoid self blame Help with intensified feelings including anger Suicide assessment and prevention

Assessment and Intervention

See Sattler’s assessment of children’s risk for suicide.

ASK: “Are you thinking of killing yourself?” ASK as often as you wonder. If yes, “how would you do it?” If the client has a plan, do they have the

means to implement the plan?

Intervention/Prevention

If yes, a plan, and the means to implement the plan, you have an emergency. Do not leave them alone. Hospitalize. Remove lethal means.

If no plan, use cognitive behavioral therapy to address the thinking leading to suicidal ideation.

Use contracting.

Treatment Tips

Flashbacks: Psychoeducational approach re normal response; teach control over responses; anxiety management; verbal skills to describe.

Blocking the trauma: Therapy to remove blocks to allow healing; safe place and relationship; stimuli to recreate memories

Caregiver

Self care is essential to work with complicated mourning

Model good grieving around own losses Stress management Transference and Countertransference Permission to make mistakes

Rando, 1993, p. 653