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Introduction to

Bereavement

Dalmeny lw Queensferry

Parish ChurchesJohnBirrell

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Introductions

Who are

you?

Plus one

fact

What do

we call

you?

What do

you do?

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Why?

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What do we need

from today?

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But first……the Red Line

Comfortable

Uncomfortable

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Making it safe

What do you need to

make this session safe

for you?

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Outline

1. Setting the scene – death in Scotland

2. Awareness: what does grief feel like?

3. Awareness: what is going on when

someone is grieving?

4. Knowledge: how do we understand

grief?

5. Knowledge: what helps bereaved

people?

6. Skills: what to say, what not to say,

how to say it.

7. Ethics: self-awareness and self-care

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Four dimensions to the course

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AWARENESS

SKILLS

KNOWLEDGE

ETHICS

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1. Setting the scene: Death in Scotland

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A question:

The last

great

taboo?

Or is it?

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How does Scotland deal

with death?

� Death affirming

� Death denying

� Death desiring

� Death defying

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20 Takes on Deathhttp://www.youtube.com/watch?v=qEkrrSM1YM0

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Facts and figures

454,937 x219,748

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Larger number less affected

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2. Awareness: What does grief feel like?

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Loss and Bereavement

What does grief feel like?

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3How do we know what we know?

The only source of

knowledge is experience

“Nobody ever told me that

grief felt so like fear”

Weeping WomanPicasso

1937

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I am not afraid, but sensation is

so like being afraid.JohnBirrell

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3. Awareness: What’s going on in grief?

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Thinking about loss

Fit 28 year-old

Fund Manager on good income

Married, father of three young children

Follows all the advice on health and

fitness

Life is good

APPENDICITIS!

ROBBIE

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72 year-old spinster

Retired principle RE teacher

Lives in family home

Loves reading and books

Regular church-goer

BETTY

FRACTURED FEMUR

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Robbie’s experience of loss

ROBBIE

Loss independence

Loss of dignity and privacy

Loss of sense of control

Loss of belief in his own invulnerability

Loss of family contact

Loss of body image

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BETTYLost mobility

Lost family home

Lost most of her belongings

Lost independence

Lost privacy

Can no longer get to church

Lost who she was

Betty’s Experience of loss21

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Re-instatement

Robbie

6 months later

Loss independence

Loss of dignity and privacy

Loss of sense of control

Loss of belief in his own invulnerability

Loss of family contact

Loss of body image

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BETTYLost mobility

Lost family home

Lost most of her belongings

Lost independence

Lost privacy

Can no longer get to church

Lost who she was

Acceptance6 months later

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Resolution of loss?

Re-instatement – back to the

way it was before

Acceptance – never be the

same again

??

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No variables have more far-reaching

effects on personality development than a

child's experiences within the family.

Starting during his first months in his relation

to both parents, he builds up working

models of how attachment figures are likely

to behave towards him in any of a variety of

situations, and on all those models are

based all his expectations, and therefore all

his plans, for the rest of his life.

Attachment and Loss 1979 p 369

John Bowlby

1907 - 90

Attachment Theory25

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What happens between conception and the age

of two shapes the adult a child will become

“When a baby cries, it doesn't know it is wet, tired, hungry, bored or hot – it just knows something is wrong, and it relies on a loving adult to soothe its feelings. The baby whose basic needs are met learns that the world is a good place, and he or she will retain this sense for life, as almost an instinct.”

The Guardian: 12 Sept 2012

www.theguardian.com/social-care-network/2012/sep/12/secure-early-bonding-essential-babies

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The corollary is that when that sense of

security is fractured, for example when the

attachment is broken, the child experiences

distress. We see this in the Strange

Situation observations of Mary Ainsworth,

when a child is left in the care of a stranger

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What happens when the security of their care giver is removed?28

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Separation distress

The urge to cry aloud and to search for the

lost person, which human beings and other

species experience whenever they are

separated from those to whom they are

attached, has the obvious function of

promoting reunion with the lost person.

The intelligent human adult knows that it is

illogical to cry aloud for a dead person but

this does not prevent us from doing just that.

Colin Murray Parkes

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Bereavement affects people

• INTELLECTUALLY

Threat to the structure of the world

• PSYCHOLOGICALLY

Threat to self-identity

• BEHAVIOURALLY

Breaks habit patterns and creates new ones

• SPIRITUALLY

Crisis of faith, meaning of life challenged

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• PHYSICALLY

Stress-related illness

• EMOTIONALLY

Feeling strong emotions, being out of control

• PRACTICALLY

New arrangements for self/children

• SOCIALLYChange in role/status Susan Le Poidevin

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Bereavement: a particular kind of loss

The world as we know it is shattered

• it challenges our assumptive world

• we are faced with the loss across a wide range of dimensions

• and there is no re-instatement

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4. Knowledge: How can we understand grieving?

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Model: A representation of a system

that allows for investigation of

the properties and, in some cases,

prediction of future outcomes.

JohnBirrell Consultancy 2014 34

Models of grief34

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Stages Model

Elisabeth Kubler Ross (1926 – 2004)

FIVE STAGES OF GRIEF

1. Denial and Isolation

2. Anger

3. Bargaining

4. Depression

5. Acceptance

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Task model

FOUR TASKS OF MOURNING

1. To accept the reality of the loss

2. To process the pain of grief

3. To adjust to a world without the deceased

4. To find an enduring connection with the deceased in the midst of embarking on a new life

J William WordenGrief Counselling and Grief Therapy 4th ed 2010

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Mary’s story

• Reality of the loss

• Pain of the grief

• Adjustment to alone-ness

• Enduring connection

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Dual Process ModelMargaret Stroebe and Henk Schut

LOSSRESTORATION

Experiences in every day life

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Mary’s story

• Loss orientation

• Restoration orientation

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Factors Effecting Grief

1. Who the person was

2. Nature of the attachment

3. Mode of death

4. Historical antecedents

5. Personality variables

6. Social variables

7. Concurrent stressors

8. Disenfranchised grief

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Funeral Poverty

• Funeral Debt

• Relative Debt

• Bereavement Poverty

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Timescale of grief

Weeks?

Months?

Years?

It will take as long as it takes

“It takes longer than you may think and certainly longer than others

will tell you”

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To find an enduring connection with the deceased in the

midst of embarking on a new life [Worden Task 4]JohnBirrell

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How long does grief last?

When is grief over?

• Resolved grief

• Reconciled grief

• Continuing bonds

Some have seen it [grief] as

having the function of enabling

the bereaved to detach

themselves from the lost person,

others have seen it as enabling

them ‘to find an appropriate

place for the dead in their

emotional lives’. [Parkes]

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Chronic 5-30%

Delayed 0%?

Recovery 15-25%

Resilience 35-60%

Loss(PTE)

1year

2years

G Bonano 2008

Trajectories of Grief44

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Grief is not an illness

• Around 90% experience “normal” grief …

• A debilitating, albeit normally a temporary, condition,

comprising a range of dysphoric states

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“Normal” Bereavement Reactions

Affective

• Depression, despair, dejection

• Anxiety, fears, dreads,

• Guilt, self-blame, self-accusation

• Anger, hostility, irritability

• Anhedonia - loss of pleasure

• Loneliness, yearning, longing, pining

• Shock, numbness

Physiological / somatic

• Loss of appetite

• Sleep disturbances

• Energy loss, exhaustion

• Somatic complaints

• Physical complaints similar to deceased

• Susceptibility to illness, disease &:

immune & endocrine changes

Cognitive

• Preoccupation with thoughts of deceased.

• Lowered self esteem

• Self-reproach

• Helplessness, hopelessness, suicidal

• Sense of unreality

• Suppression, denial of reality of death

• Memory, concentration problems

Behavioural

• Agitation, tenseness, restlessness

• Fatigue

• Over-activity

• Searching

• Weeping, sobbing, crying

• Social withdrawal

(Stroebe, Schut & Stroebe, 2007, The Lancet) 46

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� Accept loss as reality

� Find meaning, purpose

� See future potential for fulfillment

� Enjoy leisure, productive activities

� Explore new roles, relationships

� Begin to emerge with identity intact

� No significant impairment in function

By six months47

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The other 10% - Complicated Grief

When the acute phase persists, and is accompanied by complicating factors

• Counter-factual thoughts – preoccupation with “what-if” thoughts, or conviction that you are unable to cope

• Avoidance behaviours – where the grief is so intense that you become afraid of the grief and of any reminders of the loss

• Lack of emotional regulation and self-care – where you cannot find or learn healthy strategies to cope with the intense emotions

Katherine Shear

Practice Update Interview 2015

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5. Knowledge: What helps bereaved people?

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What helps?

• What did others do to help?

• What did you do to help yourself?

• What was unhelpful?

• What help was missing?

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Grief and the family51

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Remember

me?

Security

is a blanket… …or an ear

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6. Skills: What to say, what not to say,

and how to say it.

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Listening54

But what makes a good

listener?

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Two ears ------ -----Two eyes---------One mouth

55 Listening tools

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Blocks to listening56

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• Mindreading

• Rehearsing

• Filtering

• Daydreaming

• Advising

• Sparring

• Being right

• Derailing

• Placating

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How do we know we are being listened to?

Did

you

hear

me?

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Minimal

https://www.youtube.com/watch?v=Qg8PIK74KO4

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Core Skills in Active / Attentive Listening

• Paraphrasing

• Reflecting

• Clarifying

• Summarising

• It sounds like

• What I am hearing is

• Can I just check

• So what you have told me is

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Closed questionDid that make you happy or sad?

Questions, Questions, Questions

Open questionHow did that make you feel?

Leading questionI guess that would make you

happy?

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https://www.youtube.com/watch?v=oSM79QiCS2w63

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What is going on for this person or family?

• Grieving process• Coping ability

• Support• Other stressors

What is going on for me?• Am I grieving this death?• Does this remind me of

other deaths?

Conversation64

The intersubjective telling of a story, is often thought to be the vehicle through which healing occurs. The narrator tells and

retells, “working on” and “working through” the loss until the account feels complete and the storyteller recognizes a changed identity.

Bronna Romanof Research in Therapy

In Meaning Reconstruction and the Experience of Loss

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J. William Worden – task model

.

Worden’s Tasks of Mourning Story Telling

To accept the reality of the loss Telling the stories makes the

death more real

To process the pain of grief Sharing the stories is painful –

but helps us face the pain

To adjust to a world without the

deceased

Re-telling the stories puts us in

touch with the deceased

To find an enduring connection

with the deceased in the midst

of embarking on a new life

Recalling the stories keeps the

bond alive

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Telling stories66

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Hearing stories67

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Reassuring, Normalising and Referring on

• Normalising – self-help groups etc

• Psycho-education – literature, websites etc

• Intervention – skilled listening, counselling

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7. Self-awareness and Self-care

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It is essential that all care workers

examine their own feelings and

thoughts on these difficult issues in

order to help others to cope with

them. To be an effective care worker it

is important that you recognise and

address these uncomfortable

thoughts.

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Where can you turn for help?

How do you support yourself?

Look after yourself71

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Pointers

DO• Acknowledge their pain

• Take time to listen – attentively

• Suggest a quiet place to sit together

• Use the name of the person who has died

• Share resources – leaflets and contacts

• Remember everyone is different

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Pointers

DON’T• Say you know how they feel – you can’t

• Talk about your own experiences

• Use platitudes like Time’s a great healer

• Rush the conversation – or the ending

• Promise what you cannot deliver

• Forget that you need support too

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A final question:

What will you take from

today into your own practice?

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Resources• When Someone Has Died - access from

http://www.nhsinform.co.uk/bereavement/practical

• NHS Inform www.nhsinform.co.uk/bereavement

• Cruse Bereavement Care Scotland www.crusescotland.org.uk

• SANDS www.uk-sands.org

• Child Bereavement UK www.childbereavementuk.org

• The Little Book of Loss www.littlewebsite.org

• Smart Grief Guide www.smartgriefguide.co.uk

• Age UK www.ageuk.org

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Thank You

mail@johnbirrell.com

presentation available at

www.johnbirrell.com for 14 days

click on Handouts

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