GRIEF COUNSELING AND GRIEF THERAPY

J. W. Worden

• Loss of loved one through death, separation, divorce, incarceration.
• Loss of an emotionally charged object or circumstance, e.g. loss of a prized possession or a valued job or position.
• Loss of a fantasized love object, e.g. death of a intrauterine fetus, birth of a malformed infant.
• Loss resulting from narcissistic injury, e.g. amputation, mastectomy

• Shock and denial. Patient's initial reaction is shock, followed by denial that anything is wrong. Some patients never pass beyond this stage and may go doctor shopping until they find one who supports their position.
• Anger. Patients become frustrated irritable, and angry that they are ill; they ask, "Why me?" Patients in this stage are difficult to manage because their anger is displaced on doctors, hospital staff, church/God, and family. Sometimes anger is directed at themselves in the belief that illness has occurred as a punishment for wrongdoing.
• Bargaining. Patient may attempt to negotiate with physicians, friends, or even god, that in return for a cure, he/she will fulfil one or many promises, e.g. give to charity or attend church regularly.
• Depression. Patient shows clinical signs of depression: withdrawal, hopelessness, psychomotor retardation, sleep disturbances, and possibly suicidal thoughts. the depression may be a reaction to the effects of the illness on his/her life, e.g. loss of job, economic hardship, isolation from friends and family, or it may be in anticipation of the actual loss of life that will occur shortly.
• Acceptance. Person realizes that death is inevitable and accepts its universality.

• Alarm - a stressful state characterized by physiological changes,e.g. rise in blood pressure and heart rate
• Numbness - Person appears superficially affected by loss, but is actually protecting himself/herself from acute distress.
• Pining (searching) - Person looks for or is reminded of the lost person.
• Depression - Person feels hopeless about future, cannot go on living, and withdraws from family and friends.
• Recovery and reorganization - Person realizes that his/her life will continue with new adjustments and different goals.

• to accept the reality of the loss
• to work through the pain of grief
• to adjust to an environment in which the deceased is missing

• Economic as much as emotional!

• to emotionally relocate the deceased and move on with life.

• Anything the counselor can do that helps family members stay connected to each other and to extended families and extrafamilial resources will have a profound impact on the long-term postdeath adjustment of the family.

Feelings

• sadness
• anger
• guilt and self-reproach
• anxiety
• loneliness
• fatigue
• helplessness
• shock
• yearning ("pining")
• emancipation
• relief
• numbness

Physical sensations

• hollowness in the stomach
• tightness in the chest
• tightness in the throat
• oversensitivity to noise
• depersonalization ("I walk down the street and nothing seems real, including myself.")
• feeling short of breath
• weakness in the muscles
• lack of energy
• dry mouth

Cognitions

• disbelief
• confusion
• preoccupation
• sense of presence of the deceased
• hallucinations

Behaviors

• sleep disturbances
• appetite disturbances
• absent-minded behavior
• social withdrawal
• dreams of the deceased
• avoiding reminders of the deceased
• searching and calling out
• sighing
• restless overactivity
• crying
• visiting places of carrying objects that remind the survivor of the deceased
• treasuring objects that belonged to the deceased

• Help the survivor actualize the loss
  talk about the loss
  visit the gravesite

• Help the survivor to identify (focus) and express
  feelings:
  anger
  guilt
  anxiety and helplessness
  sadness

• Assist living without the deceased
  decision-making
  sexuality

• Facilitate emotional relocation of the deceased"
  find a new place for the lost loved one that allows the survivor to move on
  reminisce

• Provide the time to grieve
  3 months
  1 year

• Interpret "normal" behavior

• Allow for individual differences

• Provide continuing support (groups?)

• Examine defenses and coping styles
  alcohol/drugs
  withdrawal

• Identify pathology and refer

• Evocative language

• Use of symbols

• Writing
  letters to deceased
  journal

• Drawing (esp. with children)

• Role playing

• Cognitive restructuring
  Identify damaging self-talk, e.g. "No one will ever love me again."

• Memory book

• Directed imagery
  imagine deceased as present and address him/her

• The person cannot speak of the deceased without experiencing intense and fresh grief.

• Some relatively minor event triggers and intense grief reaction.

• Themes of loss come up in the person's talk.

• The person who has sustained loss is unwilling to move materials possessions belonging to the deceased.

• The person is developing physical symptoms like those the deceased experienced before death.

• The person makes radical changes in lifestyle following a death or excludes from their life friends, family members, and/or activities associated with the deceased.

• The person seems chronically depressed (together with persistent guilt and low self-esteem) or experiences false euphoria following a death.

• Person shows a compulsion to imitate the deceased.

• Self-destructive impulses

• Unaccountable sadness occurring .at a certain time each year

• A phobia about illness or death.

• Facts about how they acted at the time of the death (e.g. avoiding visiting the grave or participating in funeral, etc.)

• Suicide
• Sudden death
• Sudden Infant Death Syndrome
• Miscarriages
• Still Births
• Abortion
• AIDS

• social and ethnic context

• history of previous losses

• timing of death in the life cycle

• nature of death

• family position of the dead or dying family member

• openness of the family system (Differentiation / level of family stress)

• The lower the level of differentiation (and the higher the level of stress!), the less able to express directly to each other divergent or anxiety-provoking thoughts and feelings without either becoming angry or upset.

• View the family in context (three-generations).
• Talk openly, directly, factually (unanxiously).
• Help family members (at least two of them) to talk openly, directly, factually with each other.
• Respect the family's hope for life and living, when a member is dying.
• Remain human but emotionally nonreactive (at peace) to the family's pain (Not that the pastor should not experience emotions, but that his or her actions should not be guided by emotions.)
• Deal with the symptoms of stress ("sideshows").

1. Help family to use its own style, customs, and rituals to deal with death.
2. Funeral should be personalized as much as possible, and include the wishes of the dying.
3. Family members should see the dead member.
4. Children need to be told, given opportunity to see dead member, attend funeral, say good-bye.
5. Family should talk frequently of the dead member.

• Help family get a balanced view of the person who died.

Death creates a vacuum, and emotional systems will rush to fill it (cutoffs, freedom, shifts in responsibility, replacement).

Six opportunities during this rite of passage:

1. Chance to take or shift responsibility.
2. Chance to reestablish contact with distant relatives (or close relatives who live at a distance).
3. Opportunity to learn family history.
4. Chance to learn how to deal with the most anxious forces that formed one's emotional being.
5. Chance to shift energy directions in the family triangles, all of which seem to resurrect themselves at such moments.
6. Chance to reduce the debilitating effects of grief.
   Grief is the residue of the unworked-out part of the relationship.

It is not so much an individual who is dying as it is a member of the family--part of the organism is dying. As long as the dying person is above ground, he or she is a live part of the organism.

In rites of passage it is really the family that is making the transition to a new stage of life rather than the identified member focussed on during the occasion.

The months before and after rites of passage are "nodal" periods that function as "hinges of time." Family relationship systems seem to unlock, so that doors between family members can be opened or closed with less effort than at other times.

This is because these events occur, not at random, but at critical times in the family life cycle.

• The family is breaking down (because of physical distance).

But a major issue is the development of alternative types of families, with major ramifications for rites of passage.

• Culture determines family process in fundamental ways. (Rather it appears that individuals and families adhere to those societal values that most coincide with their own lifestyle.)

When someone reacts fanatically to a value issue in family life, the roots of the fanaticism lie in the family member's unworked-out relationships with the family of origin.

• The rite of passage is the same as the ceremony that celebrates it. (Corollary: The family members who are the focus of the ceremony are the only ones going through the passage.)

Some individuals are married long before the ceremony, and some never do leave home. Some family members are buried long before they expire and some remain around to haunt for years, if not generations.

The ceremony can be useful for:

• meeting people
• putting people together
• reestablishing relationships
• learning about the family
• creating transitions

But the more important time is the months before and after. Use the event as an excuse for reentry.

e.g. bring brother and sister into communication again while the loved one is dying, rather than depending on the funeral to do it.

When clergy facilitate the meaningful involvement of family members at life cycle ceremonies, they are in fact allowing natural healing processes to flow.

In fact, rites of passage always indicate significant movement in a family system.

Look for extremes in handling the transitions as symptoms of lack of flexibility in the system. (no one or everyone invited; cremation, no funeral or major extravanganza)