Bereavement Care Training PowerPoint Presentation

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Providing Quality Bereavement Care Objectives: Define bereavement terms Identify myths associated with grief Identify five theories related to grief Describe normal grief reactions Discuss typical grief stages Identify specific types of losses Discuss effective listening skills- including phone support

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Providing Quality Bereavement Care Objectives: Describe techniques to assist the bereaved Discuss the use of bereavement support groups List complicated grief factors Discuss interventions for complicated grief Differentiate between depression and grief Describe interventions for depression Describe suicide assessment and intervention techniques

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Personal Exploration Describe the very first loss you experienced. Were you able to share your concerns about your loss? What is your greatest fear concerning loss? How do you respond to others who are experiencing loss? What is a good helping relationship? What is your greatest asset that you bring into a helping relationship?

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Definitions Bereavement- objective event of loss Grief- physical, emotional and social response to loss Secondary Loss- losses that are consequences of the initial loss Mourning- outward acknowledgement of the loss Grief Work- process of confronting the reality of the death

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Common Myths about Grief All bereaved grieve in the same way It takes a year to “get over” a significant loss It’s better to not think or talk about the pain The intensity and length of your grief reflects how much you loved the deceased

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When you are sorrowful, look again in your heart, and you shall see that in truth you are weeping for that which has been your delight. -Kahill Gibran, The Prophet

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Grief Theorists John Bowlby Human beings are “hard wired” to attach, to love, and therefore to grieve The stronger OR more ambivalent the attachment, the stronger the grief reaction

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Grief Theorists William Worden- Four Tasks of Mourning Accept the reality of the loss Work through the pain of grief Adjust to an environment in which the deceased is missing Emotionally relocate the deceased and move on with life

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Grief Theorists Therese Rando Avoidance Confrontation Reestablishment Judy Tatelbaum Shock Suffering/ Disorganization Aftershock/ Reorganization

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Grief Theorists Monica McGoldrick -Family Grief Response Developmental differences Family reorganization Reassignment of roles

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Contemporary Thoughts on Grief No “endpoint” to mourning Dwelling on what has been “lost” is not productive The relationship does not “end” but instead reincorporated in new ways Remembering is comforting and life-enhancing

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“If life is a journey, then dealing with the death of a loved one is one of those steep rocky mountain roads that you don’t know if you have the strength to climb up and over. The only way is one step at a time, moment by moment, and eventually you are on top of the mountain with an easier path to follow.” - Patricia Rose Upczak

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The Physical and Cognitive Experience of Grief Confusion, Dizziness, Irritability Anxiety, Shortness of Breath Tightening of the Chest and Throat Sleep and Eating Disturbances

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The Physical and Cognitive Experience of Grief Depression, Paranoia Memory gaps Auditory and visual hallucinations Frightening Dreams Inactivity/ Hyperactivity Searching Behavior

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Stage One: Shock and Disbelief “When Dr. Redding told me my mother was dead I remember thinking he must be speaking about someone else’s mother.” “I remember almost nothing in the week following the death of my son. That week seems like a blur.”

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Stage One: Shock and Disbelief Adaptive response Able to cope with final arrangements Funerals/memorials assist transition to reality Feelings of disbelief return during the grief process

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Stage Two: Suffering and Disorganization When the reality of the loss sinks in, the bereaved may…… Feel profound sadness, loneliness Feel despair over lost dreams Loose confidence in themselves Be forced to establish identity as single person

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Stage Two: Suffering and Disorganization When the reality of the loss sinks in, the bereaved may…… Have to take on roles and tasks of deceased spouse Express difficulty being with others Cope with changing relationships with others Feel embarrassed about emotional outbursts Re-experience prior losses

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Additional Stage Two Emotions Guilt “I could have done more to prevent her suffering” “I didn’t get to see him before he died.” “I was supposed to die first, not him.” “I shouldn’t feel relieved, but I do.” “I didn’t tell her I loved her before she died.” Anger “How dare you die and leave me with all this.” “I blame the doctor. He missed finding the lump.” “If God loved me, he wouldn’t have taken her from me.”

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Additional Stage Two Emotions Jealousy “Why didn’t it happen to someone else?” “I can’t stand to see them so happy together.” Idealization of the deceased “My father never once got angry in his whole life.” “My wife was perfect in every way.”

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Stage Three: Aftershock and Reorganization As the bereaved “reconstruct their life without their loved one” they may…... Define what is meaningful to them Report confidence in acquiring new skills Rekindling of old relationships- start new ones Take on new hobbies and interests

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Stage Three: Aftershock and Reorganization As the bereaved “reconstruct their life without their loved one” they may…... Enjoy reminiscing about life with their loved one Accept the reality and finality of death Return to stable eating and sleeping patterns Experience release and relief from their loved one Adjust to new role changes

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Specific Types of Losses Loss of a Spouse Men are more “instrumental” grievers Women are more “expressive” grievers Length of relationship does not predict grief response Adult Loss of a Parent Most common form of bereavement Adult child left feeling “orphaned” “Cushion” of mortality gone

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Specific Types of Losses Adult Loss of a Sibling Most neglected loss Loss of connection to past Guilt about any unresolved issues Loss of a Child Anger, guilt, separation, search for meaning May be the hardest loss May have negative effects on couple’s relationship Miscarriage, stillborn and newborn death must be acknowledged

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Listening Skills Strong emotion, even months after the loss, is not abnormal Listening to someone crying is difficult, but important Calm down someone who is hysterical Don’t change the subject or distract the griever Don’t give advice or quiz for details

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Listening Skills Empathy is helpful-don’t over-do sympathy Realistic reassurance is OK Don’t interrupt- speak when they are done Be nonjudgmental- what the survivor feels is important (even anger) Allow silence

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Listening Skills Listen for content AND the feelings underneath the content Look for the main idea of the speaker Pay attention to non-verbal communication Relax, be yourself Secure a quiet place to talk

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Listening Responses Nod, smile, intermittent eye contact Pause Casual Remark -“I see” “Uh huh” Echo- repeating back the last few words

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Listening Responses Clarify- asking for more information Paraphrase- summarizing what you heard Interpret the speaker’s ideas within context

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Phone Support Use words and tone of voice that convey concern Enunciate and speak slowly Convey understanding even if the response is superficial Visualize the speaker in a positive way

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Phone Support Respect a desire not to engage in conversation Reinforce that they are not alone Schedule a visit Review VITAS bereavement services

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Reflective Listening Exercise

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Techniques to Assist the Bereaved Encourage the survivor to grieve in their own way Find a quiet, private place to talk Use the deceased’ name in the past tense Use the words died, death, dead Have them describe the death and any memorial events

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Techniques to Assist the Bereaved Ask how they’ve been coping since the death Ask how they coped with prior losses/ crises Acknowledge their strengths and past accomplishments Affirm their surviving the current loss

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Techniques to Assist the Bereaved Ask them about their relationship with deceased Help them examine their special qualities/talents Advise against any drastic changes Reassure them it’s normal to feel overwhelmed

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Techniques to Assist the Bereaved Help them identify feelings, including relief Warn them that emotional ups and downs are normal Remind them to take care of themselves physically- eat well, rest, exercise Suggest they limit alcohol and mind altering medications

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Techniques to Assist the Bereaved Suggest that the bereaved…. Be patient with themselves and others Set realistic expectations-small goals Take one day at a time Start slowly with customary chores Do small things for other people Set limits and say “no” when appropriate

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Techniques to Assist the Bereaved You can also… Validate the survivor for developing new skills, roles Affirm their right to feel joy and to develop new relationships

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Specific Aids Validate the bereaved’ desire to review medical records Encourage the use of symbols and “transitional objects”-photos, clothing, jewelry

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Specific Aids Suggest that the bereaved: Journal to express their grief Write a letter to the deceased, to God Read about grief- library, bookstore, internet Make a family memory book or box Do art work to express their grief Play out “unfinished business” Role play to increase coping skills

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Support From Others Don’t tell me that you understand Don’t tell me that you know Don’t tell me that I will survive How I will surely grow Don’t come at me with answers That can only come from me Don’t tell me how my grief will pass That I will soon be free Accept me in my ups and downs I need someone to share Just hold my hand and let me cry And say, “My friend, I care.” -Anonymous

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Support From Others Support system important in adjustment to loss Encourage bereaved to: Reach out for help-talk with people who listen well and reminisce about the deceased Reach out for professional help if needed Take people up on their offers to help-and be specific with requests

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Support From Others Educate bereaved that: Friends may call less- fear of intruding or don’t know what to say It’s not their role to protect or provide support to others It’s OK to set limits with someone who gives advice

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Bereavement Support Group Benefits of Support Groups Talk with others who understand Learn ways to cope Average time is 3 months after loss Assess that survivor is appropriate for group experience

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Bereavement Support Group Groups should be organized by similar losses (i.e., death, suicide) similar ages (i.e., teens, adults) Suggest the survivor try the group at least twice before dropping out

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Complicated Grief Reactions Grief is generally complicated when it is extremely intense and consuming for more than six months What is Complicated Grief? High risk factors that lead to maladaptive adjustment, or…. Normal symptoms with abnormal intensity and duration

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Complicated Grief Reactions In Assessment, we look for … Risk factors Bio-psycho-social-spiritual factors Naturally resilient? Physically healthy? Positive or negative outlook? Adequate support system? Concurrent life stressors? Strength from spiritual faith? Normal grievers are generally more in touch with reality

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Complicated Grief Reactions Suicidal ideation Alcohol or prescription and non-prescription drug abuse Self destructive behaviors Lack of self care Radical lifestyle changes Ongoing numbness Isolation from self or others

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Complicated Grief Reactions Highly anxious and restless Depression with sleep and eating disturbances False euphoria Persistent guilt and/or lowered self esteem Irritable and angry continually Paranoia

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Complicated Grief Reactions Preoccupation with loved one or with their death Themes of loss come up in other areas Inability to speak about the deceased without experiencing intense and fresh grief Inability to change or move possessions of the deceased

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Complicated Grief Reactions Having chronic physical symptoms- especially if the symptoms resemble those of the deceased Extreme fear about their own illness and death Extreme idealization of the deceased Compulsion to take on mannerisms of the deceased Inability to function and feeling out of control.

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Patterns of Complicated Grief Responses Chronic Grief- excessive in duration Coincides with ambivalent/dependent relationship May include obsessive trips to grave, constant conversations about the deceased, etc. Delayed Grief- inability to deal with loss Grief from original loss may be experienced with future loss Sometimes denies remembering the deceased Happens when mourner is unable to grieve original loss due to other responsibilities

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Patterns of Complicated Grief Responses Disenfranchised Grief- inability to publicly acknowledge loss If loss was related to AIDS, stillborn, infertility, abortion, loss of personality from Alzheimer’s If deceased was a pet, a friend, gay partner, lover, ex-spouse If mourner is a child, elderly person or person with developmental disabilities Exaggerated Grief- intensification of normal grief reaction Nightmares, extreme anxiety, anger, guilt and depression common

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Patterns of Complicated Grief Responses Masked Grief- inability to associate poor coping with loss May develop: psychosomatic symptoms, psychiatric symptoms- depression, paranoia, or delinquent behaviors Sudden Grief- results from an unexpected loss Can increase denial and numbness May feel regret for things not said or done May experience increased anger at others Search for meaning of death may prolong grief process

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Interventions for Complicated Grief Requires intervention from a trained mental health professional VITAS bereavement team should… Make an assessment of the nature of the complication Make an appropriate referral Follow-up on referral

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Interventions for Complicated Grief VITAS bereavement team should… Educate about normal grief process Instill hope- pain will subside with time Validate their requesting help Provide support to mourner and family Suggest a thorough medical and psychiatric evaluation

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Interventions for Complicated Grief For disenfranchised survivors Validate significance of loss Assist them in accessing appropriate support For sudden loss survivors Provide stability, control Help them recognize loss and changes to “assumptive world”

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Differential Diagnosis Grief vs. Depression Depression Self esteem gradually decreases over time Isolation from self and others the norm May have active suicide plan Grief Sudden decline in self esteem-related to loss Support from others reassuring May have vague thoughts of suicide

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Differential Diagnosis Grief vs. Depression Depression Consistent depressed mood Pain is chronic-hard to identify origin Little decrease in somatic symptoms Grief Mood fluctuates Pain directly related to loss Decrease in somatic symptoms with time

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Treatment of Depression Combination of drug and talk therapy most effective Refer to MD and mental health professional You can intervene by… Establishing rapport Providing psycho education Affirming their strengths and accomplishments

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Treatment of Depression You can intervene…. Teach them to substitute negative thoughts with positive affirmations Encourage them to discuss negative emotions Instill hope- remind them they don’t have to suffer

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Treatment of Depression You can intervene…. Help them set a reasonable goal around a fixable problem Encourage them to do things for themselves, take risks, find solutions to their problems Encourage distractions- pets, children, TV Suggest pastoral counseling, art, music, and pet therapy

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Suicide Assessment Not uncommon for bereaved to have suicidal thoughts Reunite with loved one Relief from the pain of grief Indications of Suicidal Ideation Affairs put in order- personal items given away Delegating responsibility for pets, other people Ask questions about death Sudden change in attitude (happier) Statements of hopelessness, helplessness

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Suicide Assessment Motivation Plan Means Risk Factors White Protestant male 45 and older Lives alone Financial worries Health problems Low risk- vague thoughts Moderate risk- ideation but vague plan High risk- lethal plan and means

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Suicide Interventions Use least restrictive method possible - verbal/written contract - 24-hour suicide watch - voluntary hospitalization - involuntary hospitalization Involve the VITAS senior management team Always give them the suicide or crisis hotline number in your area Do not leave until you feel they are safe

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Suicide Interventions Reinforce their confiding in you Be nonjudgmental and warm Use both open and close-ended questions Use direct terms (kill yourself, die) Get identifying info on the phone

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Suicide Interventions If they are not at imminent risk… Explore ambivalence, alternative options Partialize problems-focus on strengths Encourage them to remove any means of harming themselves Encourage support for others Help them focus on meaning in their life

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In closing… It is one of the most beautiful compensations of life that no man can sincerely try to help another without helping himself -Ralph Waldo Emerson