Counseling People Dealing with Bereavement - Assignment Example

Possible Approaches in Counseling People Dealing With Bereavement The loss of a relative, close friend or even a pet can be a traumatic and stressfulexperience to people of all ages. But fact is that death is one of life's inevitable realities, more than two million people die in the United States each year. Although most are older, death occurs in all age groups. The causes of death vary both with age and gender. Among those under age 35, intentional and non-intentional injury is the primary cause of death. Among older Americans, cancer and heart disease are the top killers. Men typically die at younger ages than women (Minino & Smith, 9 October 2001). Death is not a mystery to those who have died. The people living are the ones who struggle to find meaning in it. As far back as 60,000 years ago, prehistoric people observed special ceremonies when burying their dead. Many early cultures believed that people continued to exist after death and had the same needs that they did in life; hence they buried their loved ones with food, dishes, weapons, and jewels. Some religions, such as Christianity, believe that the dead will rise again; to them, the burial of the body is symbolic, like the planting of a seed in the earth to await rebirth. Many Eastern religions share the belief that death marks the end only of physical existence and of the limited view of reality that human beings can grasp. Death itself is a remote experience in most lives today, something that takes place off-stage in a hospital or nursing-home. In earlier times, dying was a much more visible part of daily living. Families, friends, and other loved ones in a community would share in caring for those at the end of life (Schulz et al., 27 June 2001) Most deaths occurred at home, often following a brief illness and unaffected by the limited medical care available. Today, the process of dying almost has become invisible, but it still summons pain among the loved ones left (Bern-Krug et al., February 2001). Coping with loss is a process with an individual course, tempo and length that varies in response to personality and both social and cultural factors. Among the bereaved are those who find within themselves and their surroundings the requisite support and resources to reorganize their lives following the death of a loved one. There are others who benefit from, and still others who continue to require the assistance of, qualified psychotherapists in confronting the void left by death. There is no single ideal time point for therapeutic intervention. As practiced today, bereavement counselling is a valuable and non-stigmatizing method of assisting the bereaved who have difficulty entering, traversing or exiting the grief and mourning process. Review of Literature Throughout history, numerous writers and researchers have articulated their views of what constitutes the bereaved state and its associated actions, particularly since 1970. The earliest conceptualizations was done by Freud (1957), where he related it to loss situation-specific depressive syndromes, and he spoke of restitution of cathected or invested energies, particularly those of id origin. Later formulations bore the hallmark of attachment theory grounding, wherein the broken bond with the lost object/person is the subject and object of a universal psychosocial process leading to eventual reconciliation of painful feelings and reattachment to life, living and, for some, even new relationships. Colin Murray Parkes (1972) also cited stigma and deprivation as key features of the bereavement experience. These authors based their findings largely on studies of widows in Britain, Australia, and North America. Many of these seminal works on bereavement brought about a linear stage model of progression to some better state post-loss. Examples include the popularized views of Elisabeth Kbler-Ross (1969), who wrote of movement from denial, through anger, to bargaining, then to depression, and finally to acceptance. This often misrepresented and misused description none the less has lingered to the present day as the best-known Western layperson's view of what happens to the psyche anticipating imminent mortality. John Bowlby (1982) also wrote of four phases as characteristic of the bereaved person's experience: numbing; yearning and searching; disorganization and despair; and eventual reorganization. Most of this work was conducted in clinical settings or via self-report from survivors who presented for help, thus limiting the generalizability of findings to a minority of bereaved people. Erich Lindemann's (1944) classic study of fiery, poisonous smoke-caused death loss in Boston yielded a profile of characteristics that still appears to be a valid, if incomplete picture. He found five major symptom sets to be problematic - somatic distress; preoccupation with the dead person's image; guilt feelings; angry and hostile reactions; and atypical daily conduct - all in reaction to the sudden death loss of a significant other. More comprehensive renderings offer expanded views of bereavement that still include the phasic, the biological or somatic, the clinical, and diverse variant patterns, but represent a wider swathe of coverage and, in some cases, a shift to a postmodern view that argues for validation of continuity mindsets rather than solely replacement thoughts as legitimate alternative explanations of adult reactions to death loss. The lead writers representing this view base their assertions on findings in a number of populations in Europe and argue for a bimodal pattern that entails oscillation between loss-oriented and restoration-oriented behaviors and cognitions by the bereaved. Another prominent somewhat similar set of postulates sees bereavement as auguring a set of tasks to be completed in coping successfully with death loss. Finally, there is an abundance of spiritual or religious documents citing that bereavement is an essential aspect of the core experience of many who come to be bereaved. Indeed, many bereaved people cite their religious and spiritual beliefs and practices as central features of their response to death loss, and to the notion of mortality itself. Grief Therapy Indeed, when dealing with bereavement, grief therapy seemed to be most applicable. Throughout the years, grief therapy has undergone significant changes of both a theoretical and applied nature related to developments in the field. Bereavement that was once viewed as a time-limited process with the individual resuming "normal" life upon its completion is now recognized as a much more complicated process. Grief therapy was then aimed at assisting the bereaved to work through the grief and to reach completion, resulting in a full return to 'normal' life. Grief therapy was a tool to facilitate this restoration. It is now conducted in multiple ways and at multiple levels. Shifts away from these models have led to redefining the process of dealing with loss to include meaning construction as well as attention to the emotional and interpersonal life of the bereaved. As the grieving individual struggles to cope with the balance between what was and what is, therapy with the bereaved is a process of accepting this ever-changing reality. It is remembering the dead without being overwhelmed by memories. It is continuing with life, and managing the internal and external worlds. Rubin (1981) had suggested a bifocal approach to bereavement relating to the process of adaptation to bereavement that is linked both to the disruption in, and the achievement of, new levels of homeostatic function when it relates to both the bereaved person's function and attachment to the deceased. Grief therapy is designated for those bereaved who require the assistance of qualified psychotherapists in confronting the void left by death. Grieving, as a natural process, has historically been facilitated through informal, often spontaneous support networks. The basic human responses of caring, comforting and consoling were available for grieving persons through the family, church or the community-at-large. Today, such unconditional support has subsided or is no longer available. It is therefore understandable and expected (not surprisingly) that a variety of therapeutic approaches to assist the bereaved have been developed and their effectiveness is being studied. Self-help groups, initiated by the bereaved, have become an important resource of support provided by persons who themselves were 'wounded' and therefore can best understand the loss and the painful life that follows. Grief counseling and grief therapy are forms of structured, systematically planned interventions, applied for the individual or family. A distinction between grief counselling (helping people facilitate uncomplicated, or normal, grief) and grief therapy (a therapeutic intervention with complicated grief reactions) has been proposed indicating the importance of a careful assessment of the individual needs without stigmatizing grief as a human response to loss. The literature on grief therapy is in agreement that caring, support availability and empathy are central ingredients that go above and beyond a specific mode of intervention. Also, all forms of interventions regardless of their theoretical adherence, focus on loss, are structured and time-limited. Such are the examples of therapeutic approaches of traditional psychodynamic, symbolic leave-taking ritual, and cognitive therapies, applied to working with complicated bereavement. Various researches have been conducted to try to evaluate the effectiveness of therapeutic interventions. Studies reporting the application of interventions with bereaved patients when compared to delayed treatment control groups have been found to be effective in facilitating a normal grief process or at least reduce the risk of subsequent pathology for some high risk bereaved people. These findings are of special importance for those among bereaved at risk (traumatic loss) or who experience complicated grief. Assessment and diagnosis are the initial stages of grief therapy. For example, in the two-track model of bereavement, the therapist can pinpoint the precipitating difficulty as related to some level of difficulty along one or both tracks: functioning and relationship to the deceased. In grief therapy it is important that the therapist is an actively emphatic listener. A variety of modalities of treatment are available; the following section gives a brief overview of the prominent ones. Grief therapy from a psychodynamic perspective views the relationship that develops between the client and the therapist as a focal point of the therapeutic process. The elements that are considered to be central during the course of therapy are (1) the real or actual relationship of the participants and their interactions; (2) the relationship of client to therapist (transference); and (3) the relationship of therapist to client (counter-transference) (Stroebe et al., 1993). Applying this paradigm with dysfunctional bereavement suggests a modification of technique that may be required in grief therapy with the bereaved. In particular, a contention that the relationship to the deceased should be accorded a central place in the treatment - at times even superseding the transference relationship. Grief therapy from a psychodynamic perspective aims at reworking the relationship to the deceased, and its centrality to the therapeutic goals can require a conceptual shift in the therapeutic paradigm of the transference model. This may well place the deceased, and not the therapist, as the central transference figure. Another kind of grief therapy is a symbolic leave-taking ritual. It is an integrative and comprehensive short-term model of therapy which uses 'leave-taking rituals' and metaphor to help patients who suffer from unresolved and complicated grief. This model constructs a fixed framework for the mourning process, in using a variety of means including continued letter-writing to the deceased, accepting a linking object from the patient and planning the final leave-taking ritual (in which the patient buries or separates from their precious linking object) (see objects). The main purpose of this approach is to help the mourner express his or her feelings, resolve the inhibiting emotional block and to give him or her the possibility of expressing the whole range of feelings so that the process of separation from the deceased may be completed. Culturally sensitive leave-taking rituals are employed (Stroebe et al., 1993). Cognitive therapies emphasize the meanings constructed by the bereaved person about an event such as death over which they had no control. It links the cognitive map of the bereaved to the emotional and behavioural responses following loss. Cognitive therapy not only recognizes the healing value of the grief process, but also the traumatic nature of the death event, and its effect on the bereaved person's belief system, increasing the human tendency to think in a distorted manner. Cognitive therapy specifies differences between adaptive (sadness) and maladaptive (depression) responses to interpersonal bereavement, and defines complicated (dysfunctional) grief as persistence over time of a rigid distorted belief system. Cognitive grief therapy utilizes a variety of cognitive, emotive and behavioural interventions aimed at assisting the bereaved to create a sense of coherence between what was lost and reconstruct in a healthy manner a new meaning to a reality that has changed forever (Malkinson et al., 1999). Therapy from a constructivist perspective regards grief as a form of meaning construction of the loss with the intervention aimed at meaning-making. Bereavement is a personal idiosyncratic process of meaning construction to a life without the deceased. From this perspective, bereavement and its implications are viewed from the vantage of a process rather than the emotional and symptomatic sequelae and its implications for treatment (Stroebe et al., 1993). Characteristics such as time frame, outcome and recovery lose much of their influence in so far as the way in which individuals interpret the experience becomes primary. Rather, death is an event that seems to affect the bereaved person's constructions in ways of validating or invalidating them, a process of meaning reconstruction which is an intensely active one and is the central dynamic of grieving. Conclusion We must always keep in mind that grief is a psychological necessity, not self-indulgence. Psychotherapists refer to grief as work, and it is-slow, tedious, and painful. Yet, only by working through grief, by dealing with feelings of anger and despair, and adjusting emotionally and intellectually to the loss, can bereaved individuals make their way back to the living world of hope and love. Bereavement could cause grief to anyone, including children. For this reason, some parents inevitably approach the problem by trying to shield their children from experiences related to dying and death. Rather than solving the problem, this avoidance leaves the child unprepared to face a natural part of the life cycle. Many children, though they may not have an accurate concept of death, want to know about the many aspects of life related to dying and death, such as funerals and cemeteries. Death education for children can help meet this need. Its objectives are to allow children to clarify their values about death and dying, to provide factual information about the subject, and to encourage students to discuss openly the vital issues concerning the natural end of the life cycle. McGlauflin (1998) suggested that the three most important factors in helping children grieve are an understanding of the grieving process, an openness to that process, and the integration of that process into the daily operations of the school. There are many ways for counselors and other school personnel to learn about the grieving process. Both workshops and books are good sources of information. For example, Jarrat (1994) suggested the following list of important things to say to very young children who have suffered a loss: "Someone [name who, preferably] will take care of you. [If it is not going to be you, continue ] It will not be me, but I will stay with you until [name] is here to keep you safe." "It was not your fault. It was not because you were bad in any way or because you were unlovable. There is nothing you could have done, or can do, to make things different." "It is OK for you to know about what happened, to think about it, and to figure it out." "You can have your own feelings about what has happened. You may feel differently from other people, even those you live with. No one can tell you what you feel or what you should feel." "You can take as much time as you need to figure things out and have your own feelings. You do not have to rush or pretend that you don't think or feel as you do." (pp. 9-10) Although very young children do not understand that death is permanent, they do experience loss and the changes that take place when a family member dies. According to Grollman (1995), these children may regress to earlier behaviors (thumb sucking or bed-wetting, for example), become irritable, or develop bowel or bladder disturbances. They can also become very fearful, afraid to go to preschool or to sleep, and cling to their caregivers. The children's primary caregiver should watch for these behaviors, understand them as a reaction to loss, and use them as an opportunity to allow the child to grieve openly. Although all people grieve for the dead, the ones bereaved are the ones who need help. As health professionals, we should know how to ease bereavement because it is such an intense situation that survivors may be too numb or too stunned to ask for help. We also should let family and friends take the initiative and spend time with them, even if that means sitting together silently. Offering empathy and support, and letting the grieving person know with verbal and nonverbal expressions that you care and wish to help would be helpful for the bereaved people. Works Cited Bern-Krug, Mercedes, et al. "The Need to Revise Assumptions About the End of Life." Health and Social Work, 26.1, February 2001. Bowlby, J. Attachment and Loss: Sadness and Depression, Volume 3, New York: Basic Books, 1982. Freud, Sigmund. Mourning and Melancholia, in J. Strachey (ed. and trans.), Standard Edition, vol. 13, London: Hogarth Press, 1957. Grollman, E. A. Explaining Death to Young Children: Some Questions and Answers. In E. A. Grollman (Ed.), Bereaved children and teens: A support guide for parents and professionals. Boston : Beacon Press, 1995: 3-19. Jarrat, C. J. Helping Children Cope with Separation and Loss. Boston: Harvard Common Press , 1994. Kbler-Ross, E. On Death and Dying, New York: Macmillan (1969). Lindemann, E. "Symptomatology and Management of Acute Grief", American Journal of Psychiatry 101 (1944): 141-8. Malkinson, R., Rubin, S. and Witztum, E. (eds). Traumatic and Non-traumatic Loss and Bereavement: Clinical Theory and Research. Madison, CT: Psychosocial Press, 1999. McGlauflin, H. Helping Children Grieve at School. Professional School Counseling,1 (1998): 46-49 Minino, Arialdi, and Betty Smith. "Deaths: Preliminary Data for 2000." National Vital Statistics Reports, 49.2, October 9, 2001. Parkes, C.M. Bereavement: Studies in Grief in Adult Life, New York: International Universities Press, 1972. Rubin, S. "A Two-Track Model of Bereavement: Theory and Application in Research", American Journal of Orthopsychiatry 51 (1981): 101-9. Schulz, Richard, et al. "Involvement in Caregiving and Adjustment to Death of a Spouse." Journal of the American Medical Association, 285, June 27, 2001. Stroebe, M. S., Stroebe, W. and Hansson, R.O. (eds). Handbook of Bereavement, Cambridge: Cambridge University Press, 1993. Read More