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Grief depersonalization

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					                  Grief

 Daniel Robitshek, MD
 Professor of Medicine
UC Irvine Medical Center
  Hospitalist Program
              Death is a fearful thing.
                William Shakespeare

    Death! thou comest when I had thee least in
                       mind!
                      Unknown

While grief is fresh, every attempt to divert only
  irritates. You must wait till it be digested, and
 then amusement will dissipate the remains of it.
                   Samuel Johnson
     Every death
has a life of its own…
                        Grief
   “Grief is neither a disorder nor a healing
    process: it is a sign of health itself, a whole and
    natural gesture of love. Nor must we see grief as
    a step towards something better. No matter
    how much it hurts – and it may be the greatest
    pain in life – grief can be an end in itself, a pure
    expression of love.”
                                        Gerald May, MD
            The Grieving Process


    “…restoring the fit
  between the world that
   is and the world that
       should be…”




(Reference: Parkes, Colin M. Mortality: Virtual Themed Issue, 2003)
                         Loss Defined

   Loss is the experience of parting with an object,
    person, belief, or relationship that one values.
       Losses are encountered daily by each of us.
       The experience of loss must be defined broadly and with a clear
        understanding of the personal pain and disruption that can accompany it.
       Losses can be minor or major.
          The designation of “minor” or “major” depends upon the perception
            of the loss by the person experiencing the loss.
       The impact of loss depends upon the value the person placed on what
        was lost.
             Language of Loss

Bereavement – the state of having experienced loss

Mourning – the private and public processes, rituals
             and practices to loss
BEREAVEMENT

     “Bereavement is darkness
       impenetrable to the imagination
       of the unbereaved.”

     Iris Murdoch 1919-1999
     Types Of Loss

   Tangible (actual or physical) losses are apparent and
    easily recognized:
       Loss of a body part.
       Changes in physical health.
       Loss of a loved one.
   Intangible (perceived or psychological) losses are less
    obvious:
       May be tied to personal perceptions such as one’s prestige, power, dreams, plans,
        security, etc.
       Because these losses are less likely to be acknowledged, admitting to the
        accompanying feelings of loss can be difficult or embarrassing.
       Consequently, emotional support may be inadequate.
                   What is Grief?
   Multidimensional result of/response to loss
     Emotional
     Physical

     Cognitive

     Behavioral
            Why Do We Grieve?
   Attachment theory – Bowlby
     Attachment occurs in absence of the reinforcement
      of biological needs (e.g. food)
     Based on need for safety and security

     Observed in animals and humans

     Develop early in life, are directed toward a few
      specific individuals and tend to endure
     Grief occurs with the loss of the attachment bond
             Why Do We Grieve?
   Reestablish equilibrium – Worden
     Mourning is necessary
     After a loss is sustained, a healing process is
      necessary to re-establish equilibrium
              Surviving the Loss:
             The Grieving Process
   The dual process model of coping with
    bereavement (DPM) lists two types of stressors.
     Loss-oriented stressors- those having to do with the
      loss itself.
     Restoration-oriented stressors- those related to
      adapting to the survivor’s new life situation.
                 Dual Process Model
                                                 Restoration
            Loss                                  Oriented
           Oriented
                                               Dealing with the
    Involves the                              many life changes
   emotional and                              and new roles that
 reactive processing                         are brought about by
     of the loss                                    the loss


                     Oscillating between these stressors

(Reference: Stroebe and Schut, 1999)
         Emotional Response to Loss
   Anger
        Frustration with helplessness to change the situation
        Regressive experience
   Guilt and self-reproach
   Anxiety
        Fears about not being able to take care of oneself after the loss
        Heightened sense of own mortality
   Loneliness
   Fatigue
   Helplessness
   Shock
   Yearning
   Emancipation
   Relief, especially after the dying person has suffered during a lengthy illness
   Numbness
       Physical Response to Loss
   Tightness in chest and throat
   Hollowness in stomach
   Heightened sensitivity to noise and light
   Depersonalization
   Breathlessness
   Weakness
   Lack of energy
   Dry mouth
      Cognitive Response to Loss
   Disbelief
   Disorientation
   Confusion
   Preoccupation
   Sense of presence (feeling that the deceased is in
    the room or close by)
   Hallucinations
      Behavioral Response to Loss
   Sleep and appetite disturbances
   Social withdrawal
   Dreams of the deceased
   Avoiding reminders of the deceased
   Searching or calling out for the deceased
   Sighing
   Restlessness
   Crying
   Visiting places or carrying objects that remind one of the
    deceased
   Treasuring objects of the deceased
     Depression and Normal Grief
   Full depressive reaction may accompany normal
    grief response
   Grief does not include the loss of self-esteem,
    overall sense of guilt
   Grief may develop into depression
    What Determines the Intensity and
           Duration of Grief?
   Intensity is highly variable; may continue for months to several years
   Dependant upon
        Type of loss
        Nature of the attachment
              Strength of attachment – intensity of grief proportionate to the intensity of the relationship
              Security of the attachment – how necessary was it for a sense of well-being of the survivor
              Ambivalence – coexisting positive and negative feelings
        Mode of loss
              Natural, accidental, sudden/unexpected, expected, intentional, traumatic
        Historical antecedents
              Experience of earlier losses
              History of depression
              Previous stresses
        Personality variables
              Coping resources and styles
              Psychological resilience
              Optimism
        Social and cultural factors
              Traditions and rituals; social netword
        What are the Tasks of Grief?
   Accepting the reality of the loss
       Denial impedes this task
          Disbelief that the loss has occurred
          Denial of the meaning of the loss

          Denial that death is irreversible

       Acceptance must include understanding that the loss
        has occurred and/or the death is irreversible
        What are the Tasks of Grief?
   Experience the pain of grief
       Social expectation may make resolution of this
        difficult
            Others may try to distract the bereaved from the pain
       Ways of not experiencing affect
          Over involvement in work
          Idealizing the loss

          Geographic cure

          Minimizing the significance of the loss
        What are the Tasks of Grief?
   Adjusting to an environment in which the
    loss/deceased is missing
     Taking on new roles, developing new skills
     If not resolved, helplessness may occur

     Survivor may not be aware of all the roles filled by
      the deceased until the loss occurs
        What are the Tasks of Grief?
   Withdraw emotional energy and reinvest it in
    another relationship
     Many people misunderstand this task and are unable
      to work through it
     Some people believe that to reinvest emional energy
      in someone else is to dishonor the dead
     Fear of the prospect of experiencing new loss may
      impede the successful working through to this loss
       What are the Stages of Grief?
   Elizabeth Kubler-Ross (1969) suggested grief be seen as
    occurring in five stages
           Denial and isolation
           Anger
           Bargaining
           Depression
           Acceptance
   Stage concept has been criticized, but framework is
    valuable
           Most people do not progress through the stages in a systematic way or in a
            specific order
           All people will experience a variety of emotions which change over time
          NATURAL GRIEF: INSTINCTIVE
           BIOBEHAVIORAL RESPONSE
                            BEREAVEMENT




                               Acceptance
PRIMARY GRIEF                  Positive emotions
  Traumatic Distress           Forgiveness, Compassion
                               Meaning-making
                                                           INTEGRATED
  Separation Distress
                                                              GRIEF
  Guilt                           ? ~ 6 months

  Social withdrawal                                Permanent background state
                                                   Bittersweet memories that are
                                                   accessible and changing
Transient, dominant state
Painful and preoccupying
         How is Grief Resolved?
   Impossible to place a time limit: may be long
    term with close attachment (one year or more)
   A process
     Grief work – the mental and behavioral processing
      of the loss
     Gradual evolution of thoughts, emotions and
      experiences toward greater acceptance of the loss
      and emerging ability to resume life
     THE ROLE OF PHYSICIANS
   Educate
     Normal and natural grief processes
     Range of different feelings (positive and negative)
   Assess progress and prognosis
     Physical and mental health
     Life context
   Support
     Condolence letter
     Active listening
     Link to local resources (spiritual, support groups,
      counselors)
“…physicians who aid grief-stricken patients are
 afforded the rewarding, quintessentially human
 opportunity of transforming a personal sorry
 they inevitably will experience into sympathetic
 and supportive aftercare.”


Prigerson and Jacobs JAMA 2001
     Nine Ways to Help with Grief*
1.   Increase the reality of the loss
2.   Allow time and place for the expression of feelings
3.   Normalize feelings
4.   Reality test
5.   Help with problem solving as survivor adjusts to an
     environment without the deceased
6.   Discourage major life decisions too soon
7.   Encourage healthy reinvestment of emotion
8.   Allow for individual differences
9.   Provide continued support
                          *Worden, 1989; Rando, 1984; Cook & Dworkin, 1992; Bertman, 1991
1. Increase the Reality of the Loss
   Talking and traditions help
   Especially important early after the loss
   Provide ways to allow family members to say goodbyes at the
    bedside, before death when possible
   Encourage family members to provide care for the dying person
    and recognize their contributions (all can say that they were there
    and did as much as was possible)
   Encourage and support the family as they follow cultural and
    social traditions and rituals
   Express sympathy
   Listen to family members talk about the deceased and their
    experiences grieving
   Encourage reminiscing
      2. Allow Time and Place for the
             Expression of Feelings
   Provide for a quiet room free of distractions, offer
    tissues
   If appropriate, given the person’s culture and the social
    situation, a touch on the shoulder or hand may provide
    a tangible gesture of concern and support
   Make telephone available for family members to
    contact significant others
   Verbal permission to grieve or express emotions and
    thoughts
   Listen without judgment
          3. Normalize Feelings
   Especially important when the bereaved feels
    anger or relief with the loss (or other emotion
    that may be perceived as inappropriate)
   Let person know that ambivalent feelings are
    normal and common
   Very important not to minimize feelings
                   4. Reality Test
   Help the bereaved person understand difficult
    feelings in the context of the situation
   Example
       47 yo who expresses feeling of relief and resultant
        guilt after death of parent from long illness in which
        she was the primary caregiver
5. Help with Problem Solving as Survivor Adjusts
    to an Environment Without the Deceased
   Practical discussion of new roles and
    responsibilities for survivor
   Help survivor break down tasks into small steps
    that can be accomplished
   Identify sources of support in community
   Referral to social service, financial advisors,
    counselors
    6. Discourage Major Life Decisions
                Too Soon
   Making major life decisions early in the grieving process
    may be counterproductive or even harmful
        Moving, marriage, pregnancy, change in employment
   When is it “too soon”?
        Experience of intense, fresh grief
        Difficulty accepting the paing and reality of the loss
        difficulty starting new activities without the deceased
        Complicated grieving
   Nine Ways to Help with Grief
7. Encourage healthy reinvestment of emotion
   Previous roles and responsibilities
   New activities and relationships

8. Allow for individual differences
   Broad range of emotions and other experiences
    during grieving
   Variation in the time needed to grieve

9. Provide continued support
My wife of 40 years died at a prestigious teaching
  hospital…Neither the hospital management nor the attending
  physician or anyone from the house staff ever troubled to
  write or telephone to express sympathy or offer an account of
  what had gone so wrong those last disastrous days. The effect
  of that bizarre silence was to make me wonder whether some
  monumental mistake might have been made in preparing the
  dose that was to end her life. The next of kin are entitled to
  some expression of sympathy or concern, even when it is not
  deeply felt. Those close to the deceased can only be baffled,
  resentful, or suspicious when no condolences are expressed.

Lerner A NEJM 345: 374-375 2001
    Benchmarks of Grief Resolution
   Survivor is able to talk about the deceased
    without intense affect
   Survivor can reinvest emotions in another
            EVOLUTION OF GRIEF


           Problems
            + 30%

Major Depression
Posttraumatic Stress
Disorder
Complicated Grief

                             Adaptive
                              + 70%
            Special Problems*
   Failure to Grieve
   Avoidance of Grief
   Chronic Grief
   Delayed Grief
   Exaggerated Grief
   Masked Grief
   Anticipatory Grief
                         *Worden, 1982; Cook & Dworkin, 1992
             Anticipatory Grief
   Grief occurring in advance of the loss
   Often seen among family members who expect
    the future loss of their loved one
   A dying person can experience anticipatory grief
Professionals and Family Caregivers Must
           Attend to Self Care
    Issues for Health Care Professionals

•   Overwork
•   Multiple Loss and Grief
•   Boundaries
•   Burnout
                           Overwork
•   Occupational realities of working in medicine
•   Institutional realities
•   Unrealistic self-expectations & errors in thinking :
      “If I don’t do it, no one will”

      “I can do it better than anyone, so I should”

      Working harder to make up for mistakes

      “Helpaholism”

      “I’m in this alone”

      “There’s no way out of this”
           Multiple Loss and Grief
•   Stigma of working with the dying
•   Professional caregivers not expected to grieve
•   “Bereavement overload” (Kastenbaum, 1969) - falling over the
    edge of hope
•   Our early experiences with loss shape our approach/response to
    present-day losses
•   Re-living past deaths with each new death
•   Letting go, and letting go, and letting go ….
                      Boundary Issues
•   Occupational realities of working with the dying: multiple roles
      caregiver as health care provider

      caregiver as advocate

      caregiver as primary support person

      caregiver as individual/couples/family therapist

      caregiver as bereavement counselor

•   Personal issues involved in becoming a caregiver (Berry, C. R.,
    When Helping You is Hurting Me, 1988, Harper)
          Symptoms of Caregiver Burnout
•   Reduced productivity/impaired performance
•   Lowered energy/enthusiasm/humor
•   Chronic fatigue/insomnia/bodily aches & pains
•   Less interest in co-workers, clients, families
•   Opposition to change
•   Failure to manage basic life maintenance activities
•   Dislike of work environment
•   Expressed dislike for recipients of services
•   Increases in “going by the book”
                     Self-Care at Work
•   Case conference/staff retreats
•   Expect (and seek) positive feedback from supervisors
•   Consult with a back-up expert
•   Assignment of specific duties and knowing expectations
•   Drawing/maintaining clear boundaries on professional obligations
•   Enlisting help of volunteers
•   “Time out” activities
•   Varying tasks
•   Building in mental health days
                   Self-Care at Home
•   Meditation, relaxation exercises
•   Therapeutic massage
•   Regular exercise!!!
•   Nutrition as a self-nurturing activity
•   Recreation and pleasant events
•   Sharing experiences/feelings with friends & family
•   Professional support group
•   Individual therapy
                     Reference
   Knight, Sara J., PhD
       Robert H. Lurie Comprehensive Cancer Center Web
        Site
             Case Study: Sophia
   45 yo financial advisor who lost her husband
    Ben 1 yr ago after a brief, but aggressive illness
     Married for 20 yrs since graduated college
     No children, but were an extremely close couple

     Spent most of their time together and were each
      other’s best friend
              Case Study: Sophia
   1 year after Ben's death, Sophia described herself as
    never having gotten over his loss
   Experienced daily panic attacks that limited her ability
    to leave her apt.
   Was considering taking disability leave from work
   Was unable to talk about Ben w/o crying and noted
    that she was having great deal of difficulty cleaning
    Ben’s closet out
   She felt Ben would have wanted to donate his clothes
    to someone who would use them, but she could not
    decide what to give away and what to keep
                 Case Study: Sophia
   Reflection
       Loss of a spouse is very difficult
       Strong grief responses can be experienced for a year or more
        by bereaved
       Not unusual to have anxiety as they attempt to resume their
        lives
       Common to have difficulty giving up possessions of their
        loved one
       However, Sophia is experiencing severe limitations in her
        ability to take care of herself and is still experiencing intense,
        fresh grief when thinking of Ben 1 year later
                Case Study: Sophia
   Considerations
       Sophia’s experience suggests the possibility of
        anxiety and depression
          Should a referral to a mental health professional be made?
          What other resources might be helpful for Sophia?
            Grief vs. Depression*
                 UNCOMPLICATED GRIEF CLINICAL DEPRESSION

LOSS             Recognizable and current                         Loss may be symbolic/not recognized

REACTIONS        Initially intense, then variable                 Intense and persistent

MOOD             Labile, acute heightened when thinking           Consistently low, pervasive, chronic,
                 about loss                                       absence of emotion

BEHAVIOR         Variable, shifting                               Refusal of most previously enjoyed
                                                                  activities

ANGER            Often expressed                                  Thought to be self-directed

SADNESS          Periodic weeping or crying                       Little variability (inhibited or uncontrolled)

COGNITION        Preoccupied with loss, confusion                 Preoccupied with self, worthlessness, self-
                                                                  blame, hopelessness

HISTORY          Little history of psych disorder                 Previous history of depression or other

SLEEP            Periodic difficulties falling asleep and early   Regular early morning awakening
                 am awakening

IMAGERY          Vivid dreams, capacity for imagery and           Self-punitive imagery
                 fantasy

RESPONSIVENESS   Responds to warmth and assurance                 Hopelessness and helplessness limit
                                                                  responsiveness to others
                                                                                           *Cook & Dworkin, 1992
When is Professional Help Needed?
   Intense fresh grief with discussion of deceased long after loss
   Minor event triggers intense grief reaction
   Themes of loss continue long after loss has occurred
   Survivor unwilling to move material possessions of deceased
   Survivor experiences physical symptoms of deceased
   Radical changes in lifestyle
   History of depression, or other psych disorder
   Compulsion to imitated deceased
   Self-destructive impulses
   Unaccountable sadness
   Phobia about illness or death
    Grief Counseling/Support Services
            vs. Grief Therapy
   Grief Counseling/Support Services
       Best for individuals who are experienceing grief that would
        not be considered “complicated”
       Goals
            Support persons as they go through the grieving process
            Prevent complicated grief reactions
   Grief therapy for complicated grief
       May have pre-existing issue/disorder that may interfere with
        normal grief
       Invlolves helpf with both pre-existing issues as well as the
        grief process
            Professional help
            Medication may be used