Chapter 5 Loss, Grief, and Bereavement

Mindfulness-based practices such as _____________________________________________________________ can help people in crisis reduce their distress and can promote long-term well-being (Humphrey, 2009).

meditation, focused breathing, and body scans

As outlined in the training protocol for the Maryland State Police (Jackson-Cherry, 2009; Kanable, 2010; Page, 2008), but adapted for the training of crisis counselors for this section, death notifications should be

provided in person and in pairs, in an appropriate time frame with accurate information, in plain language, and with compassion.

Factors that determine whether the death will cause a significant crisis event that impairs daily functioning are as follows:

· how the person died (e.g., whether it was sudden and unexpected or the result of a prolonged or chronic illness); · cultural and spiritual influences of the bereaved; · individual temperament; · life circumstances; · unresolved issues connected with the death; · previous experiences with death and loss; · and the order of death (e.g., whether it is a grandparent at the end of a long life or a young person just starting out in life).

The biggest job of the crisis counselor when working with bereaved clients is to help them

· make sense of the loss, · accept the changes that they did not wish for or create, · and restore meaning to their lives.

Stage V: Acceptance -

"Death is very close now, and it's all right." Some people are able to cope with the news of a terminal illness and work through the anger and sadness to reach an emotional equilibrium that allows them to live out their final weeks and months with inner peace.

Stage I: Denial -

"Not me." "I am not dying." "A miracle will happen." Such comments are typical reactions to being told of a terminal illness. According to Kübler-Ross, denial serves a protective function in the initial stages by cushioning the blow that death is inevitable.

Stage II: Rage and anger -

"Why me?" The seemingly arbitrary nature of the news of one's impending death almost always causes one to erupt into anger and rage. Such anger is often targeted at those who are living and will survive, as well as at God for handing down the death sentence. Kübler-Ross believed such feelings were not only acceptable but also inevitable.

Stage III: Bargaining -

"Yes, me, but . . ." In the bargaining stage, one begins to accept the inevitability of death. But one bargains for more time, often by offering to do good deeds or change in a specific way.

Stage IV: Depression -

"Yes, me." The depression stage is the beginning of acceptance. Initially, the person mourns previous regrets and losses, but this turns into an acceptance of the impending death and what is referred to as "preparatory grief." During this time, the dying person begins to face any unfinished business and prepares to "let go" peacefully.

Three areas that might affect a crisis counselor's ability to be helpful:

(1) counselors who have had a similar loss that they have not worked through, (2) counselors working with a client's loss when they fear a similar loss of their own (such as the death of a parent or child), and (3) existential fears resulting from the counselor's failure to come to terms with their own mortality (Worden, 2009).

The five stages of death and dying developed by Elizabeth Kübler-Ross:

(1) denial, (2) rage and anger, (3) bargaining, (4) depression, and (5) acceptance.

Lindemann (1944) identified three tasks of mourners:

(1) emancipation from the bond to the deceased, (2) readjustment to a life in which the deceased is missing, and (3) formation of new relationships (Berzoff & Silverman, 2010).

When the focus shifts from curative efforts to end-of-life care, dying persons should have the following four needs met:

(1) freedom from pain: physically, the focus should be on comfort care and reducing fear; (2) legal and ethical issues: they should have the opportunity to put affairs in order, to allow a natural death, and to experience a more humane transition; (3) emotional support: they deserve to have a sacred space in which acceptance of the coming separation from their loved ones is acknowledged, they are given the opportunity to grieve, to make amends, and to say good-bye to loved ones; and (4) social support: they deserve to have people around them, to have family support for themselves and for the other members of their family (Corr, Nabe, & Corr, 2012).

Several factors should be taken into consideration when working with survivors of sudden loss:

(1) natural versus human-made losses (e.g., heart attacks and tsunamis are examples of natural causes; hostile actions and bombings are human made); (2) the degree of intentionality (e.g., accident versus drunk driving); and (3) how preventable the death was.

Bowlby (1980) noted four phases of the mourning process:

(1) numbing, which lasts from a few hours to a week; (2) yearning or searching for the lost figure, lasting for months or even years; (3) disorganization or despair; and (4) some degree of reorganization.

In his classic research, Bowlby (1980) notes five conditions that affect the course of grieving and should be used in a crisis intervention assessment:

(1) the role of the person who died; (2) the age and gender of the bereaved person; (3) the cause and circumstances surrounding the death; (4) the social and psychological circumstances affecting the bereaved at that time of loss; and (5) the personality of the bereaved, especially as it relates to one's capacity for making attachments and for coping with stressful situations.

____________________________________________ is a cognitive-structural model of spiritual and religious development that counselors can use to assess the client's stage of spiritual growth and development and to identify any developmental crisis that may be occurring.

Faith development theory (FDT)

Fowler's (1981) model of faith development theory (FDT) incorporates the following six stages:

Stage 1—Intuitive-Projective Stage: Stage 2—Mythic-Literal Stage: Stage 3—Synthetic-Conventional Stage: Stage 4—Individuative-Reflective Stage: Stage 5—Conjunctive Stage: Stage 6—Universalizing Faith Stage:

Grief that is repressed or denied can result in

aberrant behavior or can cause physical symptoms.

Long-term effects of living with ambiguous loss can include

depression, anxiety, guilt, ambivalence, and interpersonal conflicts.

back-to-back losses are called

grief overload

Worden (2009) considers it a "benchmark of a completed grief reaction" when

the person is "able to think of the deceased without pain" (p. 46).

People want and need to be able to discuss aspects of their faith with clinicians. In recognition of that need, Christine Pulchaski, a physician, developed the FICA spiritual assessment, a four-step process that includes questions clinicians can ask to assess a patient's spiritual attitude quickly:

1) Faith, Belief, Meaning: Do you consider yourself a spiritual or religious person? Where do you find meaning in life? 2) Importance and Influence: How important is your faith to your life? How do your beliefs help you to cope in times of stress? 3) Church and Community: Are you a part of a faith-based or religious community? If so, what type of support does this community provide? 4) Apply and Address: How would you like me to address or apply this information in our work together? (Borneman et al., 2010)

Counselors who do grief work or who work with dying clients should

1) recognize their own limitations and accept these limitations with compassion and without judgment, (2) work to prevent burnout by practicing mindfulness meditation and active grieving, and ( 3) know how to ask for help, seeking supervision when necessary (Halifax, 2011; Renzenbrink, 2011; Worden, 2009).

Other specified trauma- and stressor-related disorder (specified by "persistent complex bereavement disorder") is applied most often to individuals who meet the following diagnostic criteria (American Psychiatric Association, 2013):

1. "The individual experienced the death of someone with whom there was a close relationship." (p. 789) 2. At least one of these symptoms has persisted more often than not, with clinical impairment, in an adult for at least 12 months following the death (at least 6 months for a child): persistent yearning of the deceased; intense sorrow in response to the death; preoccupation with the deceased; preoccupation with the circumstances of the death. 3. At least six of these symptoms have persisted more often than not, with clinical impairment, in an adult for at least 12 months following the death (at least 6 months for a child): difficulty accepting the death; experiencing emotional numbness; difficulty in positive reminiscing; bitterness or anger related to the loss; self-blame; desire to die; difficulty trusting others; feeling detached; feeling life is meaningless; confusion about one's role in life; reluctance in pursuing life goals. 4. The individual is experiencing significant occupational, social, or other impairment. 5. The bereavement reaction conforms to cultural, religious, or age-appropriate norms.

Worden (2009) proposed a task model of grieving that empowers the bereaved to accomplish the following four tasks:

1. Accept the loss: 2. Experience the pain: 3. Adjust to an environment without the person: 4. Reinvest emotional energy in other relationships:

Working on ___________________________________ often becomes the goal of long-term counseling after the crisis is stabilized.

meaning and purpose

Berzoff and Silverman (2010) categorized death education as:

prevention (i.e., preparing for the inevitable), intervention (i.e., dealing with the immediate), and postvention (i.e., understanding the crisis or experience).

Helping people focus on _______________________________ is the most important function of the grieving process

recreating a meaningful existence

Rosenblatt, Walsh, and Jackson (1976) found that people in all cultures express grief through

tears, depressed affect, anger, disorganization, and difficulty performing normal activities.

In the DSM-5 (American Psychiatric Association, 2013), bereavement has been narrowly defined as

the loss of a loved one with whom one has had a close relationship