Bereavement, Grief, Mourning and Loss

So I went on a training day about bereavement and loss, because many of the people I treat have experienced one of these, and for some of them it is this loss which stops them from moving forward. I felt I needed the training because I haven’t gone through that much loss myself and I wanted to understand their perspective a little better and how to help them.
What surprised me was that we learnt that we don’t need someone to die to feel bereaved. We can feel that loss at so many things; divorce, diagnosis of a long-term illness, redundancy, when children fly the nest; I could continue ad infinitum. And as a result I learnt that whilst I (luckily) haven’t had so many people die with whom I’m close, I have experienced some of those other losses and this can help me, and others, understand some of what people feel when they feel bereaved.

The most important lesson I learnt is that grief can be delayed or immediate, severe or mild, prolonged or brief because we are all different. And because of that, we should approach those who are grieving with an open mind, without assuming we know what has happened, what they are experiencing and what they will be going through.

How grief works (or doesn’t)

We can use different terms to signify grief but I think the best explanation of what it is is as follows:

  • Bereavement = what happens to you
  • Grief = the feeling afterwards
  • Mourning = what you do

To help us understand grief and mourning we use different models.
The one with which most of us are familiar is the Kubler-Ross model of grief which explains that following a loss, we go through different stages of grief as follows (but not in a any particular order):

• Denial – when we act as if the loved one has not gone, or avoid talking about it

• Anger – we feel angry that this has happened to them and us and dwell on the injustice

• Depression – we feel low and hopeless, demotivated to do anything because what is the point?

• Bargaining – we think of the ‘what if’s and the ‘if only’s which would have prevented it happening in the first place or which might bring them back or prevent worse happening in the future

• Acceptance – we accept that what is gone has gone and we continue with life despite this loss

A lot of us might be able to relate to this model. The difficulty with this model is that it suggests that the stages are part of a process which we go through in order to achieve something or to come out the other side. But for people who have lost someone, there is often no other side, their world is changed permanently and there is no resolution.

The simplest model of grief and mourning is the Dual Process Model of grief (Stroebe & Schut). It explains that when we’re grieving, we move from action to emotion and back again, continuously. For example, we might be consumed with sadness in the morning, but then in the afternoon we might call the funeral directors, but by the evening we might be crying uncontrollably again and then the next week we might decide to take the deceased’s clothes to the charity shop. It suggests that it is natural for us to engage in a little bit of both which I think helps us give ourselves permission to cry, to take time to dwell on things and then to throw ourselves into something practical.

A further model is the Biographical Model of grief (Walter) which simply suggests that as we talk about the lost person, and what happened and what they were like, it helps us understand and process what has happened and ‘write the last chapter’. This can help us come to terms with what has happened so that the distress we experience is reduced.

Another model which helps us understand grief is the Fried Egg model of grief. It explains that, if we imagine our grief to be the yolk of the egg and the white of the egg is the rest of our life, most of us would expect the yolk part to decrease over time; from this:


To this:


 

Not so. What changes is not the yolk (the grief), but the white (the rest of our life). Sometimes the white gets smaller so that all we can see in our life is the grief.


Sometimes the rest of our life expands, so that there is more white, and so, whilst the grief has not diminished, it is, proportionately, a smaller part of the total of what we are experiencing and focussing on.

In brief; our grief remains but our life expands. I love this model. It’s simple and makes sense and it pays respect to what is lost and does not ask us to ‘move on’.

There is an element of truth in all of these models.

When grief gets more complicated

Some people may have difficulty with some of the things which we do to cope, normally because they are concerned for your wellbeing and may interpret your behaviour as you being stuck in a certain stage of grief and that you are not ‘moving on’. I think this would only normally be a problem if you are struggling to recognise the reality of the loss or the fact that you can’t change the situation after a significant amount of time.

The reality is that when we lose someone, we are at higher risk of mental and physical health problems. So it doesn’t hurt for others to keep an eye out for you, or indeed you for yourself.

Multiple, unexpected or untimely bereavements and lack of support can have a bigger impact on those who are left. These complications can chip away at your capacity to cope, no matter how resilient you are.

If you know someone who is grieving ask yourself:

• Do they feel supported or isolated?

• Are they able to talk about feelings with family and friends?

• If the death was predicted, were they able to plan and talk about their expectations beforehand?

• Are they still in denial?

• Are they still angry?

• Are they experiencing financial or medical difficulties or another life change at the same time?

If the answer above is yes to any of these then the path of grief can be impeded and they may benefit from further support.


What helps when grieving

Support

When we talk about what’s best to do when grieving, the simplest answer is “do what you need to do”.

It means, really, that there is no formula for grieving well, because everyone is different, everyone copes differently and everyone finds different things meaningful or helpful.

We heard of a client who took her childhood teddy to a church the morning after she miscarried a child. We were told of someone who kept their grandma’s room as she left it for a year. If it helps you cope. Do it.

It’s also worth remembering that death often affects more than one person and family dynamics are complex. Everyone has different needs, expectations and desires from the beloved and others affected by the grief and this can cause conflict and confusion. It is normally impossible to manage all of this or help everyone at the same time or in the same way, so try not to make assumptions and be realistic about what you can do.

Importantly, though, the single, most positive factor in encouraging a healthy grieving journey is being able to talk, unconditionally, without judgement, about the loss with someone who listens.

For those supporting someone grieving it can be daunting.

“What should I say to someone grieving?” is something I’ve often asked others when talking with grieving individuals.

What helps, is knowing that if what they need most is someone who listens, we don’t even need to worry about what to say; someone who listens does not give advice, because responses don’t make people better, connections do.

So reaching out to them, being there, or simply saying something like “I don’t even know what to say right now I’m just so glad you told me” can be enough.

When we talk about listening, it’s not just letting someone talk but trying to understand what is happening for them. Doing this takes empathy, and it needs to come from within you (which can be exhausting) but it is, in brief:.

• Perspective taking – try to reach where they’re coming from

• No judgement – your opinion is not needed right now

• Recognising emotion – try to see what they are feeling, it might not be simple sadness

• Communicating that you recognise it – letting them know you’re understanding a little of what’s happening for them

Be mindful though, that the differences between us and the person we are supporting also make a difference to how we interpret the loss, so it’s important to be reflective and aware of this so that we can come ‘alongside’ and not project our perspective on others.

What can also help is validating and normalising what they’re going through so that they don’t feel so alone, or like they’re going out of their mind. This might come from you, but equally, support groups for those who have experienced similar situations can be hugely helpful.

Rituals

Rituals or traditions, or symbolic gestures which we do after a death can help because they mark in a symbolic way a transition from one position to another. They can be almost like a stake in the ground communicating to the world, yourself and others that something has happened and thus the world has changed but that now you are moving on your way forward.

Some different rituals which people might find helpful are:

• Burial within 24 hours

• Washing the body and preparing for the deathbed

• Playing certain music

• Sending cards

• Planting trees

• Letting balloons off

• Making memory boxes

• Funeral

• Sprinkling ashes

• Flowers set somewhere

• Writing a letter

• Lighting a candle

I hope that this article has conveyed what I feel are important and useful ideas in understanding and helping support people who are bereaved.

www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

Asking Powerful Questions

Asking the right thing,  at the right time, and listening to that answer is one of the most important skills any of us can ever learn.  But it’s an art, not a science so here I’ve tried to look at how we can ask better questions which will in turn help therapists (and anyone trying to support a friend or family member) to create meaningful,  constructive and positive conversations.

Most of us have heard of Socrates, he was a philosopher, born in Ancient Greece about 470BC.  A lot of people think of him as the father of Western Philosophy.

Many of us will have heard of Socratic questioning too, as a way of asking ourselves about things in a structured way, so that it narrows our focus in (eventually), towards the truth. It’s used in order to gain further insight into a topic, often when we already know a little bit about it.

But when is Socratic questioning useful and why is is used so often in therapy?

In the therapy world, it’s important for a client to understand what they’re going through themselves. So, Socratic questioning it is a way we can guide our client’s  discovery of their own difficulties. It’s not trick questioning where we lead the client to discover what we always knew, it’s a joint discovery where the new information provides fresh perspectives on problems and solutions.

It can be defined by:

  1. Asking the client questions about something they already know something about
  2. Drawing focus towards relevant topics but topics which may have not previously been considered
  3. Moving from a concrete issue toward a more abstract view of it
  4. Encouraging the client, at the end, to use this new information to come to a new perspective in the issue which can help them move forward

A great example of some Socratic questioning in therapy is provided below (taken from Christine Padesky’s speech to the European Congress of Behavioural and Cognitive Therapies in London in 1993):

Client: I’m a failure in every way

Therapist: You look defeated when you said that. Do you feel defeated?

C: Yes, I’m no good

T: What do you mean by that?

C: I’ve completely screwed up my life, I haven’t done anything right

T: Has something happened which led you to this conclusion or have you felt like this for a long time?

C: I think I see myself more clearly now

T: So this is a change in your thinking?

C: Yes. I went to that family reunion and saw my bother and his kids and wife. They all looked so happy. And idealised that my family’s not happy. And it’s all my fault because of my depression. If they were in my brother’s family they would be better off.

T: And so, because you care about your family you then decided you were a complete failure, that you’ve let them down.

C: Thats right.

T: You also indicated that this was a change in your thinking. You’ve been depressed many times. And you’ve seen your brother and his family many times. How did you think about this in the past?

C: I guess I always used to think I was ok because I tried to be a good father and husband, but I see now that trying isn’t enough.

T: Why is trying not enough?

C: Because no matter how hard I try, they are still not as happy as they’d be with someone else

T: Is that what they say to you?

C: No, but I can see how happy my brother’s kids are.

T: And you’d like your kids to be happier…

C: Yes

T: What things could you do differently if you were less depressed or a better father in your own eyes?

C: I think I’d like to talk to them more, laugh more, encourage them like I see my brother do

T: Are these things you could do even when you are depressed?

C: Well, yes, I think I could

T: Would that feel better to you- trying some new things as a father, rather than simply doing the same things?

C: Yes, I think it would. but I’m not sure it would be enough if I’m still depressed.

T: How would you find that out?

C: I guess I could try it out for a week or so.

I’ve also come across a few really powerful therapeutic questions that my colleagues in the therapy world use regularly to help clients explore the meaning of what they’re going through. I’ve listed a few of the best therapeutic questions below :

  • If I could wave a magic wand and you were happier, what would you be doing differently?
  • If you weren’t scared what would you do?
  • If the person you loved most in the world was thinking the way you are what would you say to them?
  • In five years from now will this situation matter?
  • What is the worst that can happen in this situation? (don’t use this as a stock phrase,  but ask this genuinely, out of interest)
  • What would your best friend say to you right now?
  • What does this say about you?
  • What does this say about others?
  • What does this say about the world we live in?
  • If someone observed you for a week, without taking to you,  what would they say you cared about most in the world?
  • What would they be surprised you care about?

Knowing the right question to ask at the right time takes skill and experience, but I believe the two most important aspects of these questions, are to ask these questions without expecting a certain answer and then to listen and react to the answer itself, not some pre-prepared structure. Then we are truly working empirically, as scientists, testing hypotheses and evaluating the results, but together with our clients.

www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.

You can contact her here.

Post Traumatic Stress Disorder – what is it and how to treat it

What is Post Traumatic Stress Disorder (PTSD)?

PTSD is when, following a traumatic incident, individuals experience distressing symptoms such as flashbacks, nightmares and intrusive thoughts about the incident. This can mean that they re-experience the event, they might avoid any memories of the event or even small triggers which bring on memories of the event and they often exhibit symptoms of low mood, anxiety and depression and negative thoughts about themselves, others or the future. Individuals with PTSD are often very sensitive to things around them; this might manifest itself in being on guard more than other people, maybe jumpy or quick to react to small things. They might also come across as more aggressive or reckless because small things might make them more stressed than usual and they therefore react in a more extreme way than they would have normally.

What kinds of traumas cause PTSD?

Normally the events are ones where the individual feared for their life or someone else’s life. Individuals can develop PTSD if they were victim to the event, saw the event or even if they heard about it happening to someone who was important to them.

Events such as road traffic accidents or assaults of any nature may bring on these symptoms, burglary and rape too. Sometimes repeated exposure to the details of an event through work can cause the same effects.

Why does it happen?

Shapiro said that when we experience a threatening event, our brain’s memory systems don’t work as well as normal. When it’s processing the traumatic event it can be too upsetting to process and so it simply doesn’t turn it into a memory. This means it remains a current event in our minds so that our body reacts as if it is in that event again, and so it can feel like it’s happening now (rather than in the past) and right here (rather than where the event happened).

How do they treat it?

Government guidelines recommend CBT therapy, EMDR or anti-anxiety and anti-depressants as a treatment for PTSD.

What is EMDR?

Do you know the saying, ‘sleep on it’? Or ‘everything feels better after a good night’s sleep’? This is because when we sleep, and enter REM (Rapid Eye Movement) sleep, the brain starts to process what happened the day before, and to make sense and store the memories of it in a helpful, useful way. This way, when we wake up, we can access the information from the day before in an easier and more accessible way. EMDR is said to work in a similar way but for traumatic events.

EMDR stands for Eye Movement Desensitisation and Reprocessing Therapy.

EMDR is complex, thorough and goes through 8 phases of treatment including History and Treatment Planning, Preparation (where trust between the client and the practitioner is established), Assessment, Desensitisation, Installation (of a new positive belief), Body Scan and Closure.

It is perhaps the Desensitisation stage for which the treatment is most known. In it, the therapist will encourage the client to identify some of the disturbing emotions they are experiencing and asks them to move their eyes through different sets of structured movements as they focus on different aspects of the trauma. This movement, which is thought to mimic that of REM, desensitises them to the trauma.

If you think that you or someone you know are suffering from PTSD and would like to receive therapy for PTSD then I would encourage you to refer yourself to your local IAPT service which is part of the NHS and which provides free treatment for this disorder. Your GP can provide this number. In Buckinghamshire please google Healthy Minds Bucks. If you do not wish to have to wait for treatment then please search for EMDR therapist in your local area.

www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.

You can contact her here.