From pain to healing: Navigating complicated grief and trauma

I'd like to welcome everybody to today's presentation on complicated grief. Complicated grief is like, it sounds a little bit different than regular old grief. So we're going to define what it is, examine the impact of complicated grief and what the risk factors are. So there are other terms for complicated grief, you know, extended bereavement, complicated bereavement, unresolved grief, whatever you want to call it by, that's what we're talking about. Somebody who goes through and experiences a loss of some sort and it doesn't resolve in the traditional period of time. And I always work hard to try to avoid the word normal, because normal is really relative for every single person in every single situation. And then we're going to explore the tasks for successful grief resolution. Attention, therapists all. CEUS is grateful to our new sponsor, the Diversion Center. They offer workbooks that are 100% editable and delivered to you in a word document on topics including anger management, substance use disorders, domestic violence, parenting, and shoplifting addiction. Each workbook can be used for individual or group sessions and is over 120 pages. You have the option to add or remove content, insert your name as the author and reprint and resell the workbooks to your clients. Go to privatelabelworkbooks.com and take advantage of their buy one, get one free bundle offers. Remember, that's privatelabelworkbooks.com so real quickly, some definitions. A loss Remember, we've talked before about how a loss is not just a death. It can be any kind of change that includes being without someone or something. We have physical losses of tangible things like people, and that can be a death. A car, a house, a breast, if you go through a mastectomy. You can also have psychosocial losses of things that are intangible, like divorce or your health. A job is not exactly tangible. You can also lose your hopes and dreams and kind of the way you think things were supposed to be. You know, you had envisioned your life going down this path, and all of a sudden it took a sharp right. And that can be considered a loss. It's a change for, for many, many of my clients. They want to grieve the fact that they never got to have a childhood or the Beaver cleaver childhood that they thought they should have been able to have. So we need to talk about, you know, losses that have happened. And we also talk about losses that can happen. Sometimes it's helpful to help people start processing things if they know they're getting ready to get divorced or, for example, if they Know, they're getting ready to move, and you're like, well, a move isn't a big deal. Well, it is a big deal because you're leaving everything, your routine, you're leaving a particular house, you're leaving your friends, you're leaving a job, you know, you know, where the grocery stores are and everything. And you're having to relearn. Now, it can be very exciting. But there are also things that you may, you know, mourn over a little bit. We're getting ready to sell the house that my daughter grew up in. And, you know, it's. It is really hard, especially for my husband. He went down there to try to sell it and. Or get it ready for sale. And he calls me and he's like, you know, every time I drive up, I expect little Squeaker to come running out the door to greet me, because she always came. Ran out and greeted him when he came home. So there are things, you know, we think nostalgia, and they can be super traumatic, or they can be just mildly nostalgic and, you know, a little bit sad. Bereavement comes from the Latin root word to have been robbed. So to experience a loss, you've been robbed of something. Safety, security, something tangible. Secondary losses are other losses as a result of a primary loss. So if a breadwinner dies, you know, you're losing potential income when you're not in a relationship anymore, you know, maybe that person was helping with the bills. Maybe they were providing emotional support. You know, you have secondary losses. Grief is the reaction or response to loss that includes physical, social, emotional, intellectual, and spiritual dimensions. So it's not just emotional. It changes how we think about things. It changes us. You know, every experience we go through changes us. And we can either let it change us for the better, or we can let it defeat us. And mourning are rituals or behaviors associated with grief and courses of action in response to a loss. So what do you do in mourning? There are certain things that particular religions and particular cultures may prescribe for mourning, especially after a death. But there are also other things that, you know, we all do. We have our own little rituals after we lose something in order to try to make sense of the world again and come to acceptance with that loss. So complicated grief, separation, distress involving intrusive, distressing, preoccupation with the deceased. A lot of this is going to sound really similar to acute stress and ptsd, because guess what? There is significant overlap. Now, does it mean that the person has ptsd? Not necessarily. But we do want to look at some of the similar symptoms. The traumatic stress is reflecting specific ways the person was traumatized by the death. So avoidance of reminders of the death. I know after my father died, I didn't want to go back down to the neighborhood. I didn't want to see the house. You know, it's just, you know, if I didn't see it, then maybe it didn't actually happen. And I can live in that wonderful little world of denial, Intrusive, painful thoughts thinking about it if, you know. And a lot of times what we're talking about with complicated grief is going to be the loss of a person or some. Someone you. Something you loved. I remember after my dog was killed, you know, I would close my eyes and I would see him, you know, and that would be really distressing to me. Emotional numbing, just, you know, not being, not being able to feel much of anything right now. Just kind of being numb to everything and sometimes people emotionally numb. Right after my grandmother died recently, my mother kind of got emotionally numb because she had stuff she had to take care of. You know, she couldn't afford, as she put it, to feel at that point in time. She needed to kind of compartmentalize it so. So she could do what she needed to do. And then she was able to un numb as soon as that got done and work through the process. But some people get emotionally numb and they kind of stay frozen. Irritability, feelings of hopelessness and purposelessness and a shattered self identity. So sometimes you may have a failure to assimilate the loss, which creates an identity crisis and problems with self regulation. So if you've got, you know, this couple that's been married for 40 years and John is the husband passes away and his wife is like, I've always been a homemaker, I've always been John's wife. What am I if I'm not John's wife? I don't know who I am or what I do because that's how I've, you know, found purpose in life was being a homemaker. So that can be difficult for people, people to assimilate. If a parent loses a child and it can be an adult child, it doesn't have to be a, you know, young child. But if a child dies before their parent does, that's kind of out of the natural order of things. So the parent may say, you know, who am I if I'm not Sally's mother? And there's all kinds of other guilt and grief things that they go through, but figuring out how to handle that and how to close out that chapter. And there may be people, you know, after, you know, adults after their second parent passes away who says, you know, who's there to protect me now that both of my parents are gone? And even though we're adults, we're paying our own bills, we're adulting all on our own. It feels, feels weird if you know you have no parents, you know your parents have both passed away. So helping people figure out how to negotiate that complicated grief can be reliably identified by administering the inventory of complicated grief more than six months after the death of a loved one. So it gives you an idea about how intense the symptoms are, how intrusive, how debilitating some of them may be. So what exactly are we talking about? Like I said, there's significant overlap between grief and trauma. In one study, 53% of participants had significant elevations in trauma symptoms six months after the death. So we want to take a look at that, what was going on. And I will remind you from our trauma class things that can make it more devastating. If there are significant stressors in the preceding six months, if there's a history of mental health problems or addiction issues, if the person doesn't receive social support. When we're talking about loss, when we're talking about grief here, those are the three big ones. So looking at what that means, those impact how significantly the loss can affect somebody, but it's not, that's a good screening triage to say, you know, this person may be at higher risk. We can't say who's going to be in this 53% for sure. One of the things we do need to be aware of if we're working with a patient, especially working with a patient on loss issues that losing a therapist. So if you quit your job and you have to move your caseload to somebody else, or at the time the client is ready to discharge, they've made maximal gains. At this level of care, it can trigger past complicated grief reactions. So stuff you may have thought you already dealt with in counseling or you didn't even really know was there may resurge. So be aware of that. Be aware of your client's reactions when you're starting to work through the discharge process. For many of our clients, or at least many of my clients, the relationship they have with their parents and with their parents, golly with their therapist and hopefully their peers are actually the first kind of pseudo healthy relationships they've had in a long time. So you know, I come from working in a residential co occurring disorders treatment setting. So there's generally a lot of dysfunction in the relationships with significant others. So losing this relationship or terminating this relationship can activate some abandonment issues as well as complicated grief issues that clients may still need to deal with. Does it mean they shouldn't be discharged? It means they should probably be stepped down to a lower level of care and then help to resolve those issues. But, you know, sometimes you need to keep them at that level of care. But a lot of times, complicated grief can be handled on an outpatient basis. The first and most pressing question whenever there is a crisis, whenever there is a loss, is what in the world just happened? You know, I remember when I got the call from my father that he had been diagnosed with stage four cancer. You know, that was kind of the beginning of this whole grieving process. And I hung up the phone, and I was just kind of sitting there like somebody kicked me in the gut. And I'm like, what just happened? Was it a dream? Please tell me I'm going to wake up from this. Immediately following is the question, how do I manage this right now? This is probably something I haven't dealt with. You know, I may have known it was coming. You know, I knew my father was going to die at some point, but I didn't expect it right now. So how can I manage this information, this knowledge, this situation right now? And then finally, the larger questions of grief and meaning are formulated. But right after a loss happens, right after somebody passes away or you get the news that they're terminal, you're worried about, what do I need to do right now? What are the functions? And a lot of times we go. A lot of us go into this hyperdrive of what is the next thing, how can I fix it? What do I need to do? And a lot of times that's a way of getting out of ourselves so we don't feel the pain, we're staying busy. We're figuring out what phone calls need to be made, who needs to be notified, what the next step is. That's all very intellectual. So you're not touching those emotions. Once you get past that and you're kind of catching your breath a little bit, then the larger questions and the emotions start to hit in, and you're like, what does this mean to my life? So grief takes time. The whole first year after a loss is one loss after another. So you think about it. There's anniversaries, there's birthdays, there's holidays, there's driving past, you know, landmarks. There's all kinds of stuff. That people are going to experience for the first time without that person. So the first year is hard for anybody regardless of whether it's complicated grief or not after that, you know, some people, it's harder depending on how many losses they've had and how old they are. Complicated grief issues can be more complicated for children who have know fewer experiences, fewer frames of reference, etc. Be aware of special occasions and holidays all year long. And it can be those silly Hallmark holidays. It can be big things like Thanksgiving and Christmas, but it can also be, I don't know, Sister's Day or. I'm sure there's a, there's a holiday for everything. So if there's a particular thing you used to celebrate or maybe you used to go to spring break even after you were out of college, you used to go on a spring break vacation with your sister and your sister died. You know, every time spring break time comes up, even though that's not a Hallmark holiday, it's a time, it's a reunion time for you. Uncomplicated morning is usually normally two to three years now I had always been taught one year, so when I did this presentation I was like oh okay, well you know, that gives me a little bit more information. Two to three years for people. First set of holidays really tough. Second set of holidays, hopefully a little bit easier. Third set of holidays starting to make meaning complicated. Mourning may be a five to seven year process or even a little bit longer. And depending. And I've shared before that my stepfathers first family was killed in a house fire on New Year's Eve. And you know, I love the man to death. He's 87 years old now and Christmas is still hard for him. And you know, I totally get that. I can't imagine what it would be like to be in his shoes. So you know, this has been. He's 87. That was when he was like 24, 60 some odd years and certain hollow. Well, the anniversary of their death is really, really hard for him every single year. And you know, now that Christmas seems to start oh in September in all the stores and they start putting out all the Christmas stuff, all the triggers and reminders start coming in. You know, earlier has he desensitized to a lot of it? Yeah, you know, he doesn't have nearly the issues even today that he did 20 years ago when he married my mother. However, you know, I can imagine the stuff he doesn't say because he's a kind of a stoic person. I imagine it still pains him Sometimes. So, you know, let's not put time limits on stuff and say, well, you. You should be over it by that here. Or it's pathological. It is what it is. Grief continues for a lifetime through major life milestones. If you lose a child to cancer, for example, their 16th birthday, when they would have graduated from college, when they would have moved out of the house, when they would have turned 18, all of those major developmental milestones, you're probably going to feel lot harder when, if your parent dies and you're young and they're not there for you when you graduate from high school and they're not there for you to give you away at the altar, and they're, you know, there are certain things that you kind of expect your parents to be there, and if they're not, then it reopens that grief wound a little bit. So making sure clients are prepared for that. Things may be going really well, but. But there are things that can trigger it, and you just need to recognize what they are and kind of, let's work on a plan to deal with them. It doesn't mean you're going way back there, but you can have a resurgence of your grief reaction. So grief impacts us holistically, socially, physically, cognitively, emotionally, and spiritually. All of these needs kind of overlap. When we lose a parent, for example, socially, they're not there anymore. They're not. You know, I always used to call my daddy when I was having a bad time or I needed advice on, you know, business stuff, and not there anymore. It also impacted how I interacted with my stepmother. And, you know, there are probably other social ramifications. But looking at how does it impact your relationships? You know, if it was a family member with your family members, with your friends, how you trust other people, if a widower, you know, somebody who's. Whose spouse has died, how does that impact them? Socially, physically? Those are probably the easiest ones to identify. We know when somebody is grieving that they, you know, there was a threat, they had a loss. So they're probably going to have a lot of stress going on from that reaction. There's going to be tearfulness, difficulty sleeping, changes in eating, changes in libido. There's a lot of stuff that's going to go on until the person gets out of that crisis, period. Cognitively, it can make people very cynical, it can make people very angry. It can make people reach more towards their spirituality. And we don't know how grief is going to impact people in particularly, but we do have to look at how did it change your worldview? How does it change your thought processes right now? And it may not be about everything. It may be about certain things. Emotionally, that's a no brainer. You know, depression, anxiety, a sense of guilt sometimes over things you said that you shouldn't have or things you should have said that you didn't say. You know, that stuff. The, oh, that person is gone and I can't make amends now. And spiritually, what does it mean to the greater order of things and connectedness now that this person or this entity or whatever is not in my life? Physical responses. Eating disturbances. Sometimes when people get upset, their stomach gets upset and they just, they can't hold food down. When your sleep gets out of whack, when you're not getting good quality sleep, the hormones that regulate your hunger and satiation get all out of whack. Sometimes people eat a lot and that's how they cope. They're trying to get that rush of serotonin and dopamine to feel better. They don't think about it that way, but a lot of times that's why we crave stressed foods. High sugar, high fat foods. Other times, you know, people can't eat at all. Energy. A lot of people report they have virtually no energy. They're tired, they're lethargic, feels like they're wearing weights on their wrists and their arms. And it just takes all kinds of energy just to get out of bed. Sleep disturbances. Cold, especially for children. Sometimes when children get really stressed out, they start to have difficulty regulating their own temperature. Anxiety, which could come on as sweating or trembling. GI disturbances. When you get stressed out, think about, you know, what happens to your GI tract. Your body is saying there's a threat, we need to fight or flee, so we need to speed things up. Well, not only do your thoughts get sped up and your heart rate gets sped up, but your GI system often gets sped up. So you know, you can follow the dots there. And a compromised immune response and increased illness. If you're not sleeping well, if you're not eating well, or if you're just under chronic stress, your body is not sending as much stuff to your immune system to keep it elevated. So it's important to be aware that it's easier to get sick when you're run down. We all know this, but grief is a form of being run down intellectually. People start having confusion about what is real. You know, I told you before. When, after my father passed, I didn't want to go down to where he lived. Because you know, if I didn't see it, then I didn't have to acknowledge that he wasn't there anymore. And I knew exactly what I was doing. I just did it anyway. But what is real? So you're trying to figure out, is this person, you know, still alive? And even if you don't have quite that reaction after somebody passes away, you know, four, five, six months later, you may reach over and pick up the phone and get ready to call them and then be like, oh, oh wait, they're not there anymore. Difficulty concentrating. People may read the same page six times and not know what they read. And I'm not talking about journals here, I'm talking about the newspaper. They may have a short attention span. They can't finish sitting through a 30 minute program. You know, they've got to do something else. They can't focus. Nothing is getting their attention. Now that in many cases is a sign of neurochemical imbalance. Remember, there are certain hormones that help us focus, dopamine and norepinephrine being two of the big ones. So if your dopamine levels are low, you may not be able to focus as much. Difficulty learning new material, short term memory loss. So if you're doing, if you're trying to do your income taxes and you're in a crisis situation and you're grieving, probably going to be difficult to focus for that long and it's going to be difficult to remember, you know, what step did you just do and learn how to do your income taxes. So thinking about all of these things, when we're working with a client who is grieving, a lot of times they think it's just an emotional thing and then they go to do their income taxes or something simpler and they don't feel like they can do it or they're not doing it as effectively as they want to and they get frustrated because they don't understand why they feel so inept. Let's bring it together. Help them see that their entire body is kind of in chaos right now. Difficulty making decisions. Again, how can we help people who are grieving? Number one, prepare for that. So they know that this is not the time to be trying to make big decisions. But when decisions have to be made, you know, who can you rely on? Think about family, who is there for their child, who's dying of cancer and they have decisions they've got to make. So, you know, it's going to be hard to make those decisions on a whole bunch of different levels. And then, you know, making Other decisions, like, what do you want to eat for dinner? You know, that pales in comparison. It's like, I don't know. I don't even care. So it's going to be difficult to make difficult decisions, and you may not have the energy to make other decisions. You just can't even begin to think about that right now. Now, a lack of a sense of purpose. And we can help people figure out, you know, what their purpose is. When, you know, so and so was alive, when so and so was in your life, what was your purpose? Like I said, if you had. I don't remember what names I used earlier, but this couple that was married forever, my grandparents. When my grandpa Ed died, my grandmother handled it really well. It was a blessing. But some people, when their spouse dies, don't. And my grandmother had always been a homemaker and had always puttered around the house. And, you know, she was a typical wife of the 50s. So she could have gone down a path where she didn't know, you know, what do I do now, now that I'm not Eddie's wife, you know, now that he's passed on and my kids are all out and grown, what do I do? What's my purpose in life? Because I'm not. And you can see a lot of people who are grieving, especially widowers who start having problems getting adequate nutrition and fall into a deep depression because the stuff like, my grandmother used to always make meals for my grandfather. So obviously she would eat, too. But when there wasn't somebody else to cook for, it was, what's the point? Plus, cooking was a reminder that she wasn't cooking for anybody. If she did cook, there wasn't anybody to eat with her. So it was kind of devastating. So we want to help them find their sense of purpose and again, think through what might be some really benign triggers that may happen. Like cooking a meal could be a trigger for complicated grief and letting people realize that you're going to come across these. How do you handle them when you start feeling triggered, an inability to find meaning in the events and life itself. So we want to look at, okay, this happened, you know, this person has terminal cancer, this person died. What does that mean? You know, what did they mean to you when they were alive? What was their purpose in your life? What. How do you get meaning from that? What does this event mean? You know, that they passed away? What can you take from that? And how do you integrate it into your sense of purpose and life and what have you? And it's going to Be different for every person. You know, I like to try to learn from the people that cross my path, and I like to grow and kind of steal parts of them. You know, there's. There's still parts of a lot of people that I've encountered in my brain, you know, things that I learned from them. So I keep their memory alive by maintaining those things that I learned from them. Socially, grief can affect people through withdrawal. You know, they may just. I don't want to see anybody, you know, pull the curtains, don't come visit. I don't. Can't do it right now. Which, without social support, it makes people at greater risk for complicated grief. Do they want to have every friend in town stopping by? Do they want people calling every 10 minutes, going, how you doing? No. You know, most people when they're in grief, a grief period, really don't want to have quite that much input. So we want to ask the person, what is it that you need? How can I be there for you? And encourage our clients to reach out. Maybe they're not reaching out to their best friend, Sally, who doesn't seem to have a clue as to what's going on, but they are reaching out to a support group for, you know, people whose spouses have just died. Okay, Those people get it. So at least you're reaching out to somebody. We don't want people to be isolated. We want them. There's a period of mourning. There's a period where they're going to want to have some downtime, potentially, where they just want to think or kind of get their thoughts in order, and that's going to be up to that person. Some people want support immediately, and then this downtime comes later, or sometimes it never comes because they work it out while people are there. But we do need to let them know that the desire to be alone for a short period, totally normal. You know, if you start going into weeks of not wanting anybody around, then it's. You know, we might want to take a look at that, Encouraging them to find people that they do want to affiliate with. And I generally avoid the word socialize because when somebody's grieving, the last thing they want to do is go to a party or what they think of as socializing. Where can you get support? Where can you reach out and connect with other people? So I use different words. They may avoid not only other people, but they also may avoid places that remind them of that person. So they may not drive down certain roads or whatever, which can lead people to feel kind of boxed in if they know they can't go over to this side of town or they can't drive past this thing or whatever. Irritability. And when you're sick, when you're grieving, when you're tired, there are a lot of things that can make you irritable. But if you're irritable for long enough, it tends to have a negative impact on your relationships. Self absorption. Sometimes people just can't get past the, you know, I don't know what I'm going to do now. I don't know, you know, how I'm going to get through this grief. I don't know how I, I, I normally we encourage I statements. If you're working with a family, with a person who lost somebody in their family, the other people in the family may also be having similar feelings. And they're like, well, Sally's only concerned about how she feels and how it affects her. What about how it affects us? So, you know, sometimes the self absorption actually alienates other people who could be there as supports, encouraging our clients to reach out to those family members that are healthy social supports, you know, and they'll define who those are and say, how is your sister doing with it? Or how's your mother doing with this whole change and everything? It may prompt them to reach out and call because they were so focused on thinking about themselves that they may say, you know what? I don't really know how she's doing with it. I haven't talked to her in a week. So it may prompt them to reach out. The other side of that is some people, instead of withdrawing, become very clingy and dependent when they're so lost. We see this a lot more in children, especially children who lose a parent. You know, it can be very obviously traumatic for them, so they're clinging to the caregiver that is there. It's like, okay, you can't leave now. You know, it's kind of like for most of us, we've got two kidneys. If we, if we have both kidneys, we're like, okay, you know, we get a kidney infection. It sucks, but we can get through it. We lose a kidney, and then we get a kidney infection. We start getting freaked out. So you want to kind of think of it in terms of that. You know, children need their caregivers in order to survive. They can't pay the rent, they can't do that kind of stuff. So if one caregiver goes away and there's only one left, then it's very, very Terrifying that, you know, what happens if this caregiver goes away. And you can do a whole class on how to help kids deal with grief and to make a plan and help them feel more confident and everything. But clinging independence is not unheard of in adults. When somebody passes away, if a parent lose children, they may either split up emotionally and, or physically and, or, you know, marriage wise or they can become one partner, can be, become very, very dependent on the other one in order to, you know, keep going emotionally. Grieving runs the gamut from angry at higher powers, angry at the situation, angry at others or whatever caused it, angry at yourself for things you did do or didn't do. Anger just kind of can cover everything. Depression, Remember depression is a sense of hopelessness and helplessness. Well, when you lose somebody, that little glimmer of hope that they brought to your life dims a little bit because you know there's no hope of getting them back and you feel helpless because there's no hope of getting them back. Now there's probably hopefully other people and other glimmers of hope in your life. But sometimes it takes a second to help clients remember that you're right, you are powerless to get them back. But what can you do with, you know, in our family, for example, after my father passed away and both of my kids were, my son was in diapers and my daughter was an infant. And so they don't really remember Paparon, but we talk about him a lot and I share the things that he taught me and we share memories, especially around holiday times. You know, I tell them what Paparon used to do. So those are things that you can do in order to help people figure out how to maybe get a sense of hope and control or empowerment in this situation so they don't feel helpless and they don't feel hopeless. Yes, you can't get the person back, but what can you do to either keep their memory alive or, you know, whatever they want to do, whatever they want to do in order to feel empowered. People can be feel sad. And when you lose something important to you, you're going to feel sad and that's okay, you know, recognizing that, crying, irritable. Some people may be afraid that they can't go on, that they can't go on without. So and so did see that a little bit in my grandmother right after my grandfather passed because he paid the bills and he always, whenever anything went wrong at the house, he handled it. So for the first few months after he passed, when things went wrong at the house, she Kind of went into a tailspin until she realized that, you know what? I can do this. And if I can't, my Uncle Jim lives like five miles away. She could just call him and he would come over and help her out. So she realized that, you know what? I can go on. I can do this by myself, even though my partner's not here anymore. In some people, it can also trigger death anxiety. Now, they found that that's not as true. Older adults. Older adults have generally kind of come to terms with things. Younger people may have significant death anxiety. People may feel lonely or relieved, guilty or regretful. Now, relieved is one that people can feel really guilty about, because after somebody dies, if they've been going through an illness, whether it's Alzheimer's or cancer or whatever it is, sometimes the loved ones are just relieved that that person isn't in pain anymore. When people get older, though, and when you can see that there's clear pain, then the relief. A lot of times people don't feel as guilty that they feel relieved, but when somebody is older and they just die of natural causes, you know, when people feel relieved that the person is gone, they're, you know, gone to a better place. However they want to say it, they may still feel guilty about that. After my grandmother passed, my mother felt guilty because my grandmother really, she was. Her quality of life was dwindling, that was true. And she was, you know, quite old. But still there was nothing that we could point at that said, well, this killed her. You know, it was just kind of. Everything kind of gave out. And my mother felt relieved that she wasn't struggling anymore. But it was also a relief off of her shoulders because she and my uncle had been doing a lot to intervene and caregive. So they were starting to get really burned out. And she wasn't angry about that. But when that was done, she was like, oh, I can breathe again. I'm not constantly worried about mother. So relief is one of those weird emotions that we may need to help people process and understand why they feel it and come to terms with it so they can address any guilt they may have about feeling relieved, guilty that you did things you shouldn't have or you should have done things that you didn't do. Spent a lot of time with clients working through the grieving process, dealing with their guilt issues, writing letters to the person, empty chair technique. I'm sure you have tools in your toolbox to help people deal with some of that stuff. So spiritual beliefs are challenged. The question why reverberates A lot of times, and many times when it's just a normal natural death, there isn't complicated grief. But when there's something that, you know, it's a sudden death, it's a violent death, it's a death that's out of the natural order or a loss that's out of the natural order, the question why may reverberate. Where was God or my higher power? If God or my higher power is all powerful, why did. Why was this allowed? How can this be okay? If God or my higher power loves me, how could this be? You know, my prayers obviously weren't answered. And this is. I find for a lot of times I will refer people to their spiritual leader to answer some of these, because that person, the spiritual leader, is the expert on their religion, their spirituality. And it also gives them another contact to reach out to. And it broadens that support system from me to, you know, another professional that can also help them. We talk about it in session, but it's much more reflective, humanistic, the way I approach it, because I'm not a certified Christian counselor. So I try to stay away from that. And, you know, I know little to nothing about most of the other religions. Common and unique. Death and grief are unique. Each person's experience is his or hers alone, and each experience is unlike any other. So if you've had a death in the past and you have another death, don't expect them to necessarily be the same, because each person in your life or each of those people held a different role, served a different function. You know, you learned different things from them. They probably died in different ways. You know, there's a lot of stuff that's there. So each experience is unique. So we can never know exactly how somebody feels. We can empathize, and that's all we can hope to do because we haven't been in their skin and had all those experiences with that person and the world. The term complicated grief has to do with grief that does not follow the normal course or process to successful completion. People get stuck and they just can't. They don't feel like they can get out of this feeling of despair, this feeling of emotional numbing. They feel stuck. Models for normal grief. Bowlby's attachment theory. We'll talk about that. William Worden's four tasks for the normal grief process. Things people have to do to work through it. Woelfett's six reconciliation tasks. These are all different ways of looking at the same thing. And Terese Rando's six Rs. You may find one seems like it clicks for you more than the other three. Cool. You know, whatever. I'm just kind of presenting some ideas. Attachment relationships help regulate psychological and biological functions. So there's mastery and performance success. When we have attachment, think about little kids when they toddle off and try something new. And if it fails miserably, they have a safe home base to go back to. Think of Erickson's stages. In order for us to feel like we can get out beyond our comfort zone where we can perform, we need to feel like we've got secure attachments, we've got support, so if it goes bad, we have something to fall back on. But when we're doing it, we've got a cheerleader, we've got somebody at our back. Learning and performing is the same way. You know, if we are securely attached, if we're not worried about where our food's going to come from, where our love is going to come from, all those basic needs, then we have more ability to focus. You know, our HPA axis isn't going all haywire, going, there's a threat, you're in danger, it's going, somebody's got my six, I can focus on learning, you know, so you're calm, you're more focused. Relationships with others tend to go better. If you've got secure attachments, if you believe that you've got people who are there for you, then it's easier to reach out and form attachments with other people. Because you've had successes, it affects cognitive functioning. If you're not securely attached, then you're typically anxious, which impacts your ability to focus and etc. Coping and problem solving skills. We learn those from our attachment relationships. Self esteem, emotion regulation, right there. Again with the anxiety. If you don't feel safe, if you don't feel like you've got secure attachments, unconditional positive regard, whatever you want to call it, sleep quality may be disrupted because if you're stressed, you're going to maintain a higher level of cortisol, which is going to impair your sleep and pain intensity. They found that people with secure attachments tend to have higher pain tolerance and people with fewer or no secure attachments in their life tend to have more pain. Now, interestingly, I'll just kind of draw the parallel. Serotonin is responsible for moderating or modulating our pain perception. When serotonin is low, our pain tolerance is low. When serotonin is higher, we can tend to tolerate more pain before it feels excruciating. So kind of an interesting. They haven't connected attachment relationships with serotonin yet, but you can see parallel actions, exploratory behaviors are reciprocally linked to. To attachment. If we have a secure home base, we're going to be more likely to explore attachment and safety, simulate a desire to stimulate, a desire to learn, grow and explore and be all that we can be because we're like, hey, you know, I got the world by the seat of the pants. Caregivers provide support and reassurance. So a safe haven, encouragement and pleasure. They're a secure base for you to go from. And it's important to remember, you know, when I'm talking about all this, you're probably thinking of a toddler. And, well, that's true of toddlers. It's also true of adults. I mean, think about when you were in your adult life. You know, maybe you decided to make a career change and, you know, you talked it over with your spouse and you wanted their, you know, blessings or whatever before you embarked on a whole career change. Or you, maybe you're not married, you talked to your best friend and you wanted some input there. You wanted those secure attachments in your life to say, you got this and I got your back. I think you're on the right track. So it encourages us, even as adults, to get outside that comfort zone if we know that we've got secure attachments there to serve as a safety net among adults. Caregiving is at least as important as being cared for. That's an interesting, interesting thing to think about, because not a lot of, not all adults think of themselves as caregivers. My best friend has three boys that he loves dearly, but he regularly tells me, you know, I don't care about anybody. He tries to be this big, gruff, you know, whatever, but in reality, you know, I know those kids are his life, and if they weren't there, he'd be a completely different person. And he, you know, even with his other friends, when they've been really in need, I've seen him reach out and, you know, go to the sort of the ends of the earth for his true friends. So it gives him meaning and it does give him a sense of pride when he's able to do that. So even people that act gruff and aloof and all that kind of stuff, if you look deep down in there, there's probably a lot of caregiving that actually happens. So we do want to encourage people. It's another reason we don't want them to be socially isolated, because caregiving can help Us develop and keep, maintain, regain a sense of purpose. Loss of an attachment relationship disrupts attachment caregiving and exploratory systems. I don't want to explore, I don't want to attach to anybody anymore and I surely don't have the energy to be caregiving right now. You know, I'm just barely getting through the day. Makes sense. I mean the world has suddenly been turned topsy turvy. Attachment activates separation response and impacts restorative, emotional, social and biological processes. So when there's a loss, the lack of attachment activates the separation response. So then people need to recoup if you will, but it impacts the restorative, emotional, social and biological processes. The person's not going to sleep well for a little while, the person is not going to want to interact with others for a little while and other biological processes are may be out of whack. It disrupts the exploratory system because it inhibits exploration with a loss of a sense of confidence and agency or self efficacy if you will. And it disrupts caregiving because it may produce a sense of failure in caregiving and include self blame and survivor guilt. So what did I do that I shouldn't have done? What should I have done that I didn't do? Even if it didn't impact the person's demise, there can be self blame for I should have been calling that person every week or you know, whatever helping them identify the should haves that they've got and deal with any survivor guilt if there is. If you're in a car accident and you're the lone survivor of the people that were in the car, there may be some survivor guilt that needs to be dealt with. Wordens for tasks people have to experience the reality of the loss and talk about it and say what does it mean now that John is dead? What does it mean that you were in this car accident and these other three people are now dead and they're not there anymore? What does it mean that you survived, they're dead. And yes, that sounds harsh and obviously I'm not going to say it exactly that way to each person but helping them experience and come to the acceptance that this isn't a dream, you know, get out of denial, accept that it isn't a dream, there's nothing we can do to bargain our way out of it and recognize what is experience the pain of the loss. If you think of the stages of loss, you have denial, anger, bargaining, depression and acceptance. I find that bargaining, you know, kind of jumps around a little Bit in the clients that I work with. But whatever. You have anger and depression that are there. Anger and sometimes anxiety, remember, is fight or flee. There's a threat. That person was taken away from you. So the. When after a loss, after a death, a lot of times people feel disempowered. They feel somewhat out of control because this person was taken away from them and they had no control over it. So there's a sense of threat. When might this happen again? Could this happen to me? Helping them experience that anger that they didn't get to say goodbye. Anger that. I have clients write an anger that journal. I am angry that or I am angry because. And just go, you know, and get everything out on paper. What are you angry about? And then we'll kind of go from there. Adjust to an environment. And there are a lot of other ways that you can help people experience the pain of the loss in a controlled setting. Have them bring a. I almost said photo album, but most people don't have photo albums anymore. Have them bring pictures of the person. They can do it on their digital device. They can email you a link to the album, and then you can talk about the different pictures in session. So they can reminisce and experience the joy of having that person in their life, but also start coming to terms with the fact that they're not in their life anymore. You can talk about the pain of going through the loss process with them. One of my husband's co workers just recently lost a child. So, you know, talking with them, if I were their therapist, you know, we would talk about what was it like to know that this might be something that happened and then as it happened, you know, tell me about it. And if you think about cognitive processing therapy, having the person tell their story and get it out there in not just intellectually, but what did it feel like when this happened? Help them process all the way through it. Cognitive processing therapy, usually used with trauma, but complicated grief generally is happens because of a trauma. So they work. Help the person adjust to the environment without the deceased. Okay. You know, your spouse is not here anymore to pay the bills or to handle it when the roof starts to leak. So what's your plan? You know, how are you going to handle this now that this person's not here? And withdraw emotional energy from the deceased and invested in new relationships. And if this is presented to people at the very beginning, they're like, how rude. You want me to take my feelings away from this person and give it. Replace them? So no, I don't want you to replace them. But when we get to this last step, it's taking the emotional energy spent on grieving and using it to create positive new relationships. It's not replaced that person. It's taking everything that you learned from that person and keeping their spirit alive, which takes a lot less energy. But the energy required for grieving is immense. And once you start withdrawing your energy from the anger and the depression and the guilt and those emotions that you may be stuck in, that energy is liberated to do something else so you can invest it in new relationships to make your life rich and meaningful. It's not replacing the person, it's adding to Woelfet's six reconciliation tasks. Acknowledge the reality of the death. Move toward the pain of the loss, while being nurtured physically, emotionally and spiritually. Each one of these is going to talk about acknowledging, moving through the pain. And there are each person and please share if you have particular techniques that you use that can be really helpful for helping people move toward the pain and acknowledge what it feels like. Sometimes I ask clients, you know, what are your three biggest fears now that this person person is not here? And then talking about what those fears are starts opening the floodgates that talk about the pain of loss or abandonment or convert the relationship with the person who has died from one of presence to one of memory. And this is one that I like because yes, they are not physically, I can't touch them anymore, but I remember them. And I can remember the stories. I remember after my grandmother died, we were all at the wake and they started telling all kinds of stories about her, things I had never heard of. I mean, I never knew to ask, but I had never heard of. And I was just fascinated. And my family's always been good about keeping people alive through their memories and through the stories. But we want to talk with people. What do you want to do? Do you want to have pictures of them around your house or not? You know, that may be too triggering right now. You may revisit that later. Do you want to, you know how? Do you want to try to keep their memory alive and preserve them in memory? Develop a new self identity based on life without that person. And sometimes it's huge because you lost a child or a spouse. Sometimes it's not quite as right in your face when a friend dies. Or if you were in a car accident like I said with three other people and they passed away, your self identity may not have been completely intertwined with them. But you are now a survivor of a car crash where people died. So you're going to develop a new self identity as a survivor. Relate the experience of death to a context of meaning. What can you get out of this? Oh my gosh. And this is obviously we're talking about adults here and I'll get to your comment in a second about kids and experience a continued supportive presence in future years. So we don't want to just say, well, it's work through it, you're going to be done. Bada bing, let's go. No, there are going to be resurgences and that's okay. But we want to make sure that people continue to have support. If you want to go back to Bowlby's theory, we want to make sure that they continue to have those attachments that they can rely on as support networks. Kids often want pictures and reminders of people who've passed away, but the family or parents or adults in the household may not want those pictures around. So, and I can understand that if you've got multiple children and one passes away, the other child may want to continue to have pictures of his sister or whatever. And it is a balancing act. And that's one thing that is difficult to figure out sometimes. That's one of the nice things about. I mean, even back in the day you could have pictures in a shoebox under your bed, you wouldn't want to have them out on display. But since digital devices are now pretty much in front of people's faces all the time, if they have that person's pictures in a place on their phone where it's less obtrusive to the family, that might be something that may be a reasonable compromise. So it doesn't trigger other people, but it provides support. Rando's three phases and six processes. There's the avoidance phase where the person needs to move through this. The person needs to recognize the loss, the confrontation phase. The person acknowledges life without the person and moves towards the pain, reacting to the separation, recollecting and re experiencing the deceased and the relationship. Now this is reminiscing, relinquishing old attachments to the deceased and the old assumptive world. No, I can't call him or her anymore. That's gone. But what can I do? How can I contact? And now, you know, obviously I don't have a direct line up to heaven, but when I have a problem, I think, what would my father say? So that's one thing. You know, a lot of times when I'm working with clients, I'll share some of the things that I do some of the things that I know other people have done and encourage them to, you know, figure out what might work for them. And then the accommodation phase, where the person readjusts to move adaptively into the new world without forgetting the old. We don't want people to think that in order to get closure, you need to forget about that person. They're going to be in your hearts and in your minds forever. So how do you move adaptively into this new world? What does it look like without having that person physically present? And encourage them to reinvest, get reinvolved again with things that are meaningful, that bring richness and fulfillment into their life. During the avoidance phase, recognize the loss, acknowledge the death, understand the death, and understand any secondary losses as a result of the death. And remember, they can be tangible losses, they can be social losses, they can be seen status losses, or they can even be more esoteric things like loss of hope or loss of faith. Or, you know, react to the separation by experiencing the pain, feeling, identifying feel, identify, accept and give some form of expression to all the psychological reactions to the loss. So if you've got relief, let's identify it and give some form of expression to it. What does it mean to you to feel relief now? Does it feel like a balloon is going up to the heavens? Metaphors can be useful. Art projects can be super useful. And identify and mourn secondary losses. Recollect and re experience the deceased and the relationship by reviewing and remembering the person realistically and reviving and re experiencing the feelings that you had when they were there. You know, some of the awesome times. And relinquish the old attachments to the deceased. Finally, readjusting to move adaptively means revising your assumptive world. That person is always going to be here. No, not in person. Maybe they'll always be there in your heart. Develop a new relationship with the deceased so, you know, communicating with their memories and their spirit instead of with their tangible body. Adopt new ways of being in the world and form a new identity. Once you've gone through this, when you lose somebody, it changes you somehow. And when I say somehow, I mean it depends on who the person was and what the experiences were. But every experience you have changes you in some way, and you can either let it break you or help you grow. So helping people figure out, how can I use this for strength? Maybe it just teaches me how much I can endure, but what is it that I can get out of this to help me with the enhance my identity? Rando's treatment Approach assesses around the six Rs and determines where the mourner is stuck and not making progress. So you know, you go back here, reinvest, readjust, relinquish, recollect and react. Those are the R's that we're talking about. Base treatment on interventions that address the R. So if the person is stuck in recollection, you know, they're not ready to confront the pain of the loss. You know, treatment is going to be stuck or not stuck, but tailored around helping the person get unstuck. Here we're going to help them recall the person, recall the pain and move through it. Explore with the caregiver the identity and roles with the lost loved one and the meaning of the relationship. I remember when my uncle Jack passed on, he had Alzheimer's and he had it for a long time. So going through with my aunt Irene, the social worker explored with her the identity and roles that she had. Because she started out as his love and then his wife and, you know, mother of their children. And then she became his caregiver and then she became basically his executor. Once he lost a lot of his functions, he didn't even recognize her anymore. So there was a, there were a lot of different roles she played and a lot of different emotions in that relationship. Risk factors for complicated mourning Just kind of be aware of these survivors. The age of the survivor is going to be a risk factor. Younger children may have more difficulty than others. Physical issues. If the person has any physical complications from the traumatic incident that may complicate things. If they've got any cognitive issues that may complicate their ability to comprehend what's gone on. Any pre existing emotional issues. Depression, anxiety, bipolar. Remember, stress can trigger episodes of, you know, certain things. And extreme stress can even trigger the initial psychotic episode or the initial manic episode. Keeping an eye out, that's rare, but just keeping an eye out and being aware. Personality and character traits. If someone tends to be more, as the DSM identifies it, as neurotic, if they tend to be more pessimistic, more waiting for the other shoe to drop, it can be more devastating. Likewise, if they tend to be one who wears rose colored glasses all the time, this may shatter their perception of how things are supposed to be. So we just want to look at how adaptive they are, what their personality is like, their socioeconomic status. They have more wealth. I hate to say it, but it's true. They have access to more resources. Often people who work higher paying jobs tend to be able to take Family medical leave and have, you know, paid vacation. Whereas people who are working hourly jobs, if they don't go to work, they don't get paid. If they don't get paid, they can't eat. So they don't have the luxury of taking time off to kind of get things, get their mind in order. And spiritual factors, how they relate and find meaning in this, what they think happens after death and how they feel about death. The nature of the loss affects it. You know, a natural death of an older person, much less likely to trigger complicated mourning than a sudden death of someone, a violent death of someone. The number of losses that occurred. You know, if this person was your spouse for 50 years, they were also the primary breadwinner. They were your best friend, maybe they were your only friend. They were the father to your children. They were, you know, keep listing things off and then they pass away. You know, there's a lot of losses there. So that can be more impactful. Or if somebody's younger and their spouse passes away, they lose their spouse. They may lose a source of income, which means they also may lose their house. So they've got to move somewhere else and, you know, you want to look at. And when they move, they may have to move far enough away. Maybe they move back in with their parents so they have to quit their job and find a new job. All those losses build up the circumstances of the loss, resources available, the nature of the relationship. The longer the relationship, the more impactful it can be. The importance of the relationship. If this is somebody that is pivotal in your life versus somebody you talk to once every six months, the culture, the roles that the person plays. If it is a prominent person in your family because of the, you know, cultural values assigned to that person, it may be more devastating. The quality of the relationship. Obviously complicated grief is probably going to be more significant for better quality relationships. Not always. I mean, you can have some really tenuous parent child relationships. And, you know, if the child passes away or the parent passes away, there can be significant complicated grief, dependence on the person. If you were like the example I gave, if, if you were in a situation where you were financially and emotionally dependent on this person, then when they go away, you're like, I haven't worked, like, ever except for being a homemaker. And so I don't know how to go out and get a job. I don't have any work history. To give an employer the hopes and dreams you had with that person and the amount of daily change when that person's gone. If you were making their lunch every day. That's going to be more impactful than, like I said, if it's somebody you talk to once every six months. Treatment TIPS Secondary victimization occurs when support systems isolate, blame and stigmatize. So we want to look for those characteristics when we're talking to our client about their support system. Is their support system embracing them or pushing them away? Do they blame them for what happened or for not being there, you know, or anything? And is there a stigma associated with the client? Multiple losses require multiple adaptations over time and can make interventions very complex. So for example, if parents, their child is murdered, they never do quite connect again and then they end up divorcing. That may be five years later, but it's another loss as a secondary loss that results from the primary loss of the child. Homogeneity in support groups helps normalize experiences. So support groups for survivors of suicide, support groups for people who lost their spouse. Those are going to do better than if you put the two of them together and go, hey, you've all lost somebody. So find really specific support groups. Five areas of focus for people. Physical needs. They need warm, healthy foods, clothing, and they're increased. They have an increased susceptibility to illness. So encourage people to remember to feed their bodies, take care of themselves and protect themselves from illness because they're run down right now. Emotional needs. Expect grief. Expect bursts of emotion and some depression. Help them understand that and then give them tools. Ask them when you felt grief before, how have you dealt with it? When you have been depressed before, what helped you, even if it was just for an hour, what helped you feel a little bit better? Social needs. A lot of times there are not very many peers that can relate. So helping them find groups, support groups that they can connect with. Cognitive areas help people figure out what they can do during this time. When they're grieving and they have difficulty concentrating, no attention. I encourage people to write things down, simplify as much as possible. This is not the time to be making five course meals. You know, make casseroles, get TV dinners. You know, you, if you feel like you need to cook for your family, okay, fine. But don't make it some involved thing unless that helps you feel better. Simplify what you can and get assistance. Ask for help if you need help cleaning your house, if you need help with the laundry, if you need help with or you just need respite from your kids for day. A lot of times people have support systems that they can reach out to and get that, whether it's through your church or through your neighborhood or your family, somebody can help you. A lot of places also have drop in child care. A lot of cities have companies that specialize in just doing drop in child care. So that might be something. If the, if the grieving person has the financial ability to, to pay for drop in childcare, then they may be able to get respite that way. And spiritual Be aware of phrases that can confuse and frighten especially young people, such as God took her or God needed an angel, because little kids are like, well, when is he going to come take me? And what if he needs an angel? And a lot of times we call little kids angels. You're such a little angel. Okay, that can really freak kids out. The psalm that talks about walking through the shadow of the valley of death can be very scary because a lot of kids see, you know, this figure of death and the shadows and, you know, the imagery is just terrifying to some children. The concept that the good die young, Billy Joel sang about it. But if a kid is, you know, you tell kids all the time that they're good kids and then you say, well, the good die young, that can freak a kid out. And finally, he is sleeping. That's another one that we use sometimes. You know, he went to. He just went to sleep. Which can make kids not want to go to sleep because they're afraid they won't wake up. So just be aware of the verbiage you choose and try to think of it through, through the eyes of the person you're talking to, especially if it's a child who might be really freaked out because they take it literally. So a secondary loss is a loss precipitated by the initial loss, such as loss of housing or having to move and change your jobs. Loss of a friend. Anticipated loss can be defined as a death that is expected weeks to years in advance. If somebody is diagnosed with a terminal illness, you know that their death is coming sooner than would be expected. And the grieving process often starts then to a certain extent, common physical, emotional and cognitive reactions to anticipated loss includes changes in eating, sleeping mood, world outlook, and socialization. Common reactions to unexpected losses include shock, anger and guilt. If the person asks about a death, how did it happen? Did he suffer? Yada yada. Then details can be provided. Age appropriate, of course, but we don't want to necessarily always volunteer those details. Education, normalization and validation contribute to a normal adjustment after a loss. What should you expect in the next weeks, months and year? And, you know, 12 months normalizing those reactions and validating how the person feels right now and encouraging them to learn how to self validate so they can say, I feel how I feel. Education about sudden loss can help people alleviate guilt, find closure and move on, understand what has happened and find peace and normalize and decrease intense reactions. Because instead of it catching them off guard and, you know, making them feel even more out of control, they anticipate it. So they can say, all right, this is really unpleasant, but my therapist said it's not unexpected, so I just need to kind of get through it. Factors that affect the individual reactions to sudden loss include the circumstances of the death, personality and character traits, pre existing issues like mental health issues or substance abuse, and the nature of the relationship. If it was, you know, a parent, child, relationship versus friends. And sudden death makes people want to truly understand why it happened. And some people can get really stuck on that why, you know, help me understand why this happened. And a lot of times we don't have the answers. So working through the why for yourself, why do bad things happen? And figuring out why is it so important to know why it happened, it happened, and it's unfortunate. And a lot of times people want to know why, because if they know why it happened, then they can keep it from happening to them so they can help themselves feel safe. So we want to look at, which is why I ask, why is it important to know why it happened? What will this information help you with? And then we can work on figuring out other ways to help the person feel safe and secure, whatever they need.