Secrets of Overcoming Complicated Grief | Counselor Education

You. I'd like to welcome everybody today's presentation on complicated grief. I'm your host, Dr. Donnelly Snipes. In this session we're going to define complicated grief, examine the impact of complicated grief, identify some risk factors, and explore tasks for successful grief resolution. Start out with a few definitions. A loss is a change that includes being without someone or something physical. Loss of something tangible, like a person, a car, a house, a breast. Psychosocial loss can be something intangible like divorce or an illness, a job, a dream, a hope. So losses are really very diverse and it's important that we don't get stuck in only thinking about grief and bereavement in terms of death of a person. Bereavement comes from the same Latin root word meaning to have been robbed or to experience loss. And a lot of people when they're grieving feel like they've been robbed. I know, and we were just talking about this before class. When my father died. He died when he was 50 and it broke my heart. I felt like I had been robbed because he wasn't, quote, supposed to die that, that soon. So bereavement is different for different people. But we do want to recognize the sense of a loss of control that people experience. It's like, hey, this was taken away from me, I didn't have a choice in it. And we need to help them start feeling, guess what, safe and empowered in the present. Secondary losses are other losses as a result of the primary loss. For example, when, if you're in a relationship and the main breadwinner passes away, then you're going to have a loss of income. Now you may go, well, so what? Well, yeah, so what if all of a sudden your income drops by 70% and you have a house payment, a car payment, insurance, and all this other stuff that's based on having that total income, then a lot of other things in your life may get shaken up. You may have to sell the house. Well, that's a secondary or maybe even a tertiary loss. You may have to move so you don't see the same people again. So it is important to really look at the ripple effects of what happens when this person or this thing leaves my life. Grief is a reaction or a response to a loss. It includes physical, social, emotional, intellectual and spiritual dimensions. Mourning are. Comprises is our, I'm not sure what verb to use there, rituals or behaviors associated with grief, that is courses of action in response to loss. So someone who experiences a loss feels grief and engages in the mourning process. Now that's A bunch of semantics. I think a lot of us just talk about the grief process. But in terms of if you want to be totally clinical now, you know complicated grief has to do with grief that does not follow the quote normal course. What is that? Grief is different for everybody. Grief reactions are very individualized. But okay, we'll go with that. The inventory of complicated grief indic can be administered more than six months after a loss to see if the person is resolving that loss at an we'll say expected trajectory. And there's so much that goes into grief and loss that I don't know how you can really predict with any accuracy what is an appropriate trajectory versus not for people who are grieving. But it is what it is. Prolonged grief disorder. That was that new diagnosis they added to the DSM 5tr that got a lot of people upset. It specifically refers to the death of a person someone was close to. You're not going to apply prolonged grief disorder to relationships or other things. But it is important to know that that is in the DSM 5 TR and prolonged grief disorder does overlap in many ways with the symptoms of complicated grief. But again it has to do with the death of an individual. Whether you agree with that diagnostic category or not, that's between you and the apa. The symptoms of for prolonged grief disorder and complicated grief are the same. But complicated grief is often used in a broader sense. Within three months of a non death bereavement or loss like a breakup or the death of a. A pet or loss of a house. It can we can start looking at whether this qualifies as grief. Complicated grief. Within three months the person may be diagnosed with adjustment disorder. If you are needing to bill for services. Complicated grief, it ain't in the dsm. Prolonged grief disorder. Well, it doesn't apply to a lot of losses. So what does it apply to? Adjustment disorder. And that's on page 320. You also might want to consider major depressive disorder, post postpartum depression. And I don't know what the other one was that I. Postpartum depressive depressive disorder. Oh, and persistent depressive disorder. Sorry, I shouldn't have used so many abbreviations. Types of losses, death of a person. And this can include miscarriage or stillbir and in some cases a pet. A lot of people feel like their pets are part of their family. You're not going to use prolonged grief disorder to diagnose a reaction to the loss of a pet. That's not going to work. But it is important to recognize how impactful that really is, for a lot of people, the loss of a relationship through breakup, obviously that's one of them. But retirement, a lot of people don't handle retirement well because they're not interacting with those same people anymore or on the same level, the same frequency. And they may not have the same Persona, if you will. I know for soldiers and for law enforcement, when they retire, there is a huge retail readjustment process because they are no longer holding that. That title, if you will. Foster care placement and foster care reunification can also be a loss. When the child is put in foster care, they often change schools. They lose, you know, the family that they've been living with, no matter how dysfunctional, and they're put in this new place, they've got to adjust. And then if they're in that placement for much of any period of time, they're going to start to develop attachments and relationships with the foster family. And reunification with their biological family will can also be an extreme loss for the foster parents. The loss of the foster child is also a grieving process. The loss of ability to achieve dreams or shattered dreams. If you are suddenly paralyzed and you would always thought that you were going to run a marathon, well, that may not be happening now. So you've got to help the person move toward accommodation and acceptance of what happened. Prematurity. I had two preemies, and my first one was really, really hard because it showed shattered the idea of that perfect birth scenario. And I didn't get to take my son home for almost six weeks after he was born. And that's just not how it was supposed to be. And it broke my heart. There was a grieving process and disability. If you have a child, for example, who is born with or develops a disability, you also may grieve that because you are grieving that the loss of the dream of what you saw for what they would be able to do. Now, granted, they're going to be able to do a lot of stuff, but it's not how you anticipated it. You're going to have to rewrite that future. Chapter A loss of property and a sense of safety. Last year, our neighbor's house burned down and it was a pretty rapid fire before anybody could do anything. The house was a total loss, as well as, you know, all of their memories and everything else that weren't backed up in the cloud. The sense of the loss of the property, yeah, the house is stuff, but it also took away their sense of safety. The knowledge that, hey, I can leave and I can come back and everything's going to be there. I can go to sleep and I can wake up and there's not going to be a problem. And there was a readjustment process, loss of faith and humanity or a change in your worldview. If you are watching the news a lot, you may have had changes in your perception of people, places and things. And that might require some grieving to accept that it isn't this world of sugar and spice and everything nice that you had anticipated the loss of the moral self. And I have this in quotes, because morals are what you define as, are what the person defines as right or wrong. And when a person starts engaging in behaviors that go against their morals, they experience what we call moral injury. And that moral injury is the recognition of doing something that goes against your values, goes against your morals. And if you continue to do it, then you may grieve the loss of that moral self. Some people grieve never having had something. This is a huge task for a lot of people I work with because they never had secure attachment, they didn't have Ward and June Cleaver as parents, and they need to grief. The fact that, you know what, you're right, you didn't have it, and you can't go back 30 years and change the past. So. So grieving the fact that it's unfair and you didn't get to have what you deserved is a process. And finally, anticipatory loss. If you are a caregiver, working with some for somebody who has cancer, for example, anticipating what it's going to be like when that person passes away, you know it's coming. If you're working with an older parent, you know it's coming. At some point we all die. So that anticipatory loss may also be prevalent, especially if there are signs that the loss is probably impending in the next few months or years. Risk factors for complicated mourning and this comes from a book by McCall and Rando, if you want to look it up. Survivors. When you're looking at the person who survives, what characteristics stand out their age? Younger children have more difficulty understanding grief and loss. They tend to think egocentrically and they tend to personalize a lot of things which may make it more difficult. They have difficulty understanding why do we have to move now that daddy died. They may get angry at their surviving caregivers because they don't understand all of the. The big picture, if you will. They're very concrete. Egocentric physical issues can complicate mourning. If someone is struggling with chronic pain and mental Health issues or other things that can make it more complicated. If they developed physical issues as a result of the loss, that may make it more difficult because it's an ever present reminder of that loss. Cognitive understanding. Now, this is different than age because you can have somebody who is 18, 20, 50 years old who doesn't have a good cognitive understanding of loss and what it means or doesn't choose to understand that. So we need to explore that. Personality and character traits. This is pretty broad, but you can envision, if you've been working with clients for a while, people with abandonment anxiety, with attached, insecure attachment, who may have what I begrudgingly refer to as borderline personality traits. All of those things, codependency traits, all of those things can make it more difficult for a person to move through the grieving process, more difficult to accommodate this new information, because it means admitting a loss of power. It means admitting a loss. Socioeconomic status. When people are stressed out, it is really hard to process all this stuff that's happening with grief and mourning. So a lower socioeconomic status makes people more vulnerable to complicated mourning. Likewise, when we are looking at the losses, if the loss impacted their socioeconomic standing, you know, some you lost somebody who was bringing in money to the family, that's also going to complicate the matter. And spiritual factors, that's pretty straightforward. Do they believe in life after death? Do they. What do they believe happens when somebody passes away? How do they make meaning out of that? The nature of the loss is another thing that impacts complicated mourning. If it was something that was super traumatic, that's going to be a risk factor. If it was expected, then, yeah, it's still going to hurt like heck. But it may not be as complicated. If it came from out of nowhere, if it was unexpected versus expected, the number of losses, and this includes primary and secondary losses. If somebody is in a car accident and they lose three of their family members, well, that's going to hit them pretty hard. If three of those family members, two of them were their parents, and it means that now they're going to go into foster care, they may be separated from their siblings, and they're going to have to move and start a new school. Oh my gosh. And those are only the most superficial losses that we're talking about. We need to recognize how much is this person's life going to be turned upside down by this loss. The circumstances of the loss, was it a traumatic loss? Was it something that involved threat for some reason? What were the circumstances? What resources were available for the person immediately after the loss, we find that with trauma as well as with loss, because loss and trauma really overlap, but we'll get there in a second. The quicker somebody can get back to a routine, it's probably not going to be the same exact routine, but get back to a routine and start finding there. I hate the term, but I'm going to use it anyway. New normal. The less likely they are to develop complications in mourning, the less likely they are to develop ongoing post traumatic stress. And the nature of the relationship with the whatever was lost, how long did it happen? If you've known somebody for two weeks and they pass away or you're with an animal, I foster a lot of animals and we have failure to thrive. It happens. Have that animal in my, in my care for two weeks, I'm going to have a different reaction to it. It's not easy by any means, but I'm going to have a different reaction to it than maybe an animal I'd had with me for my entire life. And so let's talk about foster care for animals. That is when I'm working with orphan kittens and one fails to thrive. Talking about the circumstances of the loss, well, it's not just hey, failed to thrive, but it failed to thrive while I was being its caregiver. It failed to thrive on my watch. And I have to process what's going on there and come to a cognitive understanding of, of the whole, of what happened. And I know for a lot of people you're like, why are we talking about kittens? They're, they're animals, they are, but they are very meaningful in my life. And every kitten, every puppy, every dog that's come through my, through my house over the years has had a special place, the importance of that thing or person in your life. Were they tangential or were they integral in your daily life? What roles did they provide? And what does your culture indicate about your relationship with that person? If you are in a culture that embraces multi generational households, for example, and interdependence, then the reaction to the loss of a grandparent or a great grandparent may be significantly different than for somebody who is in a different type of culture that you call your grandparents, like once every six months, the quality of the relationship, if it was good, then it may be your reaction is going to be different. Not necessarily better or worse, or not better or worse, not necessarily less intense, but it's going to be different than if you had a bad relationship with the person. Sometimes when you've Got a bad relationship with the person. It almost hurts more for people because stuff gets left undone, stuff gets left unsaid. Other people may have already written that person or thing out of their life. And it's like, h, whatever you, you know, I haven't talked to them in 20 years. It's important to ask the person, what does this mean to you, how dependent you were on the person, how it related to your hopes and dreams. If you thought you were going to be with this person for the rest of your life and you were going to grow old together and they pass away when y' all are 40, then not only did you lose them, but also your vision of the future, your hopes and dreams are going to be qualitatively changed. And I've said it already, but I'll say it again. The amount of daily change, if you go from being a 247 caregiver for somebody who is ailing to not having to care for them, it's a huge change if you go, well, not if. When you have kids at home and they grow up and they leave the nest. Empty nest is a grieving process because it fundamentally changes what you do. I was talking to somebody the other day who was saying after her kids moved out, she found that she went to the grocery store and she didn't know how to shop. And I kind of looked at her quizzically, and she said, I had filled my basket with everything that I needed to fill four to feed four people. And I looked in the basket and I recognized that most of that stuff was stuff I didn't want to eat, and I certainly didn't need that much. So I went and put everything back and decided, you know what? I'm getting myself a burger. And that was impactful for me because it really shows how much our life changes when kids leave the nest, if you will. These are not the only factors for complicated mourning, but they are significant factors that we do need to evaluate with the client. Prolonged grief disorder. The death was at least 12 months ago. The person was someone that was close to the bereaved individual. For children or adolescents, it only has to be six months. Six months, wow. I'm just thinking going through six months, if the person passes away in February, you haven't even reached Christmas yet or Thanksgiving yet or any of the holidays, significant holidays that you may have celebrated with that person. But it's what it says in the dsm. Since the death, there's been the development of a persistent grief response characterized by one or both of the following symptoms. Nearly every day for at least the last month. Intense yearning or longing for the deceased person. Now remember, with PGD we're only talking about a person and preoccupation with thoughts or memories of the deceased person. In children and adolescents, the preoccupation may focus on the circum circumstances of the death. This is something we really want to look at. In terms of the criteria for other losses though. When you break up with somebody, does the person continue to experience an intense yearning or longing? Are they preoccupied with the thoughts or memories of the relationship? Since the death, at least three of the following symptoms have been present most days to a clinically significant degree for at least the last month. Identity disruption. I don't know who I am. A marked sense dis of disbelief about the death. Avoidance of reminders that the person has died. Intense emotional pain, including anger, bitterness, sorrow, difficulty reintegrating into one's relationships and activities. Emotional numbness, feeling that life is meaningless and intense loneliness. Again, I challenge you. When we're talking about complicated grief for non death related losses, look at these symptoms. If you retire from the military, there's an identity disruption. I'm no longer a soldier. What do I do? Who am I? When kids move out, you're no longer a full time parent. Yeah, you're always going to be their parent. But what you do in your daily activities changes markedly. There may be a marked sense of belief about what's happening. I had a friend of mine who retired from the military after 20 years and up until the day that he turned in his papers, he was still avoiding acknowledging what was coming. He just wasn't going to accept what was going on. And then once he had to turn, turn in all his stuff and actually like legit retire, it hit him like a ton of bricks. Don't minimize. And, and I know I've said that a bunch of times and I'll continue to say it, There is a significant overlap between grief and trauma. In one study, 53% of participants had significant elevations in trauma related symptoms. Well, duh, let's think about it. Trauma is a something that happens that's out of your control. It leaves you feeling unsafe and powerless. Loss most of the time leaves you feeling unsafe and powerless. Sometimes, even when it's losses that you choose. For example, breaking up with someone who's extremely toxic, it can still hurt. Now, for people who are the ones that are proactively causing the loss, I wouldn't expect to see elevations in trauma symptoms. But for people who had the loss thrust upon them, yeah, losing A therapist or even discharging from a program can also trigger past grief reactions and complicated grief reactions. Many times, the therapeutic relationship is the first healthy relationship the person's actually had where they felt secure and they felt safe. And when they are discharged, it may trigger those feelings of abandonment again. We need to recognize that when there's a loss, the first question is often, what the heck just happened? Followed by, how can I manage right now? And the larger question, how do I go on now that I don't have this in my life? My dog. I know I keep using animals, but they're a huge part of my life. Last year may have been the year before it all runs together. Ended up rupturing part of his heart. And I don't remember the exact diagnosis, but he was really struggling to breathe, and he was acting lethargic, which was very unlike him. And we took him to the vet, and they came in and they told us what was wrong. We thought he might have the flu or, you know, an upset tummy. We weren't expecting ruptured heart. And so both my husband and I were just kind of sitting there in the vet's office going, what in the world just happened? Followed by, you know, we. We knew. We consulted with multiple vets and found out that there was no hope. Had to put him down. How do I manage right now? How do I manage my feelings about putting him down, about not seeing it sooner, about, you know, there are lots of. I'm. I'm good at guilt. I can. I can see your guilt and raise you some. But it was important for me to figure out, okay, how do I manage now? Can't change it. What do I do? And then the larger question of, how do I go on without Duke in my life? And of course, it's a dog. I'm going to go on. But recognizing the loss that was there. When we would take the dogs out, we would call all their names, and occasionally I'd call his name and, oh, he's not here anymore. And then I'd feel angst and grief, and I figure out how to deal with it. But it was important, and it is important for people to be able to answer these questions. Now that this thing is no longer in your life, how do you write the next chapter? Grief takes time. The whole first year is often one reminder of the loss after another. So it's important for people to be aware of triggers all year. Even if you're starting to diagnose someone with prolonged grief after six months, it is important to understand that there are going to be memories and triggers, please, for all things good. Stop Facebook, Google and other social media from showing you memories. They still do this? They did. They showed me memories of Duke the other day and I was like, really? I, I didn't need to see that right now because my defenses were down. Do I reminisce about him sometimes? Yes. But I'm going into it knowing I'm going to be looking at this, not just caught off guard by, oh, there's my dookie. Uncomplicated morning by the old definition is normally a two to three year process, which is why the DSM's criteria shocked me so much. Complicated morning may be a five to seven year process or more. My stepfather, his entire first family was killed on Christmas eve back in 1960 something. And he still continued to mourn their loss up until he passed away last year. And not every day, not all the time, but definitely Christmas Eve every year was very difficult for him. Grief continues for a lifetime and through major life milestones. When the child would have started school, when the child would have graduated, when the child would. You get my point? We don't want to minimize this. If somebody had a loss of a child especially, or even a spouse, you know, we were supposed to retire next year and now they're not going to be there when we retire. And so when the person goes to retire, it's going to open that grief wound again, possibly. Grief impacts all pieces of life. It impacts us physically, our, how we sleep, our stress response. A lot of times people who are grieving have increased levels of inflammatory cytokines. They have increased inflammation. They may get sick easier while they're grieving. They're under stress. Interpersonally, grief impacts our life based on what was lost as well as the reactions of those around us emotionally. Well, yeah, we can see how that happens. Cognitively, grief impacts us not only in our perception of things and how we think about things and our dreams, but it also, when you're grieving, you're under stress, you're in this state of feeling unsafe and to a certain extent disempowered, which means you're probably going to experience brain fog. Accept it, work with it. Instead of saying, I should be able to do well, that's just not happening right now. So accept it and implement things to make it more, make life more doable. Lists, push notifications, get assistance with things. Don't push yourself cognitively either. Environmentally, grief impacts our life. You may. Some people choose to take down pictures and reminders. Other people choose to create a little area where they keep pictures and reminders that they can go to but not be exposed to all the time. And other people leave it up because they want to have that person's visual representation present in their life all the time. Depends on the person. Grief, when we experience a loss, can also impact us environmentally because we have to move, because there's a lot of reasons. And spiritually, when we experience loss, sometimes we can question why, what's the meaning of this? How could this even happen? And if there is something greater than me. Physical responses Symptom Physical symptoms of grief and mourning Appetite disturbances Energy fatigue or low energy fatigue and lethargy Sleep disturbances Well, when you're stressed, guess what? Your body's not in. Rest and digest. Your body's not in, hey, let's relax and get some good sleep. You're feeling unsafe and powerless. You're going to stay on alert a little bit more, which is exhausting. Okay? It is exhausting. You are having to do a lot of processing of stuff that you hadn't anticipated. Being cold, especially for children. And I'm not sure why that happens, but they do indicate that that's a physical response. Having anxiety, panic attacks, sweating, trembling, etc, very common physical response to grief. When you start thinking about, you know, all of the changes, it can feel overwhelming and you can have those physiological responses. Some people don't associate the emotion anxiety with it. So I have it under physical responses. GI disturbances. Grief is stressful. When we're stressed, typically upsets our gut and it changes our microbiome. Compromised immune responses and increased illness. It's a side effect of stress. Grief is stress and increased pain. When we're grieving, not only are we stressed out, we're more tense. We may have more inflammation going on, which makes us feel more pain, but it's also altering our neurochemicals, including serotonin. When serotonin goes down, pain perception or pain tolerance also goes down. Physical tasks during the grieving process Circadian rhythm maintenance and readjustment. If you were a 247 caregiver, well, now's the time to get back on a regular schedule. If you had regular circadian rhythms, now's the time to make sure you're keeping them because getting your circadian rhythms out of balance is a stressor. Restore routines as quickly as possible. Work on healing or restoring your HPA axis. Your stress response going through this is exhausting and it is going to cause some level of disregulation of your stress response. So acknowledging that saying kind of like when you have the flu and it dysregulates your body and it takes you a few weeks to kind of get back to full energy and everything. Well, that's what we're talking about with grief and a few weeks on the, on the bare minimum. And practice healthy nutrition. Your body can't heal unless it's got the building blocks it needs. That doesn't mean avoid all of those good comfort foods, but it means make sure that you're eating a healthy diet and occasionally having some comfort foods. Interpersonally, symptoms include withdrawal. Sometimes it's difficult to deal with people when you're grieving and you just, you don't have patience, you don't have energy, so you withdraw isolation, not wanting to be around other people because they don't get it. Or maybe you fear that you will overwhelm them with your grief. Or again, you just don't have the patience to deal with their drama right now because you got your own. Searching for that person. Searching for connection to that person can also happen even in adults with children who don't understand object permanence. They may search, thinking, hey, if I look long enough, I'm going to find so and so. But even with adults, searching for a connection with that person is a very common symptom of grief. Sometimes they want to be involved in all the things that that person used to do so they can feel connected to them still. Likewise, avoidance of those activities is a possible interpersonal reaction. Irritability. And I have this under interpersonal because a lot of times the irritability is directed towards others. It's like, I can't deal with you. You're getting on my very last nerve and I don't have any nerves left to give right now. Self absorption. They're healing, they're recovering. They barely have enough energy and focus to engage in their activities of daily living. Sometimes, and so it may seem like the person is totally self absorbed, it's requiring all of their energy to get through the day right now. Understanding that we don't want people to stay self absorbed, but we do need to encourage them to, as we say in recovery sometimes work a selfish program until they can get healed to the point where they can be where they have energy to give to other people. And clinging and dependence is also very common in adults and children. After a loss, sometimes people will feel very weak, they'll feel very foggy, which means they rely on others more. Other times they may fear loss again, so they may be more clingy to those people. That are in their life. Interpersonal tasks. Taking on new responsibilities like house duties. If whoever it was that left or died was responsible for paying the bills. When my grandfather died, my grandmother had a very significant anxiety attack around trying to do the things that my grandfather had always done. They had very distinct roles in the household, and when he passed on, it was a shock to her system. Taking on new family duties. If the person that is no longer there used to pick everybody up from baseball or something and now they're not there, that's one of your the things you got to do. If the person that is gone used to be the empathic ear for everybody else in the household, well, somebody's got to take their place. And new people in the house and. And that can be an adjustment. If your father, for example, passes away and you move your mother in with you so you know that she's safe and you can help her out, that's great. But that may be an adjustment. So not only are you adjusting to dad being gone, but you're adjusting to mom living with you now. If you were caregiving, then adjusting to not caregiving is going to be important. Adjusting your sense of self. Who are you now? What do you want for the future? What does your rich and meaningful life look like? And coping with other people's reactions to the loss and you. And this includes setting and maintaining boundaries. When I had Sean, and he was born at 29 weeks, and I remember one of our friends coming in and just, you know, starting to boohoo cry because of how small he was and how he wasn't able to go home and everything. And I mean, I was kind of overwhelmed with her reaction to my loss, but it was important for me to be able to be there for her. You know, it worked. But also other people's reactions to you, if they blame you for the loss, then you're going to have to figure out how to deal with that. If they pity you because of whatever happened, you're going to have to figure out how to deal with that. This is where the maintaining setting and maintaining boundaries comes in. Sometimes you may need to distance yourself from people because they are unhealthy. And in your grief recovery process emotionally, well, you may feel angry, anxious, depressed, irritable, afraid, like you can't go on. You may have death anxiety. You start thinking, noticing every single ache and pain and worrying that you're going to develop the same disease. Or you may be afraid to go drive to the store and back because you're afraid that when you come out. When you come back, your house is going to have burned down or you may not come back because you'll get into a car wreck. There can be a lot of catastrophic thinking that happens, and it's important to help people address, based on the facts in context, what's the probability that this is going to happen to you? And then there can be psychosomatic manifestations of what's going on. Some people will feel lonely and some people will feel relieved, guilty for feeling relieved and regretful about all the things that weren't said. So many emotions happen when your world is turned upside down in terms of tasks, grieving. The person needs to recognize the function of their emotional reactions. What is this telling me and how accurate is it based in current facts and context? They need to identify a path toward acceptance. All right, this happened. How do I write the rest of my narrative? What is the future if I'm writing it in terms of a miniseries or some. Not a miniseries, a television series? What's next season going to look like now that we've written this character out and tolerate Grief bursts. They're going to happen. Sometimes from out of nowhere. You're going to all of a sudden start feeling like it just happened. And that is not uncommon. The grief bursts become less intense and less frequent the further you get away from the loss. But they can still happen occasionally. There are certain songs that if I hear on the radio, will remind me of my daddy. And when I hear those, it just. It all comes kind of pouring back for me. So I have to turn the song off most of the time because I'm not in a place to deal with it. Developing hardiness, that is recognizing what you can control and committing your energy to using it toward those things you can control. And tragic optimism, embracing the good with the bad. Recognizing this happened and it's awful, it sucks, it hurts, it's inconvenient, it's all kinds of things. And I do have hope that I can move forward in the future. We don't want to do toxic optimism where, hey, it'll get better. Grief will. You'll move through your grief and all those trite things that people say, they're in a better place. Tragic optimism says, let's acknowledge how much it sucks right now and recognize that there is possible hope for the future. Cognitively, people will go through symptoms like wondering what's real. They'll have difficulty concentrating. They may not be able to make it through a 30 minute TV show, or they may read the same page several times and be like I have no clue what I just read. There's going to be a short attention span, difficulty learning new material, short term memory loss, difficulty making decisions, and potentially obsessive thoughts or ruminations about the death or the circumstances of the death or their guilt about what happened. All of these are very common reactions after a trauma and common reactions in response to stress. Let's not pathologize something. This is stressful. Let's acknowledge what the common symptoms of stress are and figure out tools to deal with them instead of pretending that they don't exist. So tasks. Make a schedule or lists and use push notifications. Don't rely on your memory. Free up your energy to focus on other things when you know you can have a computer, do that stuff. Only do what must be done until you can do more. If you start doing your activities of daily living and you start realizing, hey, I'm getting through the day, I'm feeling pretty okay, then add one more thing. You know, start adding one more thing that you want to be doing. Once you get to the point where you can do that and feel like you're not exhausted, you're not drained, okay, then you can add something else in. But start out with the basics, the bare minimum, what has to be done, and then gradually back add it back in. Some of those other time and energy drainers put off important decisions or consult with an important impartial resource like a counselor or attorney general during the immediate grieving process. When you've got brain fog is not the time to be figuring out whether to sell the house unless it's something you absolutely have to do at that moment. Try journaling. This can help you mind dump, if you will, and get out some of those thoughts and obsessions and ruminations that are bouncing around in there so you can look at them, you can evaluate them, and you can decide on their accuracy and restructure is needed. Work with a therapist to write a letter to your loved one, obviously that you won't be sending. Or use the empty chair technique. It's a gestalt technique for communicating with somebody who's not there. In order to say those things that went unsaid environmentally, pay attention to those sensory triggers. It's not just pictures. It can be smells, it can be other types of sights or sounds. Okay. My dad and I used to go fishing a lot, and so when I see fishing gear, it reminds me of daddy, we don't have fishing gear around here. But if I were still grieving that loss, that might be something for me to recognize. As being a potential trigger sounds. If the person used to snore like a freight train or sing like an angel, hearing certain sounds or even certain songs may trigger that grief reaction. Just because it's triggered doesn't mean it's a bad thing. It's a bad thing, if you will, if it causes you uncontrollable or what you perceive as clinically significant distress. And this time it's important to deal with triggers. Figure out what you're going to do. Are you going to put them away? Are you going to make them more prevalent so you can feel connected? How are you going to handle it when you're exposed to triggers? In terms of housing, how are you going to maintain your housing? And that includes paying the bills as well as cutting, cutting the grass and trimming the hedges and everything else. How are you going to make that happen now? And feeling safe without that person or that animal? Some people their, their dogs help them feel safe when they go to sleep at night. So without having that dog there, they may have difficulty sleeping. What is it? What do you need to do so you can feel safe? Spiritual beliefs are challenged. The question why reverberate? Reverberates. Where was God? If God is all powerful, why allow this? If God loves me, how could this be? My prayers weren't answered and what's my purpose in life? And that's a whole different presentation that, that we could delve into. But it's important to recognize that people's sense of connection and sense of meaning and, and belief in their ability to understand the world is often shaken to its core when there's a loss. In terms of models for non complicated grief, we're going to look at Bowlby Wolfit and Therese Rando. Really quick. Bowlby. Now we all know Bowlby in terms of the attachment guy. Attachment relationships help regulate psychological and biological functions. Attachment relationships help us learn how to master tasks and perform different things. They help us when we're learning and we're performing. They help us feel secure so we can focus on what we're doing instead of feeling anxious. They help us figure out how to build relationships with others. They help us by providing additional coping and problem solving skills. They help us develop self esteem emotional regulation. When people feel securely attached, they feel safe, which improves sleep quality. And when people are less stressed, their pain perception is better. That is their pain threshold is actually a lot higher. Exploratory behaviors are reciprocally linked to attachment. If people feel like there's a safe home base, they're more likely to Explore and step out of their comfort zone. Attachment and safety stimulate a desire to learn, grow and explore. So if this person's loss involved somebody that they were attached to, they may feel unsafe exploring for a while. They may not have a desire to learn, to grow or to explore for a while. And that's expected until they reestablish a new sense of a safe home base, a new sense of attachment. Attachment relationships provide support and reassurance, or that safe haven and encouragement and pleasure from being a secure base among adults. Caregiving is at least as important as being cared for in developing that attachment relationship. So when to feel attached, not only do we need to have people respond to our needs, but we also need to have them ask for our help and us respond to their needs. I thought that was really interesting. Loss of an attachment relationship disrupts attachment, disrupts a person's sense of security and it also disrupts their caregiving and exploratory systems. Attachment active activates the separation response and impacts restorative, emotional, social and biological processes. When people's attachment relationship is disrupted, all of a sudden they feel like that child who was separated from their primary caregiver. And it puts them in a state of stress and anxiety, which causes them to not want to explore and produces a sense of failure in caregiving and can include self blame and survivor guilt. If this attachment relationship is disrupted for some reason, the person may look back and go what did I do? How was it my fault? So we need to address that guilt. Wolf 6 reconciliation tasks acknowledge the reality of the death or loss. Move toward the pain of the loss while being nurtured physically, emotionally and spiritually. Convert the relationship with what was lost from one of presence, what you expect to be in your life right now to one of memory. Making sure that you have that body of memories that display case of memories that you can look, look, look in on. Develop a new self identity based on life without that person, thing or experience. Find meaning in the loss and experience a continued supportive presence. And finally, Rando provides a very similar approach to grieving, but a little bit different. There are three phases and six processes in his grieving resolution. The phases are avoidance, confrontation and accommodation. That roughly correlates to denial and then anger, bargaining and depression. And then accommodation is acceptance. If you want to parallel it with our typical grief phases. The processes include recognizing, reacting, recalling, relinquishing, readjusting and reinvesting. In the avoidance phase, people need to move toward recognizing the loss, developing an understanding of what happened if it is a death, avoid phrases that can confuse and frighten the person. Like, God took her, God needed an angel. Or quoting psalms like, yea, though I walked through the shadow of the valley of death, or saying, only the good die young, or he's just sleeping right now. Children that they take that stuff literally. And that can be very terrifying to a child who doesn't understand you're speaking metaphorically. And help the person recognize not only the primary but also the secondary losses in confrontation. The person needs to react to the loss by experiencing the pain, not avoiding it anymore, saying, all right, this hurts. Let's tolerate it and move through it. They need to feel, identify, accept, and give some form of expression to all of the psychological reactions to the loss. Guilt, guilt, anger, anxiety. That whole list that we went through, recall and re. Experience what was lost. The primary and secondary losses. What was life like before and what. What is life like now? What does that mean? What's the. My experience of losing each one of those things and relinquish the old attachments to what was lost and your old assumptions, the old beliefs and the old dreams that you had, or your old assumptions about life, well, they're going to have to change a little bit in accommodation. And this is actually based on Piaget's term, readjust to moving adaptively into the new world without forgetting the old. So the person is going to revise their assumptions about the world and the future. They're going to develop a new relationship with what was lost instead of something, you know, I can't call my daddy or my mom up anymore and say, hey, I need your advice. How can I? What does my relationship with them look like now? And now I call on my memories and think to myself, what advice would they give me? Adopt new ways of being in the world and potentially form a new identity. And then reinvest your energy that you were using for that whatever was lost toward your new goals. Secondary victimization occurs when support systems isolate blame and stigmatize. Multiple losses, require multiple adaptations over time, and make intervention very complex. For example, when parents divorce after a child is murdered, we want to take each change one at a time. You'll get there, but it's important to recognize if that you have this huge map of this web of losses as a result of the primary loss. Okay, there's a lot of stuff there. Let's start pulling that web apart one strand at a time and help the person move toward accommodation. And similarity in support groups helps normalize the experience. If you have people who have lost a loved one to suicide, having them in their own group and people who've lost a child to cancer in a different group. Not that they're not both grieving, but they have gone through very, very different experiences and they can provide more tailored support to one another. A secondary loss is a loss precipitated by the initial loss. Anticipated loss can be defined as a death or loss that is expected weeks to years in advance. Common physical, emotional, and cognitive reactions to anticipated loss include changes in eating, sleeping, mood, world outlook, and socialization. Common reactions to an unexpected loss include shock, anger, and guilt. Details about a death should be provided. If the person asks, not everybody wants to know. We don't need to get into the nitty gritty details. But if the person wants to know what what happened to so and so, it's important that we help them find some answer that will help them get closure. Education and normalization and validation contribute to normal adjustment after a loss. Educating them about what happened so they can cognitively understand what happened is important. Normalizing their experience, normalizing their pain, all of that is important. 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. For example, after a car wreck, some people will say, did they suffer? They don't want to know exactly what caused their death. I mean, we know generally it was the car accident. What they want to know is did they suffer? And it's important that we're able to provide them or someone is able to help them get answers to their questions. Factors that affect individual reactions to sudden loss include the circumstances of the death, personality and character traits, pre existing issues, and the nature of the relationship. Sudden death makes people want to understand why it happened.