Sowing seeds of insight

I have been spending a lot of time sowing seeds in the garden over the past few months (when the pollen count is not too high), and I began to think that there were parallels to working with clients to help them gain new insights and thus move towards making changes.

Clearing out the debris to make space for new seeds

There is often a lot of storytelling and offloading that needs to occur first, and attempting to sow new seeds of insight before this has occurred makes it much less likely that the “seeds” will germinate. We also need to fertilise the soil with rapport building and nurturing a relationship of trust and caring.

Germination rates and growth

In the garden some seeds never germinate, no matter how carefully we tend them, and this can be the same with some clients. I remember those who seem to stay stuck forever in offloading mode, talking about the same issues over and over again, and seemingly not moving forward to process them.

Some seeds emerge strongly, whilst others are more delicate and tiny, and all need their own ideal temperature to germinate. With clients I would liken the right “temperature” to the right context and readiness to begin to consider new perspectives and/ or work on growing. With some clients new insight emerge strongly, once they “germinate”, whilst with others we may not notice this until the new insight begins to grow in size and become more visible.

First and second order change

Some new insights are like the annuals – they bloom brightly for a time and then fade and die. I would liken these to first order change in clients. Change occurs initially but is not sustained, and is usually about short term behaviour change.

Others are like perennials, where the plants continue to grow and strengthen. These are like second order change where a new insight causes such a major change in attitude that it may be irreversible. This often occurs in the “light-bulb” moments.

Patience is needed

All of these processes take time and thus a great deal of patience is needed. We need to try not to give up when we can see no evidence of “germination”. My Carob seeds took two months to germinate and I nearly threw them out beforehand (especially as they were out of date according to the seed packet).

But we also need to be mindful of when to offer less nurturing and when to let plants survive on their own in their own environment. The same applies to our clients. 

The background contours of bereavement: Part 3

This is the final post on this segment on grief. Once again, please treat this information as something that may be used as a framework to understand a person’s grief journey, rather than as something that everyone will experience.

Neimeyer’s tasks of mourning do not occur in a linear fashion or necessarily in the order presented. Not all people will engage in all of the tasks, and this framework may be totally irrelevant for some grief journeys. However it may be useful for others.

These are Neimeyer’s tasks of mourning as he presents them in his book Lessons in Loss: a Guide to Coping (McGraw Hill, New York, 1999):

Acknowledge the reality of the loss

This is about learning the lessons of loss at a deeply emotional level and involves a series of seemingly unending confrontations with the limitations imposed by the loss. We grieve as individuals and as members of larger family systems. Children need to be included, as “protecting” them will mystify reality and deny them the chance to discuss feelings.

Open yourself to the pain

Avoiding distressing feelings may delay grieving. Feelings need to be sorted through and identified and pain embraced for long enough to learn its lessons. However focussing relentlessly on the pain may be damaging and we may need to balance “grief work” with reorientation to practical tasks and the development of new skills to cope with the changed environment. It is OK to fluctuate between feeling and doing according to need.

Revise assumptive world

Major loss undercuts the beliefs and assumptions that have been our philosophies of life. Loss invalidates our assumptive world and makes us revise it (our behaviours, commitments and values) and this will take considerable time and effort. Our assumptive world will be revised according to the personal meaning we have given to the loss, and we may be transformed by tragedy – “sadder but wiser”.

Reconstruct the relationship to that which has been lost

A continued sense of presence is common and most see this as comforting. Death transforms relationships rather than ending them, and there is a change from a relationship based on a physical presence to one that is based on symbolic connection. Reconstructing the relationship by e.g. encouraging memories, “talking” to the deceased and having cherished linking objects, gives, continuity to a life story disrupted by loss.

Reinvent self

We are social beings and construct our identities in relation to other significant persons, so part of us dies when someone we love dies. We need to rebuild an identity appropriate to new roles, whilst establishing continuity with the old. Death and loss tear vital strands that connect us to people, places and activities, and we gradually repair them by re-establishing other forms of connection. Loss diminishes us, but can also lead to renewal and wisdom.

More information on Robert Neimeyer can be found on this link, as well as access to some of his research publications:
https://dl.dropboxusercontent.com/u/66994396/home/Scholarship.html

The background contours of bereavement: Part 2

Continuing on with the background contours of mourning, here are some more to consider.

Loss orientation vs. Restoration orientation

Some bereaved alternate between feeling intense emotional upset and cognitively containing emotional upset through taking action on something to substitute for thinking about the loss. (Goodrum  S (2005) The interaction between thoughts and emotions following the news of a loved one’s murder. Omega: Journal of Death and Dying Vol 5 (2))

When working with loss orientation we need to explore the client’s experiences, feelings, hopes and fears and help them to release emotions without any pressure to move quickly beyond their pain or to find quick fixes. We need to normalise reactions, explore the significance of the loss for the client’s life and explore for related losses.

There can be multiple approaches to the expression of grief – verbal, written and artistic, and drawing and storytelling may allow trauma to be approached in the relative safety of symbolism and metaphor. Research suggests that the ability to share our feelings and stories with others is healing.

Harding says that Allowing oneself to go through the emotions that happen and accepting those emotions as part of a normal and natural process is affirming and helpful to those who grieve. (Harding D (2005) Spiritual guidance for grief: one piece of the puzzle. PsycCRITQUES  Vol 50 (51))

In Restoration orientation there is a focus on tasks and an exploration of options and possibilities. This is about external adjustment and tuning out to grief.

Meaning making/ reconstruction/ re-learning the world

On this contour we need to work at the pace of the person and pick up when they are ready to begin reconstruction (they need to be thinking beyond intense loss). We need to begin where the client is, allow the story to be heard and uncover the meanings attributed to their lives and the losses they have encountered. Our role is to act as collaborator and catalyst in the process of meaning reconstruction.

Malkinson and Bar Tur write that Grief along the life cycle is an unpatterned process with emotional and cognitive ups and downs involving a continuous search for a meaning to life. 

There are three areas of meaning-making: sense making (via communication and storytelling), benefit finding, and identity change, and we can use tools like journaling, biographies, letters, poetry and metaphoric stories to assist with meaning-making. (Malkinson & Bar Tur (2004) Long term bereavement processes of older persons: the three phases of grief. Omega: Journal of Death and Dying Vol 20 (2))

Continuing bonds

Patson and Marwit have observed that Continued contact with a loved one who has died is common in bereavement. 60% reported sensing a presence (visual, auditory or tactile) and of these, 85% found this comforting. (Patson & Marwit (1997) – but I have lost any further details, sorry)

When working on this contour we need to first explore the nature of the relationship and attachment to the deceased (some people may not want a continuing relationship with the deceased). Then, if appropriate, we may encourage the client to develop rituals that support memories, honour the dead and keep the presence/ spirit. Memories promote healing by validating grief, facilitating ritual, providing mementos and letting the bereaved tell their stories.

Some of the ways to continue bonds are to treasure objects which link to the person who has died (jewellery, clothes, photos, mementos and/or a box of memories), go to the cemetery, create memorials, continue to have thoughts of the deceased, have a relationship with them in one’s heart, have conversations with the deceased (and maybe seek guidance from them) and to write to them in letters or journals.

Music can be used to create connectedness and to facilitate rituals, and we need to encourage talk about the person who has died, as well as the observance of anniversary days.

Neimeyer’s tasks

I will elaborate on these in the next post.

Remember: All of these contours are ideas that may or may not be relevant to the individual grief journeys of our clients, and it is only appropriate to use them if they are meaningful for the client. Not every journey will follow all, or even any, of these contours, but they do give us a theoretical framework to draw on.

The background contours of bereavement

I have found that the best way to make use of these more recent theories, whilst still respecting each individual’s grief journey, is to see them as background contours (borrowing from Neimeyer’s belief that general contours of mourning exist as backdrops to individual contexts and experiences, that there are both individual and relationship contours and that ‘typical’ grief responses should be seen as general, not universal).

Reference: Neimeyer R (1999) Lessons in Loss: a Guide to Coping McGraw Hill, New York

The contours of feelings, thoughts, behaviour and physical reactions

Some feelings commonly felt by those who are grieving include numbness, sadness, anguish, anger, guilt, panic, helplessness, shock, loneliness and depression. Some members of a Bereavement Support Group that I facilitated in the past described themselves as feeling shaky, unsteady and afraid or having a hurt that is too deep for tears.

Some common thinking includes disbelief, confusion, being unable to concentrate, focusing on the loss, and disorientation. This was articulated by some members of the Bereavement Support Group as I felt there was no hope. I was confused and did not know where I was going and  I only see dark shadows and have lost sight of the light beyond.

Some common behaviour can be social withdrawal, sighing, searching and calling out, crying, restlessness and absent mindedness. Other members of the Bereavement Support Group said I have to go away to grieve – away from all the people and I've fallen off the track – my heart feels like it is outside my body.

Common physical reactions can be sleep and appetite disturbance, lack of energy, weakness and lightness in muscles, breathlessness, over-sensitivity to noise and having a dry mouth. This was described by some members of the Group as feeling like I've been through an explosion and am looking into the big black hole of space and I'm so alone – no-one is out there for me and the wheels have fallen off my cart.

The contours of common patterns of avoidance, assimilation and accommodation

Neimeyer says that these three common patterns exist in those who are mourning.

In avoidance the reality of the loss is impossible to comprehend, there is shock, panic and confusion, there is avoidance of the full awareness of too painful a reality, the mourner may act as if the person is still alive and may be unable to do normal routines, they may be disorganised and distracted, they may experience vivid emotional reactions as reality sinks in, and the sharp awareness of pain may be punctuated by the apparent denial of the reality of the death.

Neimeyer says: We accommodate loss in degrees, glancing at it, then away until it becomes undeniably real and its implications for our own future begin to be understood on an emotional level. (See reference quoted as the beginning of this post)

Assimilation is about: Learning the hard lessons of a loved one’s absence in a thousand contexts of daily living. (Neimeyer)

It is about loneliness and sorrow, longing and grief (but may also be about relief or guilt), deepening despair, withdrawal from social worlds to give more attention to ‘grief work’, there may be intrusive images and dreams, unpredictable crying spells, depressive symptoms and physical reactions and pain that comes in waves, and there may be more proneness to disease.

Accommodation is: The uneasy balancing act between remembering the past and reinvesting in the future and this continues for the rest of our lives, requiring on-going adjustments. (Neimeyer)

Accommodation includes the resigned acceptance of reality, the possible persistence of yearning and loneliness, a sense of emotional control, an improvement in concentration and functioning, reorganisation punctuated with the painful awareness of loss, possible pangs of guilt and sadness, taking two steps forward and one step back, and rebuilding a shattered social world.

Longer term contours

The grief journey can be a long climb towards reorganisation and renewal, but on a rocky path that evolves over years, not months. Deterioration may be expected on significant occasions and “grief spikes” may occur years or even decades later.

Other contours

These include loss orientation vs. restoration orientation, meaning making/ re-learning the world, continuing bonds and Neimeyer’s five tasks of mourning, and I will elaborate on these in the next post. There is so much to take on board in relation to working with grief!

Grief: the shifts in approaches

In this post I would like to summarise the main shifts in approaches to working with the bereaved, as influenced by the progression of theories in relation to grief.

The main shifts

• There had been a move from viewing the bereaved as passively reacting to grief, to seeing  them as being active in facing death's challenges.
• Old theories were not backed by research, whereas more recent ones are.
• A shift has occurred from being prescriptive and pathologising, to a focus on valuing individual meanings.
• Former approaches talked about lineal stages and phases, whereas now individual reality is the focus and a universal sequence of stages or tasks is no longer recognised.
• In the past the bereaved were discouraged to disengage from the deceased, but now the concept of forming continuing bonds with the deceased is recognised.
• Grief used to be treated as a private individual experience, but now social and relationship contexts are seen as having a great impact.
• Another move had been from a focus on emotional responses to also recognising the importance of cognitive (meaning) and behavioural impacts.
• Former theories encouraged "recovery" and return to pre-loss patterns, whereas now people are seen as being transformed by grief (and grieving is seen as something that continues, in various forms, for the remainder of people's lives).

Grief is a very individual experience

No two people will experience the same grief in response to the same loss and, although there may be some commonalities in their reactions, we need to ensure that we tap into their unique responses whilst listening to their individual stories.  

A Social Work approach to grief

Social Work intervention strategies will be based on a model that takes account of the interactions between social systems and human behaviour, and the influence of our ethical/ value base.

In human behaviour each individual is seen as a complex system of personalities, coping capacities, beliefs, values, choices, life journeys etc., and each of these parts might respond to loss in different ways. The individual will respond to loss in multiple ways, and some of these may be conflicting or ambivalent.

In social systems in relation to the family, the expression of grief will be regulated by norms of family interactions, family roles, hierarchies of power, support, conflicts and by family structures and processes. And in social systems in relation to the broader community grieving will be influenced by cultural interpretations of death and loss, imposed expectations and norms regulating grieving processes. These may be subtle or overt and may be contradictory.

As Goldsworthy says, our approaches in working with the bereaved need to be consistent with Social Work ethics of self-determination, inherent dignity and worth, empowerment and a commitment to the diversity of client experiences and meanings. We need to not pathologise the client (grief is not an illness, but a response to change).

Reference: Goldsworthy K (2005) Grief and loss theory in social work: all changes involve loss, just as all losses require change. Australian Social Work June 2005 Vol 58 No 2

Remember: Grieving is as natural as crying when you are hurt, sleeping when you are tired, eating when you are hungry, or sneezing when your nose itches. It is nature's way of healing a broken heart. (Source unknown)

Grief: the continuing theoretical journey: Part 2

The final part of our chronological theoretical journey through grief takes us to  the end of the 1990s but, of course the theoretical journey had continued over the past 15 years, building on the research of these theorists – and the theorists themselves have continued to debate and discuss their ideas amongst themselves and to produce journal articles.

The Constructivists – Klass & Silverman 1996 and Neimeyer 1999

These theorists challenged the “traditional” theories of grief and introduced the concepts of meaning making and continuing bonds. They postulated that the work of grief is not to sever bonds with the deceased, but to form continuing bonds by internalising the deceased and continuing the relationship with them in a new form. They believed that death ends a life, but not a relationship.

They said that meaning making is about attempting to reconstruct a world of meaning that has been shattered by the loss, and that the meaning of the loss can be revisited and adapted over time.

This is a broad brush-stroke and I will elaborate in a future post. My aim at the moment is just to give a quick outline on how grief theories have evolved over time.

Stroebe and Schut 1999

The main concepts of these theorists are outlined as follows:

• Individuals are unique and so is their experience of grief and loss.
• We need to focus on understanding the unique meaning each person attributes to grief and loss experiences (in both internal and external worlds).
• Grief is an active process filled with limitless choices and possibilities.
• Bereaved people’s continuing bonds differ according to their attachment style – it is better for some to work towards retaining ties and for others to work towards loosening them.
• Different coping styles are adopted by different people according to their attachment style.
• Coping strategies can be used to reduce the grief associated with loss.

They also outlined a duel process model of coping, where there is an on-going shift back and forth between two contrasting modes of functioning:

1. Loss orientation – experiencing, exploring and expressing the range of feelings associated with the loss, and trying to grasp its significance for one’s life.
2. Restoration orientation – focus on the many external adjustments required by the loss (e.g. work and home responsibilities, relationships) whilst tuning out waves of acute grief (avoidance of the reality of the loss).

I found that researching the theoretical approaches over time gave me a much greater understanding of the various approaches to working with the bereaved. How has this brush-stroke journey been for you?