Disaster and Mental Health PDF

DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS - Disasters are not uncommon events -No two disasters are exactly alike, but certain characteristics Topic Ou...

DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS - Disasters are not uncommon events -No two disasters are exactly alike, but certain characteristics Topic Outline: tend to be associated with specific reactions among Topic I: Introduction: Disaster and Mental Health survivors. Topic II: Stress Reactions of Survivors Topic III: Grief DEFINITION OF DISASTER DOES THE FOLLOWING: WEEK 1: INTRODUCTION: DISASTER AND MENTAL HEALTH BRIEF OVERVIEW OF THE PRACTICE OF DISASTER MENTAL HEALTH DEFINING DISASTER - “A major disaster is defined as any natural catastrophe, or Survivor Reaction regardless of cause, any fire, flood, or explosion that causes damage of sufficient severity and magnitude to warrant CHARACTERISTICS OF DISASTER assistance supplementing State, local, and disaster relief 1. Size organization efforts to alleviate damage, loss, hardship, or 2. Cause suffering”. 3. Expected or Unexpected - Is often defined as a critical incident whose negative impact 4. Timing is characterized by great physical damage, loss of life, or hardship. CHARACTERISTICS OF DISASTER:SIZE - A disaster is a non-routine event that exceeds the capacity Greater Scope of the affected area to respond to it in such a way as to save Intensity lives; to preserve property; and to maintain the social, Duration ecological, economic, and political stability of the affected region. CHARACTERISTICS OF DISASTER: CAUSE Natural DEFINITION OF DISASTER DOES THE FOLLOWING: Human Caused 1. Disasters are unusual events, complex and difficult Na-tech to respond to, and their impacts may last for Public Health Emergencies generations. 2. It takes into consideration the capacity of the local DISASTER’S IMPACT: A RANGE OF REACTIONS area to respond to an incident. This is important Common vs. Extreme because, in most cases, large communities, simply Recovery as the expected outcome. because of the number of their available resources, are more capable of handling very serious Post-disaster traumatic stress does not equal situations than are small communities. posttraumatic stress disorder 3. Takes into consideration the importance of maintaining the social, ecological, economic, and POST-DISASTER TRAUMATIC STRESS political stability of the affected area. Vulnerable Populations- groups that may have more - This is important because, clearly, when intense needs before, during, and after disaster, include: people are killed and homes are Children destroyed, those who survive will suffer The elderly (particularly the frail elderly) long-lasting emotional and psychological People with serious mental illness effects. People with physical disabilities People with substance dependence INTRODUCTION People living in poverty - Each day disasters occur, and each year millions of people are affected. Whether natural or human-made, the extreme Common Reactions: and overwhelming forces of disaster can have far-reaching Physical effects on individual, local community, and national stability. Emotional - Long-term recovery varies significantly due to the complex Cognitive interaction of psychological, social, cultural, political, and Behavioral economic factors. Spiritual DISASTER CHARACTERISTICS AND THEIR MENTAL LIFE CYCLE OF DISASTER REACTIONS HEALTH IMPACT NPH | 1 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS Reactions occur in stages/phases: Pre-impact: Disasters with warnings allow people to prepare and initiate coping mechanisms. Impact: Magnified arousal levels (fight, flight, or freeze); usually little panic; behavior in this phase is related to later recovery Post-impact: Reactions unfold over the heroic, honeymoon, disillusionment, and reconstruction phases 1. Pre-disaster phase. Disasters with no warning can cause feelings of vulnerability and a sense of loss of control or the ADMINISTRATIVE ROLES loss of the ability to protect yourself and your family. - Following a disaster, administrators are faced with the 2. Impact phase. Slow, low-threat disasters have challenge of having to quickly become familiar with disaster psychological effects that are different from rapid, dangerous protocols (grant applications) and resources (mutual and disasters. other aid), while meeting rapidly emerging and changing 3. Heroic phase. Characterized by a high level of activity disaster-precipitated needs. with a low level of productivity. 4. Honeymoon phase. A dramatic shift in emotion. Disaster KEY CHARACTERISTICS AND HELPING BEHAVIORS OF assistance is readily available. Community bonding occurs. DISASTER MENTAL HEALTH WORKERS Optimism exists that everything will return to normal quickly. - Disaster mental health work requires a personal orientation 5. Disillusionment phase. Communities and individuals toward adventuresomeness, sociability, and calmness. realize the limits of disaster assistance. Optimism turns to Equally important is having systems savvy, the ability to discouragement and stress continues to take a toll. exhibit empathy, genuineness, positive regard for others, and 6. Reconstruction phase. Characterized by an overall the ability to provide therapeutic structure. feeling of recovery. Individuals and communities begin to - Generally speaking, adventuresomeness, sociability, assume responsibility for rebuilding their lives, and people calmness, systems savvy, and therapeutic acumen adjust to a new normal while continuing to grieve losses. transcend theoretical orientation and are applicable across various disaster response settings. Moreover, they are DISASTER MENTAL HEALTH SERVICES essential to communicating with survivors and rescue CLINICAL ROLES workers whether informally or while providing practical help, - In a major disaster, effective mental health response defusing, debriefing, or information requires the delivery of both clinical and administrative services in ways that differ from services typically provided ADVENTURESOMENESS by mental health professionals. - Disaster work is a constant creative challenge with - The primary objective of disaster relief efforts is to restore relatively few cardinal rules to provide a priori guidance. The community equilibrium. Disaster mental health services, in inclination toward curiosity and learning from experience as particular, work toward restoring psychological and social well as the willingness to develop creative solutions to functioning of individuals and the community, and limiting the complex problems is necessary for disaster work. The occurrence and severity of adverse impacts of person who relies upon routine with minimal uncertainty is disaster-related mental health problems (e.g., post-traumatic likely to feel overwhelmed and adrift. stress reactions, depression, substance abuse). NPH | 2 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS Stressors- Physical, Emotional, Social SOCIABILITY ○ Stressors are things that cause stress. - Disaster mental health work demands long hours each day, Almost everything is a stressor depending as well as being on call throughout assignment. Survivors on the individual. and workers alike are at their best and worst in a disaster – Family Relationships courageous, selfless, dedicated, resourceful, and School compassionate... yet also plagued by doubts, selfishness, Peer Groups/ Friends resignation, confusion, and irritability. To work with people Discrimination who may be experiencing extreme stress, and to maintain Injury the stance of a sensitive and observant listener and helper, Sickness requires not just a professional commitment to others, but Fatigue the capacity to enjoy and find the best in others. Any Major Change CALMNESS PHYSICAL STRESSOR - Disaster work is a form of non-stop crisis intervention Physical stressors are physical conditions of your body and challenging the equanimity of inexperienced and the environment that affect your physical well-being. experienced clinicians alike. When nothing seems to be Thirst happening for hours at a time, powerful undercurrents of Hunger anxiety, despair, rage, and uncertainty threaten to break Lack of Sleep loose at any moment. Working and living conditions are often Sickness chaotic: noisy settings, long hours, substandard lodging, Accidents or Catastrophes unstructured schedules, ambiguous roles and rules – these high-stress circumstances call for emotional poise. EMOTIONAL STRESSOR Emotional stressors are the stressors that affect your SYSTEMS SAVVY physical and emotional well-being. - Disasters are political events. Turf and organizational Worry politics are pervasive and volatile at disaster services sites, Fear Incident Command center(s), and at national headquarters of Grief response agencies. The disaster mental health professional Depression represents a distinct interest – that of supporting and Anger enhancing the psychosocial safety and functioning of SOCIAL STRESSOR helpers, survivors, and their community. By becoming Social stressors arise from your relationships with other familiar with the scope of disaster relief operations (i.e., people. community, state, and national political arenas), the mental Family health professional can better assume the role of an impartial Friends mental health advocate. Teachers Employers THERAPEUTIC ACUMEN Peers - To provide therapeutic assistance without “therapizing” disaster survivors or workers, the mental health HOW DO WE REACT? professional’s perspective must be grounded in empathy, -Our body goes through 3 stages under stress. The first is an genuineness, and respect. These “facilitative conditions” “Alarm Stage” which is referred to as Fight or Flight. This have been found to be essential across the spectrum of is when the body reacts to the stressor. Anything that causes psychotherapy’s theoretical models and help quickly promote you to worry or get excited, or causes emotional or physical a positive relationship between helper and survivor. changes can start the alarm reaction. -Fight or Flight is the body’s natural protective technique. WEEK 2-3: STRESS REACTIONS OF SURVIVORS We react the same to both positive and negative types of stress STRESS MANAGEMENT STRESS STAGE 1: ALARM PHASE Stress - A nonspecific response of the body, or the -During the alarm phase, adrenaline is released. Adrenaline body’s reaction to a demanding situation. is the chemical which gives our body energy to perform Eustress - Results from something good and we physical acts. In an emergency our adrenaline amount rises react positively. Distress - Results from something bad and we STAGE 2: RESISTANCE react negatively. -In stage two, the resistance stage, the immune system starts to resist or fight the stressor. You feel exasperated and WHAT CAUSES STRESS? are impatient with trivial matters. You miss your sleep NPH | 3 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS schedules and find your resistance lowering. The normal indications of this level are exhaustion, weariness, anxiousness, and being forgetful. STAGE 3: EXHAUSTION In extreme cases our body is unable to handle the stress and it succumbs to the stressor and we call this the exhaustion phase. We may become sick or medical treatments may become necessary. If the stressor is too great, as in the case of disease that the body cannot fight, death can occur. PHYSICAL EFFECTS Increased stomach acid can create or irritate ulcers. HOW DO WE REACT? High blood pressure can lead to heart disease and Allergy disorders. flare-ups Lowers the effectiveness of the immune system. Backaches Cancer or severe illness can occur. Perspiring Shortness of breath MANAGING STRESS Hyperventilation One of the best and most productive ways to handle stress is Irregular Heartbeat to exercise. Exercise releases stress reducing chemicals in Tightness in throat or chest the body called Endorphins. Extreme fatigue Muscle tension Eat a Healthy Diet Trembling Your diet can create a great deal of stress within Muscle spasms your body and its systems. Your body cannot Acne flare-ups function properly without adequate nutrition. Eat 3 Difficulty sleeping healthy meals each day. Headaches Neck-aches Get Enough Sleep Blurred vision Lack of sleep can contribute to distress and can Increased blood pressure make decision making difficult. You should get at Vomiting least 8 hours of sleep each night. STRESS Other ways to manage stress: THE NATION’S #1 KILLER Avoid unnecessary, distressful situations Tackle one thing at a time / take action Manage your time effectively Try not to let little things bother you Accept what cannot be changed Think positively Find a way to relax your muscles/ reduce tension (muscle relaxation, imagery, yoga, etc.) EMOTIONAL EFFECTS OF STRESS - Explore a variety of stress reducing strategies and do what works best for you. The better you become at handling stress, and stressful situations, the healthier you will become. EMOTIONAL EFFECTS OF STRESS KEY VOCABULARY Adrenaline is the chemical which gives us energy to perform physical acts. In an emergency our adrenaline amount rises. Alarm stage is referred to as Fight or Flight and is when the body reacts to the stressor. Distress is negative stress that can cause mental and/or physical problems and you react negatively. NPH | 4 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS Emotional stressors can include anger, grief, assault, or natural disaster, dose-response is a strong anxiety, and many other emotions that interfere with predictor of who will likely be most affected. your ability to function optimally. - The greater the perceived life threat, and the greater the Endorphins are stress reducing chemicals that are sensory exposure, that is, the more one sees distressing released during exercise. sights, smells distressing odors, hears distressing sounds, or Eustress is positive stress that motivates you to is physically injured, the more likely post-traumatic stress will "rise to any challenge” and you react positively. manifest. Victims are not the only ones at risk. Helpers, Exhaustion stage is when our body is unable to including medical, morgue, and security personnel, rescue, handle the stress and it succumbs to the stressor. fire and safety workers, may also experience either direct or Fight or Flight is the body’s natural protective indirect traumatization. Family members of victims, too, are technique. at risk for what has been referred to as vicarious Physical stressors include things like lack of traumatization – relationships with traumatized individuals sleep, overheating or feeling cold, noise, or any can create much distress for others. natural disaster such as a tornado or forest fire. Resistance stage is when the immune system POST-TRAUMATIC STRESS REACTION starts to resist or fight the stressor. A COMMON RESPONSE TO DISASTER Social stressors arise from your relationships with - Although individual reactions vary, clinical researchers have other people. identified a common pattern of behavioral, biological, Stress is a nonspecific response of the body to a psychological, and social responses among individuals demanding situation. exposed directly or vicariously to life-threatening events. This Stressors are things that cause stress. Almost response pattern is known as post-traumatic stress everything is a stressor depending on the individual syndrome. It is important to help survivors recognize the normalcy of most stress reactions to disaster. STRESS REACTIONS OF SURVIVORS - Mild to moderate stress reactions in the emergency and - Stress reactions can result from a variety of shocking early post-impact phases of disaster are highly prevalent events. Before, during, or in the aftermath of a disaster, because survivors accurately recognize the grave danger survivors may have experienced additional traumas such as involved in disaster. Although stress reactions may seem lifethreatening accidents, sexual or physical abuse or “extreme,” and cause distress, they generally do not become assault, living or serving in the military in a war zone, chronic problems. Most people recover fully from moderate kidnapping or torture, or the witnessing of terrible things stress reactions within 6 to 16 months. happening to other people. It is important to avoid assuming that a dis- aster involves the same type and intensity of experience for all survivors, and that all survivors bring a similar personal history of trauma into the disaster. EACH SURVIVOR’S DISASTER IS UNIQUE - In addition to involving terrifying close encounters with death and severe physical harm, disaster often causes significant losses that may vary greatly from survivor to survivor (e.g., loss of loved ones, friends, and/or property). Persons who were physically in the same place throughout much of a disaster may have been exposed to different specific traumatic events during and after the disaster. - The “same” disaster may involve multiple elements ranging from accidental trauma (e.g., car, train, boat, or plane accidents, fires, explosions), to natural environmental cataclysm (e.g., floods, hurricanes, earthquakes), to deliberately caused devastation (e.g., lootings, riots, bombings, shootings, torture, rape, assault, and battery). Survivors may experience significant stress reactions, and among survivors, the type and intensity of these reactions EXTREME PERITRAUMATIC STRESS REACTIONS vary greatly within the same disaster. - Extreme “Peritraumatic” stress symptoms (i.e., those symptoms which occur during or immediately after the FACTORS ASSOCIATED WITH DISASTER traumatic disaster experience) include any of the following - People directly exposed to danger and life threat are at reactions if they are of sufficient intensity to cause significant risk for the greatest impact. The literature examining the impairment in reality orientation, communication, role of traumatic exposure is definitive. Regardless of the relationships, recreation and self-care, or work and traumatic stressor, be it combat, physical abuse, sexual education: NPH | 5 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS can look like anger, sadness, numbness, irritability, etc. WHAT TO DO WITH YOUR GRIEF? Don’t be afraid of it Many people are afraid that if they let the feelings of grief in, it will be all consuming and they won’t be able to get out of it. In my experience, the only time that grief becomes all consuming is when it’s hidden away. Invite it in People at highest risk for extreme peritraumatic stress You can set aside time to think about your losses. include those who experience: You can make sure you take care of yourself and ask others to help take care of you so you can invite your grief in. When grief sneaks up on you, you can say hello to it and acknowledge it instead of reacting by pushing it away. Recognize it Can you look underneath your anger? Your ACUTE STRESS DISORDER impatience? Your tearfulness? Your feelings of - A minority of disaster survivors experience sufficiently survivor guilt? Maybe underneath there is grief that persistent and debilitating stress and dissociative symptoms is looking to be expressed. to warrant a diagnosis of acute stress disorder. - The defining feature of Acute Stress Disorder is the development of Express it anxiety, dissociation, and other symptoms that occur within Emotion seeks expression. When feelings aren’t one month of exposure to a traumatic stressor. Acute Stress expressed they get stuck inside us. When feelings Disorder is characterized by five major response patterns: are stuck, all sorts of negative things can happen dissociation or a subjective sense of emotional numbing, a (for example, an over-reliance on numbing re-experiencing of the event, behavioral avoidance, activities, use of substances, emotional walls being increased physiologic arousal and social-occupational put up, etc.) impairment. Understand it POST-TRAUMATIC STRESS DISORDER When we understand our feelings, even if they get - Post-traumatic stress disorder (PTSD) is a prolonged really intense, they aren’t as scary and all post-traumatic stress response. In addition, there may be consuming. If you understand that you are grieving, much greater personality and social impairment than you can take steps to take care of yourself. evidenced in the common stress reactions survivor’s experience following a disaster. Cherish it Your grief is an expression of your love, your hope, WEEK 4-5: GRIEF and part of your authentic self. It’s meaningful and provides an important connection to what/who LIVING WITH GRIEF AND LOSS you’ve lost. DEFINITION OF GRIEF Grief is the normal process of reacting to a loss. WHAT ARE THE BARRIERS TO GRIEVING? The loss may be physical (such as a death, loss of Parents/family members want to protect you from health/function), social (such as loss of friends), or emotional pain occupational (such as a job). Cultural focus on positivity – “look on the bright Emotional reactions of grief can include anger, guilt, side”, cheering people up anxiety, sadness, and despair. Natural human instinct to avoid pain Physical reactions of grief can include sleeping Fear of being overwhelmed by grief problems, changes in appetite, physical problems, Other people’s avoidance of things they don’t want or illness. to think about Grief is real… No one escapes it. Grief is totally Lack of experience in welcoming difficult emotions, normal but sometimes it masks as other things. It lack of coping skills NPH | 6 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS WANT TO EXPLORE GRIEF FURTHER? STAGE 3: BARGAINING Ask a close friend or family member if you can talk The dying person may start to negotiate with God to them about your grief (don’t wait for them to ask i.e. “I’ll live a healthier life,” “I’ll be a nicer person,” “I you). Help educate them about what grief is and the was angry so let me ask nicely to please let me need for you to share it with them. live.” Talk to other survivors – they “get it” and you’ll be They may negotiate with the doctor by saying, “How helping them too. can I get more time so I can live in my dream home, Find a local or online grief counselor (if you have and so on. insurance benefits). There is a deep sense of yearning at this stage to Grief groups be well again. WHEN GRIEF GETS COMPLICATED STAGE 4: DEPRESSION Sometimes grief gets complicated – it can lead to When reality sets in about their near death, depression or anxiety that you can’t manage alone. bargaining turns into depression. Talk to your doctor. Fear of the unknown Sometimes you feel traumatized by what you’ve Guilt for demanding so much attention and gone through – experiencing trauma can make grief depleting the family income occurs. very complicated. Seek out a therapist who can Be available to listen instead of cheering them up, help you make sense of what you’ve gone through or rambling, repetitive talk. so you can grieve in healthy ways. Distraction like talk about sports, etc., is good but don’t ignore the situation. GRIEF AND PERSONAL GROWTH Personal growth is only possible in conjunction with STAGE 5: ACCEPTANCE inviting, understanding, and expressing your grief. When the dying have enough time and support, By itself, a focus on personal growth through loss they can often move into acceptance. can be another barrier to grieving. There is an inner peace about the upcoming death. Ways that grief helps us to grow: The dying person will want someone caring, and Search for renewed purpose in life, clarity of goals accepting by their side. and dreams, positive changes in relationships with others and yourself, changes in perspective, taking SUMMARY on new challenges, sense of peace and The stages don’t always occur in order. connectedness. Whether you are the patient or the loved one, nobody escapes grief. STAGES OF GRIEF People grieve at different rates of time. Delayed THE 5 STAGES OF GRIEF grief can occur when people suppress the emotions 1. Denial of the death and years later, get depressed. 2. Anger Cultural differences, age, gender, race, and 3. Bargaining personality change the way people grieve. 4. Depression Bereaved persons have higher rates of depression, 5. Acceptance and are at greater risk for illness than non-bereaved. STAGE 1: DENIAL Refusing to believe a probable death will occur. HELPING CHILDREN COPE You can help others face it by being available for Be straightforward; distortions can do lasting harm i.e. them to talk instead of forcing them to talk about it. “He's gone to sleep” can lead to a fear of sleep or “God took her,” leads to a hate for God. STAGE 2: ANGER Reassure that there is no way to be blamed and will be Once the diagnosis is accepted as true, anger and taken care of. hostile feelings like the following can occur: Let the child participate in the family's sorrow and grief. ○ Anger at God for not allowing them to see Give as much attention to the child who cries as to the one their kids grow up who doesn’t cry. ○ Anger at the doctors Silence between family and friends makes it worse. ○ Anger at the family Don’t say, “you are the man of the house now” or “be ○ Try not to take it personally. They have a brave.” right to be angry so allow them to express themselves so they can move on in the GRIEVING LIFE EVENTS grieving process. NPH | 7 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS Events like divorce, separation from children, a life experience to be lived. break-up of boyfriend/girlfriend, losing a a mystery to be entered. job/unemployment, can feel like going through an a stimulus for compassion and kindness. inner death. a reminder of who and what we have loved. The stages of denial, anger, bargaining, depression, a longing for relatedness. and acceptance also occur in these circumstances. Feeling “dead” in our job, in our relationship, in our DEFINITIONS: roles, in our bodies is a reality with many people. GRIEF is the process of psychological, social & somatic Do drugs “deaden” your emotions and energy? reactions to the perception of loss. Does a mother or father “deaden” your enthusiasm? MOURNING is the cultural response to grief. Turn away from these “deadening factors” and BEREAVEMENT is the state of having suffered a loss. choose to find peace, meaning, value, and purpose GRIEF WORK is the work of dealing with grief, requiring the in your life. expenditure of physical and emotional energy. HOW TO COPE WITH DEATH GRIEF MODELS Allow yourself to grieve by looking at pictures, No one accepted model. playing nostalgic music, and reading old letters. Grieving is: Use dance as a way to express how you felt. ○ Active Use painting/drawing to express your feelings. ○ Healing Imagine how Jesus, Buddah, Mohammed, or a ○ Skillful greak oak tree would tell you how to cope with it. ○ Transformative Funerals, ceremonies, and rituals help people with ○ Connective the grieving process. ○ Social GRIEF AND BEREAVEMENT: A PRACTICAL APPROACH BACKGROUND ISSUES AND FACTORS IN GRIEF: COMPOUNDING OF LOSSES INTRODUCTION TO GRIEF A single loss will precipitate other losses. Grief is a normal phenomenon common to all of us. ○ e.g. the physical loss of a breast through a As we go through life, we experience a wide variety mastectomy for breast cancer will cause of losses for which we grieve. losses in the areas of body image, It is not possible to go through life without suffering sexuality, role, good health and losses. independence. Grief is the response to any loss and is therefore a common human experience. BACKGROUND ISSUES AND FACTORS IN GRIEF: ○ a common but often unrecognized part of CHARACTERISTICS OF THE BEREAVED life cycle changes. Inconclusive evidence that men do more poorly ○ often seen as interfering with life, rather than women but there are differences in the way than being intrinsic to life. Subsequently grief may be handled. We do not mentor our children concerning this There are more consequences in children aspect of life. especially if grief is not managed well. ○ we tend to protect them, not only from Older persons in general may have less intense & death, but often also from the little losses fewer reactions but this depends somewhat on the that happen throughout our lives relationship to the deceased. A terminal illness or indeed any chronic illness is ○ Often overlooked is the intense grief replete with successive losses and consequent subsequent to the loss of adult children. grief. Poor physical health may limit the ability to expend Losing your own life i.e. dying is associated with the necessary physical and psychic energy to grief. integrate grief into our lives. Losing a loved-one is also associated with grief. The use of drugs such as psychotropic agents. Who feels the grief—all ages, all persons and often A previous history of psychiatric problems or care providers. addictions like alcoholism. Grief starts with the symptoms of illness and the There are few conclusive studies about the diagnosis of any illness. influence of personality variables and the course Good end-of-life care has incorporated the concept and outcomes of grief. of good grief (i.e. a healthy expression of our life Patterns of coping. force) as part of a good death. Past or current experiences with grief. Current other psychological or social problems or GRIEF IS: crises. NPH | 8 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS Culture, ethnicity & religion. Children cope with grief according to their There is a unique nature to each relationship. developmental stage & may revisit a grieving The role that the deceased had in the family e.g the situation as they reach new developmental stages. power authority in the family. ○ For example, a death witnessed as a The amount of unfinished business in the toddler can resurface & need to be relationship. addressed again in a 7-year-old. Dysfunctional families will react in their usual patterns—they will be dysfunctional! PSYCHOLOGICAL PHASES OF NORMAL GRIEF Need to be interpreted not necessarily as sequential BACKGROUND ISSUES AND FACTORS IN GRIEF: THE but more likely concurrent processes through much NATURE OF THE DEATH of the grief experiences that change and remit over There are no studies indicating significant time until healing occurs. differences between acute vs. chronic deaths as far as outcomes are concerned but many of studies PSYCHOLOGICAL PHASES OF NORMAL GRIEF: ACUTE have not been done in populations receiving good OR SELF-PROTECTIVE PHASE palliative care. Initial shock, denial and disbelief. Violent deaths such as those secondary to crime or May feel dissociated from the world around them accidental deaths. If the family is well prepared, there may not be the Suicidal death. same amount of shock or avoidance. Sometimes initially see an intellectualized BACKGROUND ISSUES AND FACTORS IN GRIEF: acceptance without an emotional component as an CHARACTERISTICS OF THE DECEASED initial denial of the loss, rather than a necessary self The age of the deceased particularly if young will protective mechanism. affect the course and outcomes of grief. The type of person the deceased was. PSYCHOLOGICAL PHASES OF NORMAL GRIEF: The timeliness (e.g. at retirement, around the time CONFRONTATION of an important event such as the birth of a Most intense experience of grief. grandchild, a marriage of a child, etc.) may Emotional extremes common. influence the course and outcome of grief. ○ an emotional “roller coaster”. Rapid and large swings in emotion often cause fear BACKGROUND ISSUES AND FACTORS IN GRIEF: THE & more anxiety. ADEQUACY OF SOCIAL SUPPORT Anger is a common component including anger that Persons lacking or withdrawing from support may may be directed towards physicians and other have worse outcomes. health care team members. Remarriage or other close or intimate relationships Guilt, inwardly directed anger, confronts the protect. bereaved with questions of : Culture. ○ “What if I had…?”, “Did I do enough?”, “What did I do wrong?” “What did I do to BACKGROUND ISSUES AND FACTORS IN GRIEF: deserve this?” GENDER ISSUES Guilt around so-called survivor guilt. Men may have different coping styles than women: ○ “Why wasnít it me?” ○ To remain silent. Sadness & despair. ○ To engage in solitary mourning or ìsecretî Inability to concentrate or process information. grief. Preoccupation with the deceased. ○ To take physical or legal action. Over time the extreme emotional swings lessen. ○ To become immersed in activity. Intermittent denial may also occur. ○ To exhibit addictive behaviour. Social manifestations of this phase include: ○ Restlessness & inability to sit still. BACKGROUND ISSUES AND FACTORS IN GRIEF: ○ Lack of ability to initiate & maintain CHILDREN & GRIEF organized patterns of activity. Children of all ages grieve & grief is particular to ○ Difficulty completing or concentrating on age groups. tasks at work. Children should not be protected from grief, funerals ○ Withdrawal from the very people who may or issues of death & dying. be able to help. They need to be educated in terms they can Physiological or somatic manifestations of grief are understand. common: Parents must be involved in the education. ○ Often these complaints bring the bereaved into physicians’ offices. NPH | 9 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS The elderly bereaved are a group vulnerable to Some individuals and families will illness and physical symptoms must be addressed accomplish the tasks of grieving in two appropriately. years. Spiritual issues: Advocate for sufficient time off from work ○ The basic search for meaning and value in for the bereaved especially in the first few life, i.e. “who am I?” weeks of bereavement. ○ The feeling of abandonment & anger. Discuss the fact that grief spikes continue ○ Fear of the unknown. for life through events, holidays and ○ Finding a secular framework to face the “anniversary” reactions. unknown—the mystery of death. 5. Emphasize the role of the funeral and of memorial service. PSYCHOLOGICAL PHASES OF NORMAL GRIEF: Encourage families to bring children to REESTABLISHMENT these rites. Grief gradually softens to an ìacceptanceî of the Consider having memorial services in reality of the loss. hospitals, agencies and palliative care Gradual decline in symptoms as grief becomes programs for bereaved families and for integrated into life. staff. Grief is compartmentalized but periods of grief may 6. Medications, particularly tranquilizers and arise at specific times such as holidays, birthdays, antidepressants are usually not needed for any etc. sustained period of time. 7. Contact the bereaved at regular intervals. COMPLICATED GRIEF Definitely monitor any families with high 1. Delayed or absent grief. risk for grief problems. 2. Conflicted grief. 8. Identify concurrent problems that may interfere with 3. Chronic grief. normal grief. 4. Psychiatric disturbances associated with grief. 9. Use resource books that have been written on grief 5. Physical illness associated with grief. to help the bereaved. 10. Monitor children at school for grief problems THE FOUR TASKS OF MOURNING (WORDEN) manifesting as school problems. To accept the reality of the loss. 11. Investigate to see what types of bereavement To experience the pain of grief. programs exist in your community. To adjust to an environment in which the deceased is missing. NATURE OF GRIEF WORK To withdraw emotional energy and reinvest it in A. Family (friendship) orientated: other relationships. The ability to accept loss is at the heart of all skills in healthy family relations. GRIEF COUNSELING GOALS B. Relational: To increase the reality of the loss. Opportunities for resolution, forgiveness, To help the bereaved deal with both experienced & gratitude. latent affect. C. Intergenerational: To help the bereaved overcome impediments to How we want to be remembered. readjustment. Legacy work e.g. what are we leaving To encourage the bereaved to make a healthy behind as a legacy. emotional withdrawal from the deceased & reinvest Healthy and effective parenting model. energy into other relationships Mentorship re: coping skills with children. Decreasing fear in future generations. MANAGEMENT: BASIC ISSUES Teaching children. 1. Begin grief counseling if possible while the patient is Learning from children. still alive. People die, relationships donít. 2. The family is the unit of care. D. Psycho educative: 3. Grief is a normative process and requires much Anxiety about the unknown. listening and often not a lot of intervention on the What changes to expect. part of the counselor. Forewarned is forearmed. 4. Allow sufficient time to grieve. Physical & emotional. Most people resolve to a level of Changing family dynamics/roles. functioning around one year. E. Harm reductive/preventative: Identifying destructive coping mechanisms. i.e. alcohol/drug use. NPH | 10 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS F. Community oriented: Avoidance: Shock, denial, disbelief, confusion, Looking at the larger social interaction e.g. disorganization. in school or workplace. Confrontation: “highly emotional state wherein the G. Active: grief is most intense and the psychological What do we need to do in order to reactions to loss are felt most acutely.” integrate how we are changed? Reestablishment: “gradual decline of the grief and H. Narrative: marks the beginning of an emotional and social Richly descriptive in elucidating personal re-entry back into the everyday world” meaning—”Tell me what it is you see death or this loss as?” According to Rando, the griever will: I. Supportive: Acknowledge, accept, and understand the reality of Facilitating the safe containment of the loss. emotional space. Experience the pain of the grief and react to the J. Intrapsychic: separation from that which is lost. Facilitating connection to our own deeper Adapt a new way of life. wisdom and ability to heal ourselves. Reinvest in a new way of life. K. Spiritually supportive: We are dealing with the unknown, with ANTICIPATORY MOURNING (RANDO, 2000) life’s mysteries. “The phenomenon encompassing seven generic operations: Grief SUMMARY Mourning Grieving is the active way by which we incorporate Coping grief into our lives and discover how we are Interaction changed by it. Psychosocial reorganization It is open ended and is continually transformed as Planning we go through life and experience further losses. As Balancing conflicting demands caregivers we need to be self-aware. Facilitating an appropriate death” If we cannot bear our own grief, it will be hard to work in the presence of another personís grief. DISENFRANCHISED GRIEF (DOKA, 2002) According to Doka: “this grief is experienced in connection LOSS AND GRIEF with a loss that is not socially acknowledged, publicly shared, GRIEF: A UNIVERSAL EXPERIENCE or supported through usual rituals. The significance of the “To spare oneself from grief at all cost can be achieved only loss is either not recognized or the relationship between the at the price of total detachment, which excludes the ability to deceased and the bereaved is not socially sanctioned, the experience happiness.” Erich Fromm (1900-1980) person suffering the loss is given little or no opportunity to mourn publicly. It is experienced when the relationship is not FIVE STAGES OF GRIEF (KUBLER-ROSS, 1969) recognized (lovers, ex-spouses, same-sex partners, close Denial: The initial stage: “It can’t be happening.” friends), when the loss itself is not recognized (stillbirth, Anger: “Why ME? It’s not fair?!” (either referring to miscarriage, abortion, adoption, pet loss), when the griever is God, oneself, or anybody perceived, rightly or not recognized (very young, very old, developmentally wrongly as responsible) disabled). The manner of death itself can be disenfranchising Bargaining: “Just let me live to see my son (murder, suicide, AIDS). When such deaths are treated as graduate.” less than significant losses, the process of grieving becomes Depression: “I am so sad, why bother with more difficult.” anything?” Acceptance: “It’s going to be OK.” THE GRIEF PROCESS (WORDEN, 1982) The Tasks of Grief: These stages of grief do not come in order. They can be To accept the loss applied to any form of catastrophic life losses: Experience the pain Loved One Adjust to the new environment Employment Reinvest in the new reality Home Income COMPLICATED GRIEF (WORDEN, 2001) Freedom Chronic Grief: One that is prolonged, is excessive According to Kubler-Ross a person simultaneously in duration, and never comes to a satisfactory experiences two of the stages at any given time. conclusion. Delayed Grief: Emotion that has been “inhibited, UNDERSTANDING LOSS (RANDO, 1984) suppressed, or postponed.” A subsequent loss may NPH | 11 DISASTER AND MENTAL HEALTH BS PSYCH | REVIEWER | PRELIMS elicit an exaggerated reaction because the bereaved is grieving for two losses. Exaggerated Grief: Occurs when feelings of fear, hopelessness, depression, or other symptoms become so excessive that they interfere with the daily existence of the bereaved. Masked Grief: Symptoms and behaviors experienced by a person who does not recognize the fact that these are related to a loss. PREPARED AND ARRANGED BY: _______________________________________ Nicole P. Hernandez PSYCHOLOGICAL SOCIETY OLFU-QC, HEAD OF EDUCATIONAL COMMITTEE (Special thanks to Diollana Mendoza) CHECKED BY: _______________________________________ Lian Jill Magallanes PSYCHOLOGICAL SOCIETY OLFU-QC, OFFICER-IN-CHARGE OF EDUCATIONAL COMMITTEE Note: This reviewer is exclusively for the students of the Psychology Department at OLFU-QC. Kindly refrain from sharing this material outside the program or the university, as it constitutes our intellectual property. Thank you. Disclaimer: We disclaim any responsibility if the content of this reviewer does not appear in the actual exam. Please refer to your professor's materials, such as textbooks or presentation slides, for further information. NPH | 12