Clinicians Offering Supportive Interventions
A caregiver is an individual who takes care of a patient. he/she may be a family member or a professional clinician. This, more often than not, leads to the onset and development of caregiver ‘depressive symptoms’, especially when the patient has been ill for a long period of time, and has needed constant and round the clock care for a number of years. (Mittelman; Roth; Coon; Haley, May 2004) Supportive intervention can also refer to ‘crisis intervention’, which means that the caregiver will use certain short-term and immediate methods to support and help those individuals who have experienced any incident or event that produces emotional, mental, physical or behavioral stress and strain and distress. The individual may, at that particular point of time, immediately after the traumatic event, find that he is not able to fully use his natural ability to cope or to solve problems. (Crisis Intervention)
The complex grieving situation may be any one of these, or a combination of one or two events: a life threatening situation, such as a criminal victimization, or a natural disaster, like an earthquake, a sexual assault or rape, the sudden onset of a medical illness, or a mental illness, thoughts of suicide, or at times, homicide, or a sudden loss of a loved one in a tragic situation. When a caregiver is faced with the individual who has just undergone and experienced this type of crisis situation, he will, at the outset, attempt to reduce, to a certain extent at least, and the intensity of his emotional, mental, and physical and behavioral reactions to the crisis. He will then help and aid the patient to return to the level of functioning that he had before the trauma. The caregiver, in this case the clinician, will be responsible for developing new and effective coping skills for the patient, and also for eliminating the generally ineffective methods of coping that the patient may be indulging in at the moment, like for example, withdrawal, substance abuse, or isolation. When the patient learns the better methods of coping that the clinician caregiver teaches him, he would be better able to cope, and also be able to reap the benefits of coping skills at a later date in his future. (Crisis Intervention)
The clinician is at times expected to face the traumatized patient, who has undergone a crisis and is at present going through a grieving process, independently, and offer to teach the patient effective methods of coping. One such method is the ‘non-violent crisis intervention method’, wherein the caregiver adopts a safe and a harmless and non-violent behavior management system, which would provide the best and most effective care for the patient, even when he is at his most traumatized and perhaps violent stage of reaction. For example, the caregiver is trained to notice a set of behaviors, which would lead the patient into committing violent acts: when a patient is reaching a high level of anxiety, there would be a noticeable change in his behavior, wherein he would pace to and fro or he would start to drum his fingers rapidly, or he would repeatedly wring his hands, or stare constantly at an object or a person. (Non-Violent Crisis Intervention)
When the clinician notices these symptoms of anxiety, he can immediately offer a non-judgmental support, and thereby, calm him down and bring down his anxiety levels. If for example, the patient has started to become belligerent, and starts to challenge authority, then it means that he has lost his rationality. At this time, the clinician must be trained to be supportive, and at the same time, to be able to take full control of a potentially dangerous situation, by setting limits for the traumatized and grieving patient. At times, the patient may lose complete control, and start to physically act out the traumatic episode that he has been subjected to. The clinician must be able to use restraint, with no small amount of caution; until such time that the patient may be able to regain full control of him. He must also be equipped to re-establish communication with the patient, after the patient has recovered form his irrational episode. (Non-Violent Crisis Intervention)
It must be remembered that care giving for the elderly group of population is an art in itself, and this is because of the fact that every one does have a pre-conceived notion of what it means to be old. More often than not, these opinions would have been formed when one was young and inexperienced, and based on one’s own experiences with family members and friends. Caregivers of the old therefore must, at the very outset, unlearn their preconceived ideas of the elderly, and learn what it means to take care of them, and offer support when they are in a grieving situation. It has been stated time and again, that the very tapestry of old age has a functional, as well as an aesthetic and visual use for the clinician caregiver, wherein he can learn to be a better caregiver from listening and taking note of the numerous and varied stories of experiences that old age inevitably provides to the young. (McCall, 1999)
In another common complex grieving situation, a child loses his parent, to, for example, disease. The surviving parent would, therefore, have to take up, immediately, the task of taking care of the child. He would have to provide understanding, emphatic nurturance and discipline, among other things. Most importantly, however, the child would have to be given reassurance that he would be taken care of very well, and that the no harm would come to the surviving parent. (Christie, 2000) Care giving, however, must never be romanticized or at the same time, trivialized; it can be an extremely trying process, even in the best of situations. At times, the individual who cares for a bereaved or traumatized person may well be affected himself by the devastating range of emotions that he has to witness while offering intervention, day after day. (Davidson, 1999)
When, for example, the 9/11 terrorist attacks took place, hundreds and thousands of people were left suddenly deprived of children or spouses or parents, and in the immediate aftermath, many people were too numb and grief stricken to understand what exactly was happening. Many others were left feelings shock, grief, depression, intense emotionality, disbelief, anger, and also physically unwell as a result of this massive shock. An individual in such a situation may demonstrate traumatic grief, and this is characterized by a preoccupation with the deceased, a pain in the same area as the deceased suffered before his death, and a feeling that it is not worth living any more. Professional intervention offered by clinicians and other caregivers helped these people out a great deal. (Managing Grief after Disaster)
In one study by Strobe, undertaken to assess the outcomes of the counseling offered by support groups and others, a method was developed, wherein the extent to which an individual would confront or avoid their losses, and the outcomes of this confrontation were measured. It was found that lower scores for a widow did not influence the outcome, and for a widower, a lower score predicted a poorer outcome. However, this fact became very obvious: that early intervention, offered by a professional clinician, is a very good idea in the immediate aftermath of a disaster or a trauma. Although data suggest that even after a sudden, violent incident or a death, most people eventually grieve successfully, the initial grieving process does take up an inordinate amount of time, and most people prefer not to consult a professional to help them deal with the grief. At the same time, however, it must be remembered that a sudden loss of a loved one can be extremely traumatizing, and the intensity of emotions that the bereaved person may feel can well be truly frightening, and this would mean that professional outside intervention and support would be needed immediately, to help the person. (Managing Grief after Disaster)
Some of the useful components of grief intervention would include: providing the patient with relevant information about grief, and the various symptoms of grief, the course that it generally takes, and the complications that inevitably result from grief and trauma. The next step would be to evaluate accurately the exact nature of the bereaved person’s distress and grief. This would help him to solve problems and complications arising from the grief, and also to provide the best and the most effective strategies that the patient can use to deal with his grief. The most important step of all, which the clinician can use to help the patient, is to help him to think of death in a way that would lead him towards emotional resolution. The clinician must be careful of using affect-evoking interventions and expert skill, and learn to use intervention methods that are balanced with containing and soothing strategies. According to Prigerson and Jacobs, 2001, there is a list of do’s and don’ts for how a physician or a clinician may interact with the family members of a patient who has recently suffered a devastating loss of a loved one.
The first on the recommended list is that the physician must acknowledge the grief that the person is feeling, and also acknowledge the fact that he, himself, may not know what the bereaved person is going through at that particular moment. He can directly express sympathy for the bereaved family, and he can talk freely about the deceased, and mention his name too, when talking about him. He can elicit questions about the exact circumstances in which the death had occurred, and he can ask direct questions about how the bereaved feels, and what he thinks about the death and how it has affected him. The don’ts to be followed by the physician or clinician are that the clinician must never adopt a casual or passive attitude, like for example, saying, ‘call me if you want to talk’. He must also learn never to make statements that what happened was for the best, and so on, and he also must never assume that the bereaved person is strong, and will therefore perforce get through the entire episode of grief quickly. He must never avoid talking about the deceased person, especially if the bereaved demonstrates a willingness to talk about it. (Managing Grief after Disaster)
William Worden has created a ‘Four Tasks of grief Model’. The model is to be used by a recently bereaved or a traumatized individual who has recently suffered a great loss of some kind, to help him to deal with his grief in an active manner. ‘Task One’ according to Worden, is to accept the reality of the loss that has befallen the bereaved. Task Two is to thereafter, work through the pain and trauma of the grief. Task Three is to learn to adjust to a different sort of environment, and to a world in which the dear loved one is no longer alive. Task Four, according to Worden, is to emotionally relocate the deceased, and then, move on with his own life. (J William Worden’s Four Tasks of Grief Model)
In general, a person who has recently suffered a tragedy or trauma turns to metaphors in order to deal with the grief in a better manner. Metaphorizing would also help the individual to understand, and then to express their experience better. Some examples of where a metaphor is used to describe grief: ‘grief is a whirlwind’, ‘grief is a Great Depression all over again’, and ‘grief is gray, cloudy and rainy weather’. The clinician who provides intervention for the bereaved and grief-stricken person can in fact enhance his bereavement efforts by making serious attempts to learn to identify and thereafter to cultivate such metaphorical expressions of grief, from the families and others involved. (VandeCreek, 2005)
It is interesting to note that until recent times, it was believed that everyone inevitably goes through the very same sequences of recovery from grief, and at an average, the same speed too. Any departures from the pattern of mourning, or the length of the grieving period were taken to be the indicators of pathological grief. Furthermore, the idea that the bereaved individual would eventually try to strike out on an entirely new life, different from his old one, were never highlighted in these older grief models. Recently, however, numerous other grief models have been developed, and other Worden’s four tasks of grief model, Kubler-Ross have created another, based on the various stages of accepting grief. The first stage, according to Kubler-Ross, is that of numbness. This is a stage that immediately follows the death of a loved one, and it would generally last for about seven to ten days. (the phases and Tasks of Grief Work)
Numbness refers to the sense that the person has, of disbelief and paralysis, and a sense of being far removed from what has happened, and what is happening. The clinician must remember that many people consider that this feeling of numbness is the body’s own coping mechanism in the face of devastating grief, so that one may not be overwhelmed by the grief that one feels at the bereavement that has taken place. The second stage is when the bereaved feels that he has great difficulty in accepting the reality of the loss that he has had to bear. This can lead to the bereaved behaving in an irrational manner, wherein he acts as if the death had not occurred at all. The clinician must note that complete acceptance of death is a part and parcel of the process of grieving and subsequent revival. The third stage is when the bereaved feels an irrational anger towards the entire world, against God, against fate, and also against the remaining people in their lives. Bargaining with God for the safe return of the deceased person is also a part of this stage. The fourth stage is when the bereaved gradually starts to accept reality, and what has happened. Acceptance is the fifth and final stage of grief, and this is when the bereaved has come to terms with his loss, and is finally able to move on to re-invest and re-affirm in the life that lies ahead of him, without his loved one. (the phases and Tasks of Grief Work)
Recently, researchers, including Worden and mental health specialists have come to recognize the fact that there are four important tasks that a bereaved individual must be able to achieve, before he can fully integrate his experience of loss and the trauma associated with it, into his life, and then move on to a new life, without his beloved one. These then are the four basic tasks: he must first recognize the loss that has happened to him, even though it is a fact that he may try to minimize it or even deny it completely altogether. Once he accepts the loss, then he would be able to process it intellectually. His next task would be to release the emotions that grief and loss bring into a person’s life. This may be accompanied by the myriad of emotions associated with loss: despair, sadness, anger, disbelief, and shame.
Even though these feelings may be omnipresent at first, they do fade gradually to a dull and permanent ache. The fact that grief tends to surface unexpectedly may lead people to believe that the bereaved is out of control. The third task is to develop new skills; in other words, the bereaved must try to take on new roles, and make new contacts in the world, or find a grief support group. Finally, the bereaved must be able to invest plenty of emotional energy in his present, wherein the new relationships or new contacts that he has formed would be able to derive the direct benefit. It is at this phase that the bereaved will feel that he is now, finally able to say ‘farewell’ to his deceased loved one. (the phases and Tasks of Grief Work)
When deciding on intervention in a crisis or a grief situation, the physician or the clinician must be careful in choosing who to treat, and who to include in the intervention process. The family and community of the bereaved must be taken into consideration, especially if it is a young person who has lost a loved one. According to Worden, children may often feel that they need to hide their complex reactions and trauma brought on by their parents’ divorce, perhaps because of the existing conflict between the parents. (Roberts, 2000)
It must be remembered that research has revealed the fact that grief and a grieving situation is indeed extremely complex, and it can depend on a number of varied factors. This would therefore mean that in a case where a clinician needs to bring in intervention methods to help the individual who is grieving, the personal and the situational contexts in which the bereavement has occurred must be taken into consideration. These would thereafter be allowed to influence the treatment decision that the clinician will be making at a later date, for the bereaved. Children, middle-aged persons, young people, and the aged, all experience complex symptoms of grief, and they differ from individual to individual, and from situation to situation, and the clinician must be able to focus his efforts on the appropriate and accurate mixture of physical, mental, and social factors involved, when making a treatment plan for the patient. The better the intervention and the earlier, the quicker would be the patient’s response, and the faster he would be able to get back into the mainstream of life, and overcome his grief at his loss. (Stroebe; Stroebe; Hansson, 1993)
In conclusion, it must be stated that, both conceptually as well as clinically, it is extremely important to encourage more links between trauma and grief, and thereafter, to understand the fact that there is inevitably an overlap between the two. The post traumatic stress and grieving that traumatic incidents produce must be taken into account by the intervening clinician and the physician during treatment of the grief. Crisis intervention, intermediate trauma treatments leading to trauma mastery, addressing initial tasks of grief and mourning, and finally, trauma and loss accommodation are all a part of the intervention processes, and these then would help the patient to cope better and regain a part of the life that he had lost when his loved one died. (Traumatic Grief, what we need to know as Trauma Responders)
Ambrose, Jeannette. “Traumatic Grief, what we need to know as Trauma Responders” Retrieved from http://www.ctsn-rcst.ca/Traumaticgrief.html. Accessed 15 July, 2006
Christie, Grace. (2000) “Healing Children’s Grief, surviving a parent’s death from cancer”
Crisis Intervention” Retrieved at http://www.minddisorders.com/Br-Del/Crisis-intervention.html. Accessed 14 July, 2006
Davidson, Joyce D. (1999) “Living with Grief, at work, at school, at worship”
Psychology Press (UK)
William Worden’s Four Tasks of Grief Model” Retrieved at http://www.thenewsongcenter.org/fourtasks.php. Accessed 15 July, 2006
McCall, Junietta Baker. (1999) “Grief Education for Caregivers of the Elderly”
Mittelman, Mary S; Roth, David L; Coon, David W; Haley, William E. (May 2004) “Sustained benefits of Supportive Intervention for Depressive Symptoms in Caregivers. American Journal of Psychiatry. Vol: 161; No: 4; pp: 850-856.
Roberts, Albert R. (2000) “Crisis Intervention Handbook, assessment, treatment and research”
Shear Ketherine. “Managing Grief after Disaster” Retrieved at http://www.ncptsd.va.gov/facts/disasters/fs_grief_disaster.html. Accessed 14 July, 2006
Slap-Shelton, Laura. “The phases and Tasks of Grief Work” Retrieved at http://griefandrenewal.com/article9.htm. Accessed 15 July, 2006
Stroebe, Margaret S; Stroebe, Wolfgang; Hansson, Robert O. (1993) “Handbook of Bereavement, theory, research and intervention” Cambridge University Press.
VandeCreek, Larry. (2005) “Building Metaphors and Extending models of Grief” Vol: 1; No: 2;
The Hospice Journal. pp: 79-90
Wards, Carroll, R. “Non-Violent Crisis Intervention” Retrieved at http://www.easc.noaa.gov/Security/webfile/erso.doc.gov/briefings/CPI.ppt. Accessed 14 July, 2006
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