Grief and the Wellness: A Solution Focused Faith Driven Training Manuel
A PROJECT PAPER
PRESENTED FOR
CAPELLA UNIVERSITY
BY
STEVEN L. JORDAN
July 2003
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TABLE OF CONTENTS CHAPTER
PAGE
1. INTRODUCTION.......................................................................................................................................................1 TRAINING GUIDE 2. THE NATURE OF GRIEF.........................................................................................................................................5 DEFINING GRIEF................................................................................................5 STAGES OF GRIEF................................................................................... ..........7 A BIBLICAL VIEW OF GRIEF..........................................................................12 3. DISCOVERING SELF..............................................................................................................................................15 SELF-AWARENESS EVALUATION.................................................................16 SPIRITUAL NEEDS SCRIPT..............................................................................18 4. LISTENING: THE BEGINNING OF GRIEF COUNSELING.................................................................................19 LISTENING IN CONVERSATIONS..................................................................26 LISTENING IN CONVERSATION QUESTIONAIRE......................................27 5. THE MOURNING PROCESS: THE KEY TO HEALTHY GRIEF.........................................................................28 6. AN OVERVIEW OF NORMAL/ ABNORMAL GRIEF REACTIONS...................................................................32 7. A STRATEGY OF MINISTRY TO THE GRIEVING.............................................................................................35 GENERAL PRINCIPLES OF GRIEF MINISTRY- FOUR TENDER TOUCHES FOR THE GRIEVING..........................................................................................35 8. Conclusion................................................................................................................................................................37 9. BIBLIOGRAPHY.....................................................................................................................................................42 10. APPENDIXES........................................................................................................................................................45
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CHAPTER 1 INTRODUCTION Over the past 23 years I have struggled with hidden or masked grief regarding the death of my foster mother who died when I was 12 years old. The struggle lasted for such a long time primarily because well-meaning people who were not knowledgeable of the grief process would not allow me to grieve her passing as a child. Family members, church officials, and other professional people that I needed to move on with my life before I had acknowledged and dealt with this major loss informed me. Clergy persons and family members were quick to tell me that my foster mother had gone to be with the Lord. They shared that bit of wisdom as if it was some magical cure for the separation and hurt I was feeling. When I cried or tried to communicate with my new parental figures regarding my feelings of loss, I was treated as if tears of grief represented personal inadequacy and weakness. I know now that my expressions of emotions caused feelings of helplessness in friends, family, and helping professionals. It was out of their lack of knowledge of the grief process and their desire to protect me from pain that they inadvertently inhibited my grief process. I recall being told platitudes such as, "Tears will not bring her back", and "She would want you to be a big boy and not cry. Someone forgot to tell them that crying was nature's way of releasing internal tension and allowing the bereaved person to actualize his reality. Because of those experiences and many others, I have decided to do my project paper on, "Grief: A Death and Dying Pathological Reality". This project paper represents my ability to finally come to closure with the emotional suffering caused by her death. Grief and its proper management is recognized as a vitally important component of good emotional, physical, and spiritual health. Books and articles have been written, describing both the grieving process and how to help people work through it to a healthy resolution. There is an increased interest in the area of grief care and issues related to death and dying. In the past twenty-five years, the importance of learning from the experiences of loss in our lives evolved in both the social sciences (psychology, sociology, and anthropology), and the biological sciences (medicine and biology). Thanatology, the study of death, dying, and grief has become an interdisciplinary field.
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As a result of my studies, I have concluded that underneath almost every particular psychological condition, there is an unresolved grief reality. In other words, unresolved grief is at the root of almost every personality disorder, psychiatric illness, or dysfunctional relationship. John Bowlby confirms this phenomenon when he says, "Clinical experience and a reading of the evidence leave little doubt of the truth of the main proposition--that much psychiatric illness is an expression of pathological mourning--or that such illness includes many cases of anxiety; depressive illness, and hysteria, and also more than one kind of character disorder.� (Bowlby, 1980) In this paper, I will define the grieving process in broad terms, to show that people grieve over various kinds of losses in life. This grief often surfaces as the underlying cause of various physical and mental aberrations. Chaplains, pastors, and health care providers must become more knowledgeable of the grief process and its various components, in order to provide any kind of holistic counseling. Because at the root of almost any pathological dysfunctional behavior, you will find the underlying cause to be a grief related issue. Therefore, if you can facilitate resolving the unresolved grief reality, you can enable the person to authentically address the problematic reality. The focus is to prepare a training guide that can be used to train clergy and health care professionals concerning grief. To accomplish this goal, I will draw upon experiences and encounters from staff, patients and family members I ministered to during this past year at Walter Reed Army Medical Center. After defining grief according to such experts in the field as G. Engel and E. Kubler-Ross, and looking at its expression in the lives of significant people, I will conclude with a training guide that will provide methods of addressing grief. This guide will address the following subjects: The Nature of Grief; Discovering Self; Listening: The Beginning of Grief Counseling; The Mourning Process: The Key to a Healthy Grief Process; An Overview of Normal and Abnormal Grief Reactions and A Strategy of Ministry to the Grieving.
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THE TRAINING GUIDE CHAPTER 2 THE NATURE OF GRIEF
Defining Grief Websters defines grief as "a poignant distress". Bereavement is defined as, "To deprive someone of something."(Woolf, 1981) In other words, grief is a powerful emotional response to a significant loss. As mentioned earlier, that loss may be a death, but it also can be a variety of other things. David Switzer says of grief: "It should be recognized from the outset that significant losses of persons may take place in ways other than death: divorce, extended separation related to business or military assignment.... In addition, similar emotional reactions take place in other situations involving the loss or threatened loss of things....... (Switzer, 1970) Nurses Brown and Burnes wrote also of this relationship. They said, "Loss is a universal human experience that can find expression in many ways and on many different levels. For example, we can lose face, a loved one, a town through natural disaster, or a Space Shuttle."(Brown and Burnes, 1987) A second characteristic of grief is that it is an ongoing process. Loss is like an earthquake that-shakes the foundation of our life. The initial devastation is bad enough, but there are also "after-shocks" to deal with. These are part of the sometimes long road back to full recovery and restoration after loss. C.S. Lewis discovered this aspect of grief in his own life: "Grief is like a long valley, a winding valley where any bend may reveal a totally new landscape. As I've already noted, not every bend does. Sometimes the surprise is the opposite one; you are presented with exactly the same sort of country you thought you had left behind miles ago.� (Lewis, 1988) As Lewis discovered in the loss of his wife, the process of grieving covers abroad landscape of emotional response. Each person must travel that road and view the landscape of grief in thier own way and may even repeat some parts of the journey more than once. However, the landscape of grief does have some constants that all people must deal with and recognize. Perhaps we can call these landmarks or stages on the journey through grief.
Let me take a moment here to provide my definition of a pathological reality and how I am using it in the context of this paper. It is the study of the essential nature of the abnormalities associated with grieves as an illness, problem, or disease. If helping professionals are going to assist patients through the grief process, it is important for us to know and be able to identify which stage of the grief process a person is in. Different stages require different approaches. Because an inappropriate response to a stage could lead to disastrous results, I will identify the stages and
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provide a brief definition of each. As you read the differences in each stage, you will understand why each stage requires a different approach. Moreover, you will also understand why it is so important to understand what stage of the process a person is experiencing. Stages of Grief The recognized stages of grief apply to everyone going through-a loss experience, but not all experience each stage with equal intensity. Also, people may skip a stage or even jump back and forth between them. As the chart in Appendix 1 indicates, there are many different constructions of the grief stages. For my purposes, I will use Granger Westberg's "Ten Stages of Grief" to describe the normal process most people go through as they face their loss. (Westberg, 1981) I have taken the liberty of modifying the stages according to my understanding and rearranging the order of the stages to better fit my concept of how they occurred chronologically in most patients I have observed. The stages are: (1) SHOCK - A temporary emotional and physical anesthetical reaction to keep us from experiencing the pain of loss all at once. You will often hear shock stated, "I can not believe it...I will not believe it ... this can not be happening to me ... it is all unreal." All these statements have the element of surprise and denial. Disbelief in the reality of the loss is very much present. The degree of shock is usually determined by the amount of value placed on the loss, as well as the integration of the loser's personality. Shock can last for a short duration of time, such as a day, or it can be a much longer duration, such as days, months, maybe even years. I have witnessed long durations of shock on the Maternity Ward when some of the children died. (2) EMOTIONAL RELEASE - This comes at about the time it begins to dawn on us how serious and real the loss actually is. There is an almost uncontrollable urge to express our grief. Some examples of emotional releases are crying, sighing, shouting, laughing, excessive talking, fatigue, quiet crying with withdrawal, mental anguish nd other physical symptoms accompanying this stage. The release of emotions will be different in each individual. Here are several things that must be taken into consideration: the degree of loss, social setting, how the person learns of the loss, learned behavioral responses, and the physical and emotional well-being of the person. (3) PANIC - A phase where the loss seems overwhelming. The person cannot concentrate on much else besides the immediate consequences of what has happened. They may even feel that they are losing their grip on reality. At this point, the grieving person becomes panicky when he or she is no longer able to keep the loss in perspective. When all of his or her energy is totally consumed by the loss experience, then they no longer have the energy to function in normal activities. For a short time it may be that the one who is grieving ceases to understand what is real and has a difficult time in distinguishing between reality and non-reality. (4) ANGER/HOSTILITY AND RESENTMENT - A natural response to a threat and an unwanted intrusion into our lives. Anger is often undiscriminating, it may spew out on anyone or anything in its path during the crisis. The anger, hostility and resentment are normal feelings of every grieving person. Because of being deprived a valued person or object, without choice or consent, the grieving person is reacting to the loss. (5)
DEPRESSION/LONELINESS - A feeling of isolation and self-pity. The depressed person feels
that no one cares, not even God. The Psalmist expressed it well, "Why are you cast down, 0 my soul? My soul is cast down within me. I say to God my rock, why hast thou forgotten me?" (Psalm 42:5) Depending on the
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degree of loss, a person may only experience loneliness. Depression is usually associated with traumatic loss and the grief experience. At this point a person becomes withdrawn, experiencing a feeling of heaviness. (6)
GUILT - Guilt is a normal reaction in life. It is our conscience telling us we have done or
caused something wrong, so that we can make it right but, during grief, “neurotic guilt” can plague out of all proportion to their actual involvement or responsibility. Fortunately, as Westburg reminds us, "....the mature religious person has some advantage overone who has never heard much about sin and grace." (Westburg, 1981) We must remember that in the loss experience, guilt is usually felt. The person might not be able to own their guilt,but the feelings are normally present within one's belief system. The guilt will either be accepted by the person grieving or he will project the guilt on someone or something else. The level of guilt may be either normal or abnormal. Abnormal or neurotic guilt has to do with guilt that is out of proportion to the loss; either too much or too little guilt is a problem. (7.) PHYSICAL SYMPTOMS OF DISTRESS - If the grief is strong and prolonged or we get stuck on one or more of the grief stages, physical symptoms may appear. Psychosomatic illnesses may occur. This may lead to one experiencing a organic distress which is manifested by headaches, backaches, constipation and/or diarrhea, outbreak of hives and other minor aches and pains. Here again, the degree of loss and the integration of personality play’s a big part in the response of the grieving person. (8) INABILITY TO RETURN TO USUAL ACTIVITIES - This struggle deals with outside influence and the inability or unwillingness of those around the grieving person to deal with the grief situation. It is exemplified in the conspiracy of silence ... do not speak of the loss, pretend nothing has really ever happened. The display of grief is not socially acceptable for it creates uncomfortable feelings for the griever and other persons that may need to be dealt with or worked through. (9)
HOPE - Gradually, rays of light break through and we realize there is hope for a normal life
beyond this. grieving experience. Life has a way of continuing. We will start to think that just maybe all is not lost ... there just may be some light at the end of this dark tunnel of life. It is at this point the grieving person begins to accept his loss. They also begin to feel that they can continue, though there has been the experience of loss. (10.)
ADJUSTMENT TO REALITY -This is not, "We are back to our old selves again." Because of
the experience of loss, things, situations and people will be different. We will be different people, having gone through the experience. However, depending on how we respond and work through the grief process, we can come out even healthier and stronger. We can develop a deeper faith in God and be better able to help others
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who face similar losses. One thing for sure is that, at this stage, the grieving person is well on the road to good health and adjustment. They have worked through the experience of loss and brokenness.
A Biblical View of Grief Because I believe that the Holy Bible is the final authority on all human needs, I searched the scriptures for evidence of how God wants us to view grief. The Scriptures tell us that, "there is a time to every purpose under heaven ... a time to weep and a time to laugh, a time to mourn and a time to dance." (Ecclesiastes 3:1,4) Grief, in all of its expressions, is a God-given emotion. Emotions are meant to be expressed, and in expressing them, healing and new strength comes, where before, there was only loss and grief. The Scripture teaches that God Himself, when we allow Him, is involved in this process. I experienced acceptance of my foster mother's death upon being able to express my emotions. I experienced the growth and hope that comes from God's healing and comfort as pulling us upward, just as a mountain climber moves towards the summit. The steep slopes, as we climb upward, are the losses and grief’s we encounter. Hope is found on the plateaus and high points, where we rest and pause after the difficult climb through loss. The ultimate goal is the summit of the mountain, which is the culmination of our life's journey. The road to recovery within the grief process is an upward growth reality that brings greater maturity, stronger faith and hope, in spite of and sometimes even because of the losses of life. The Apostle Paul confirms this when he says, "...we know that suffering produces perseverance, perseverance, character; and character, hope. And hope does not disappoint us ... “ (Romans 5: 3b-5a) Several words in the Old Testament illustrate how grief effects the totality of human life. They speak of the loss of grief, but also of the healing and growth that God can bring. Two Hebrew words illustrate the power and extent of grief. The first word, Choli, means "sickness, weakness, pain" and it focuses on the physical effects of grief. (Young, 1971) The prophetical description of Jesus is, of a "...man of sorrows, acquainted with grief." (Isiah 53: 3-4) The context seems to center on the grief of both other peoples, physical suffering and His own, which He ultimately faced on the cross. So grief, has a very physical, visceral side to it. The second Hebrew word, Kaas, means literally "sadness, provocation and anger."(Young, 1971) This is the more emotional side of grief. King David wrote of this, "I am weary with sighing... I dissolve my couch with tears. My eye has-wasted away with grief ... because of all my adversaries.,, (Psalms 6: 6-7) David experienced
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the emotional pain caused by broken and antagonistic relationships. His fear, anxiety and anger towards his enemies and the trouble he was in, caused intense grief and a sense of loss that found expression in his tears. Moving to the New Testament, we find one primary word for grief, Lupeo, meaning "To afflict or to grieve, (Young, 1971) This word seems to include the physical, emotional and spiritual effects of grief. In the Gospel, it is recorded that Jesus, “...after looking around at them with anger, grieved at their hardness of heart... 11 (Mark 3:5) Jesus was emotionally angered, but also spiritually hurt by the insensitivity of the religious leaders who rejected His healing of a crippled man on the Sabbath. Other examples can be found in the New Testament, such as Peter's grief at Jesus' questioning the depth of his love for Him, Jesus, reaction at the death of John the Baptist, and other instances after the crucifixion and resurrection. (John 21:17) Taken together, the Scriptual examples and teaching on grief point to a difficult, often traumatic experience that effects the whole person - body (physical), soul (emotional, mental) and spirit (spiritual). Pain, weakness, sickness, sadness, provocation, anger, fear, anxiety, affliction and spiritual agony are some of the accompanying emotions. But overall, the scriptures affirm that God is faithful and that He will be with you through the grief process and in the end he will use the process for your good.
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Chapter 3 DISCOVERING SELF Before we can assist anyone else with the grief process, or anything else, we must know who we are and whose we are. By dealing with our own grief and pain, and acknowledging our feelings of helplessness, we will be more prepared and equipped to help others. The chaplain and other non-medical helping professional, unlike most of those who enter the hospital room, bring one therapeutic tool: You bring yourself. Both your silent presence and your conversation flow out of the special person God created you to be. Therefore, it becomes important to begin by allowing us to ask ourselves some questions that we might gain a deeper awareness of our authentic and current selves. Each day that you begin another day of ministry, each day that you approach the hospital, each day that you move from one hospital room to the next, each day that you visit your battalion, church or commander, it is valuable and absolutely necessary to "check in" with yourself. After beginning with a moment of quiet meditation in which you simply allow God's loving presence with you to be real, take time to respond to the following questions:
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SELF AWARENESS EVALUATION
1.
Who are you? (Make a list of descriptive words)
2.
List some words that describe you right now.
3.
What are your feelings right now?
4.
What do you like about yourself right now?
5.
What don't you like about yourself right now?
6.
Do you feel God's presence today? (No, is an OK response.)
7.
How would you describe God today?
8.
What would you like to change about yourself right now?
9.
What gives your life purpose and meaning?
10.
How does God work in and through your life?
11.
Imagine yourself in a hospital bed. What bothers you most about being sick? How could the chaplain be of assistance to you?
12.
What do you desire from others when you are sick?
13.
Is it easy for you to express feelings of fear, of anger, of guilt, of pain?
14.
When a stranger approaches you, what is important for you to build trust?
15.
Do you enjoy praying out loud? Do you like for others to pray for your needs out loud?
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SPIRITUAL NEEDS SCRIPT In conduction with understanding and knowing ourselves, we must also know the spiritual levels of ourselves, and those we are trying to help. In order for us to hear and respond to spiritual needs, we need to recognize them. Listed below are various needs. First read through the list and write the meaning of the word to you. Then go through the list and write the symptoms by which you might notice this need as unmet in another person. LOVE________________________________________________________________________________________________________ GRACE___________________________________________________________________________________ FORGIVENESS____________________________________________________________________________ HOPE____________________________________________________________________________________ MEANING________________________________________________________________________________ REVERENCE______________________________________________________________________________ PATIENCE________________________________________________________________________________ TRUST___________________________________________________________________________________ JOY______________________________________________________________________________________ REPENTANCE_____________________________________________________________________________ SERVICE_________________________________________________________________________________ CREATIVITY______________________________________________________________________________ FAITH____________________________________________________________________________________ FELLOWSHIP_____________________________________________________________________________ PRAYER__________________________________________________________________________________ PEACE___________________________________________________________________________________
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CHAPTER 4 LISTENING: THE BEGINNING OF GRIEF COUNSELING With all of the knowledge of the grief process, knowing ourselves and the spiritual altitude of others, and ourselves it will be void if we do not learn to listen. Listening is the beginning of grief counseling. Empathetic listening to a person who is struggling with grief is necessary to provide effective pastoral care, help or support. Empathetic listening requires you to tune in to and understand the person’s feelings. Empathetic listening involves a four-part process: You must tune in to yourself, express yourself, tune in to the hurting person, and respond with understanding for their brokenness. This tool is the foundation for building relationships and helping people with grief and other conditions. For talk to become conversation there must be listening. When we know someone is listening, then speaking becomes sharing, and conversation can have a compelling, spellbinding quality. To listen to another invites the other to mean what is said, to search for words and to search for meaning. The deepest invitation to another person to share his or her soul is to listen with an expectancy (not expectations) that this time of conversation might be full of meaning. When ministering to grief stricken people you must always remember that the times of silence are just as important as the talkative times. The silence is an opportunity for both parties to listen to the Spirit of God for revelational knowledge. The following are some basic principles and insights I have learned while working in this area that have enabled me to effectively listen to and help individuals who were struggling with grief. 1. It is important to understand how the person sees himself or herself in the midst of the grief situation. Attempt to find out if, where and how the person is hurting. The pain and grief of the person might not be as you think at all. Be careful not to project your feelings unto to the person. Do not act surprised even if you are surprised. Ask the person open-ended questions and listen to their answers. Ask them, "How are you doing?" "What do you see as the problem?" "How do you see solving the problem?" "What kind of help do you want?" 2.
Allow and encourage the ventilation of feelings. Give permission if necessary, to cry, to express anger,
hurt, depression, i.e. "It is ok to cry to your heart is content."
3.
Upon hearing the feelings of the person, do not actualize the "Job's friends" syndrome. Do not feel like
you have to justify God or whomever they are expressing negative feelings towards. Accept their right to feel this way for the time being; however, if the feelings are counter-productive to the healing process, they should be dealt with at another time. Do not pass judgment. Feelings do not have to be justified. The "Why" question is not necessary in the initial stages of grief counseling.
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4.
Listen to hear and respond to key feeling words such as: sacred, lonely, anxious, irritated, bewildered,
estranged, mixed up, nauseated, distant, locked in, jealous, tired, embarrassed, etc. If the person says, "I am scared." You might ask: "What is it like when you are scared?" "What is your experience of being scared?" "What happens when you are scared?" "Can you share this with me?" The goal is to help the person process his or her feelings. Remember, it is important for you to journey with them emphatically. To accomplish this you must feel "with" them and not feel "for" them. If you find yourself feeling for them, you are being sympathetic instead of empathic. 5.
Again, pick up on key feeling words. Do not get trapped in details, the nitty-gritty, and long drawn-out
descriptions of events. This will tie up the grieving process and adds nothing productive. Ask questions such as: What did you feel then? What was it like inside? What does it feel like when... ? You must be intentional about encouraging and directing the individual to speak from the heart and not the head. If it is necessary to lead the individual to the healing balm, you must maintain an awareness, and intentionality of your actions. 6.
Listen emphatically and attentively and reflect feelings. Example of this are: I sense a lot of pain there.
That sounds like it really hurt you. That must have been a lonely time in your life. Is that so? Was it? Can you share that with me?' Remember that listening is the key to effectiveness. 7.
Generally speaking, use questions that are open ended. Open-ended questions help them to focus on
painful, conflict areas with beneficial results. What is it like? Would you care to talk about it? What is happening? Can you share that with me? Can you tell me more? Can I invite you to try and express yourself? That sounds like quite an experience, could you share that with me?
8.
Do not be afraid of silence. It has a message all of its own. After asking a question, wait out the answer, even though you might be feeling anxious. Do not jam up the process ... with your own uneasiness with silence. Silence can be like the birth process for a little chicken in his shell. The chicken must crack the shell and come out on its’ own. If you help him by forcing the crack open before time, you will kill the chicken. Likewise, if you force the person to speak before time, you can kill or inhibit the grieve recovery process. 9.
Remember empathy! Empathy involves the simultaneous blending of at least four processes: (A)
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Tuning in to your feelings, (B) Expressing your feelings, (C) Tuning in to others' feelings, and (D) Responding to those feelings with understanding. 10. Ask permission ... do not exercise power without authorization. Always elicit the cooperation of the other person if at all possible, i.e. May I visit with you? May I help you with this? May I ask some questions which will help me to understand? Will you share with me so that I can understand? Will you share with me so that I can learn from your experience? Remember, that your position does not give you the right to violate someone's privacy regardless of their state of mind. 11.
Check it out. Do not assume anything if it is possible to "check it out.� To "ass u me" something is to
potentially make a donkey's place of rest out of you and me. If the person seems angry, it might be appropriate to ask them, Are you angry? or You seem anger about something, are you? Could you share that? (He may be sick... ) May I visit with you a while? Can I do that for you? How may I help you? Would you like me to leave now? Would you like me to stop now and come back later? 12. (1)
(2)
“Two directions for a listener.� Simply stated, there are two thrusts or directions available to a listener: Be a "problem solver"; work from the outside-in; do things for the counselee/client/patient; take responsibility.
Be a "catalyst"; help the individual work through his or her own grief issues; work from the inside-out; give responsibility.
13.
Do not become the "answer person". Trust that people can come to some resolution/solution that is their very own. Give the person the dignity and liberty to work through his or her own grief issues and
difficulties. Give God a chance to work and deal with the person. Again, do not become the "answer person". This immediately stops the struggle and the growth as well as the opportunity to develop an awareness of self. It jams up the avenue for growth and awareness that arouse one to embrace authenticity based on the knowledge, gifts and talents of others. As I embrace legalism, and the law enforcement chaplaincy, I find it important to value the wealth and knowledge of the patient, and or the counselee, and to blend their practical skills and knowledge in forming a solution focus resolution that centers on their awareness and experience versus my -so called- knowledge.
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LISTENING IN CONVERSATIONS "Let no man or woman despise thy youth; but be thou an example of the believers in word, in conversation, in love, in faith and in purity." (I Timothy 4:12) According to Webster's Dictionary, conversation is "the oral giving and receiving of sentiments, observations, opinions and ideas." Oftentimes we remember a conversation by "what we said" and almost disregard that which we heard the other person say. Conversation is "oral giving and receiving". It is talking and listening. The quality of the listening sets the atmosphere or spirit of the sharing, more so than the talking. The talking "deepens" as the quality of the listening permits. Remember the five aspects of good listening: (1)
Attention - You must be receptive, with an open ear and open mind.
(2)
Substance _ Ask questions related to the subject; this requires you to sort out the substance of what is being said.
(3)
Objectivity - You must obtain and maintain this reality. We are quite often emotional or subjective in our response.
(4)
Creativity - Use your spiritual insight to creatively bring about awareness. Ask yourself, what does all of this mean or what is being said to me?
(5)
Head or Heart - Try to determine the origin of the message, i.e., thinking or feeling.
This exercise is one of memory and reflection on your own experience of being listened to and of listening. We learn best from our own experiences. Please sit quietly and prayerfully for a moment before answering each of the questions.
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LISTENING IN CONVERSATION QUESTIONNAIRE
1. Remember a time recently when someone shared with you something very important to them personally. How did you express your availability to him or her?
2. Remember a time when you wanted to tell someone something personally important to you. How did you check our whether to go ahead?
3.
Describe an uncomfortable conversation that you remember. What happened to make it so?
4.
Do you allow silence in conversation? Describe the value of silence as you experience it in conversation.
5.
How do you comfortably invite people to share/express feelings and emotions?
6. How do you express your non-judgmental or forgiving responses to people? your children? your friends? people who are very judgmental?
7.
8.
When you are angry or complaining about something, what do you want from another?
Are there times when you would prefer to share with a stranger? What sort of situations?
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Chapter 5 THE MOURNING PROCESS THE MOURNING PROCESS: THE KEY TO A HEALTHY GRIEF PROCESS After we have taken the time to learn the grief process, acquaint ourselves with the spiritual and listening processes, we should be ready for the action portion of the grief process, mourning. The key to a healthy grief process is being able to embrace the mourning process. I believe that it is imperative to begin to mourn a loss before you can adequately grieve the loss. The difference between mourning and grieving is more than simply some semantic distinctions: Mourning is the external expression of grief and bereavement. The manner in which people mourn is influenced by the customs of their culture. The mourning behavior exhibited may or may not be in agreement with true feelings of the bereaved; however, they may incur disapproval if they do not follow the prescribed social customs. Another way of defining mourning is to state that it is "grief expressed openly" or "sharing your grief outside of yourself."
Grief is an emotional suffering caused by death or another form of bereavement. Grief involves a sequence of thoughts and feelings that follow the loss and accompany mourning. Grief is a process and as a result, is not a specific emotion like fear or sadness, but indeed is a constellation of a variety of thoughts, feelings and behaviors. Grief is the internal meaning given to the external event. According to Psychiatrist George Engel's essay published in "Psychosomatic Medicine�, his thesis is that the loss of a loved one is psychologically traumatic to the same extent as being severely wounded or burned is physiologically traumatic. He asserts that grief represents a departure from the state of health and wellbeing, just as healing is necessary in the physiological realm in order to bring the body back into homeostatic balance, a period of time is likewise needed to return the mourner to a similar state of equilibrium. Therefore Engel and I see the process of mourning as similar to the process of healing. After one sustains a loss, there are certain objectives that must be accomplished in the mourning process. The objectives must be accomplished for equilibrium to be reestablished and for the process of mourning to be completed.
Erich Lindermann, a pioneer in a grief investigation described primarily three tasks that he believes are necessary for the mourning process in grief:
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1.
Emancipation from the bondage of the deceased [or issue of concern].
2.
Readjustment to the environment in which the deceased (or item] is missing, and
3. Formation of new relationships. (Lindermann, 1944) There are two forms of grief that must be remembered when providing care and counseling through the mourning process: 1.
Anticipatory Grief is most often used to describe grief that is expressed in advance of a loss
when the loss is perceived as inevitable. Historically, it was believed that anticipatory grief was positive since it provided the person the opportunity to prepare for the loss. However, more recent studies suggested that the grief experienced after an anticipated loss is no less painful than when loss is not anticipated. With that understanding, studies have shown that anticipatory grief does allow for less of an assault on the mourner's adaptive capacities.
2.
Acute Grief is the intense grief that immediately follows the loss.
Mourning and grief work are the activities associated with thinking through the loss, facing its reality, expressing the feelings and emotions experienced, and becoming reinvolved with life. The work of grief coincides with the reality of mourning. Mourning is the outer expression of the internal pains and anguish being experienced known as the grief process.
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CHAPTER 6 AN OVERVIEW OF NORMAL AND ABNORMAL GRIEF REACTIONS With a better understanding of grief, the importance of spiritual and listening processes and the outward expression of grief and mourning, it is appropriate to identify some extremes associated with grief. As in most conditions, grief can be normal or abnormal. A normal grief reaction is a term that often refers to an uncomplicated grief reaction that encompasses a host of feelings and behaviors that are common after a loss. When I use the word normal, I am using it in a clinical and a statistical sense. "Clinical', defines what the clinician calls normal mourning or grieving behavior while "statistical" refers to the frequency with which a behavior is found among a randomized bereaved population. The more frequent the behavior, the more it is defined as normal. Dr. Erich Lindemann, as Chief of Psychiatry at the Massachusetts General Hospital made one of the earliest attempts to look at normal grief reactions after a tragedy occurred which killed hundreds of people. Let me tell you the story: In the fall of 1942 in Boston, there were two Catholic colleges well known for their football rivalry. They met for one of their traditional Saturday encounters and Holy Cross beat Boston College. After the game, many of the people went to the local Coconut Grove Nightclub to celebrate. During the celebration, one of the busboys lit a match while trying to change a light bulb and accidentally set a decorative palm tree on fire. Almost immediately, the whole nightclub, which had exceeded it authorized legal capacity, was engulfed in flames. Approximately 500 people lost their lives. After this tragic event Dr. Lindemann and his colleagues worked with family members who had lost loved ones in that fire. From that data and other experiences, he wrote his classic paper, "The Symptomatology and Management of Acute Grief". Based on his observations of 101 recently bereaved patients he discovered similar patterns, which he described as the pathognomic characteristics of normal or acute grief. These normal or acute grief reactions are:
1.
Somatic or bodily distress of some type
2.
Preoccupation with the image of the deceased
3.
Guilt relating to the deceased or circumstances of the death (or the separation or loss]
4.
Hostile reactions
5.
The inability to function as one had before the loss
6.
The bereaved person appeared to develop traits of the deceased in their own behavior.
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I must state that there are many limitations to Lindemann's study according to many other experts in the field. One of the problems according to Dr. C.M. Parkes, is that Lindemann does not present figures to show the relative frequency of the syndromes described. Lindemann also neglects to mention how many interviews he had with the patients and how much time had passed between the interviews and the dates of loss. (Parkes, 1972) Nevertheless, I agree with the findings of his overall study.
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CHAPTER 7 A STRATEGY OF MINISTRY TO THE GRIEVING General Principles - Four Tender Touches for the gligyip q Lastly, I would like to suggest a basic strategy for caring professionals. This is by no means an all-inclusive guide, however, if the general principles recorded here are adhered to, they will improve the ministry we provide to the grieving, as well as others in need. All ministry involves both, an attitude and an approach by the one seeking to minister. The attitude.must be that of a genuine desire to relate to and accept the patient. The approach of the minister should be to listen and share. The four touches are relate, accept, listen and share. (1)
RELATE - as a "tender-hearted stranger"
God be in my head, And in my understanding, God be in my eye, And in my looking, God be in my mouth, And in my speaking God be in my heart, And in my thinking; God be at mine end, And at my departing. Author Unknown The chaplain comes to the patient as a stranger and must earn the right to minister. He must develop a relationship, often in a very short period of time. But, if the patients feel that you truly care, they will open the door and let you into their world. (2) ACCEPT - as an "unconditional lover" Once the door is open, and the chaplain begins to enter the patient's world, there are still many defensive barriers to cross. The patient begins to trust, only as the minister shows an unconditional acceptance. This does not mean total agreement with whatever is said or done, or an abandoning of convictions. However, it does mean that the patient knows they are loved and accepted just for who they are, a unique and valuable human being. (3) LISTEN - as a "Interested Companion."
Dr. Paul Tournier, the Swiss doctor/psychologist who ministered to body and soul said, "I realize that it is more important to listen to them (patients) with interest than to think about what my answer should be. And it is no artificial interest - there is nothing more fascinating than to understand a human life." (Tournier, 1983) The effective minister must be an active, reassuring, interpretive listener - a "sounding board" for the patient.
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(4) SHARE - as a "Fellow Struggler" The chaplain/minister has many pro-active tools with which to touch people's lives; among them are scripture, prayer and his own life experiences. I have shared personal struggles with patients, when I felt it might help them gain insight into a similar problem in their lives. Almost invariably, the result has been a closer relationship with the patient and sometimes a seed-thought for future conversation on that topic.
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CHAPTER 8 CONCLUSION My research and experiences at WAMC this past year have confirmed me the importance of patients (indeed, all of usl) working through the grief process. If we are delayed in any of the grief stages of shock, denial, panic, anger, depression, or guilt, our grief is prolonged or even worse, it remains unfinished. As I conclude this project, I do so with theunderstanding that I have only just begun to comprehend the ultimate realities associated with grief. I know that confronting loss and death is hard! However, if we fail to study this important subject matter, we find ourselves ignorant and unskilled in coping with loss, be it our own or someone else's. We may want to help, but we will not know how. Having no idea what to do when we hear of a death, many of us run away from helping the bereaved. It is my hope that by reading the contents of this project, you have discovered a number of ways you can help individuals and yourself appropriately embrace the grief process.
Remember that it is healthy to cry. Crying is essential, but it can also provoke and sometimes scare those who witness it. Our underlying feelings about crying might be: "If you cry, I might cry; If you cry, I might know I too am in pain. If you cry, I might feel self-conscious about my own difficulty in crying. If you cry, I might have to face the unpleasantness in my/your life. If you cry, I might not be able to maintain my pose of strength (or dignity, or composure, or whatever). If you dry, I might cry for all the pain in my own life and never stop crying. Therefore, if you cry, I will have to run away or shut you up to save myself." (Author Unknown) Ways to support the bereaved vary and depend heavily on the mourner. People, who become incapacitated while grieving, need help on every level. Others need to continue to function in order to testify to their capacity to cope with the loss. Both are normal responses, and we need to be sensitive to the individual style of the person grieving. There are many ways to assist people in mourning. It is most important that we do those things that we feel comfortable doing. We should support, not inhibit, the grieving process. The bereaved need to be helped on many levels, be it by our presence, our energy, our sharing, our listening, our weeping together, or the many practical services we have to offer. Even our simplest acts can yield immeasurable value. Grief is a reality that is associated with every aspect of life, death, and separation from that which is significant. Therefore, grief can be both a friend and an enemy. Grief in our bodies notifies us of a possible
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problem, and therefore, it is good. But because it does not feel good, we do not appreciate the gift of grief. In an effort to eliminate it, many mourners will quickly run to therapy or counseling to get help to stop the pain. What we often fail to realize is that the pain associated with grief often times comes to give us a gift, a gift that is not regularly appreciated for its value and significance. I believe that when dealing with the human condition of brokenness, we must learn to cherish the gift of grief, although it is painful. I will not offer an example of grief as an enemy because it is recognized as such immediately. The reality of life is that pain and joy are not always so far apart, and sometimes we do not actually know where the good or bad really is. It seems fitting to close with one of Elisabeth KublerRoss' most moving comments that also represents my theology of grief, evil, pain and suffering: "All the hardships that you face in life, all the tests and tribulations, all the nightmares and all the losses,, most people still view as curses, as punishments by God, as something negative. If you would only know that nothing that comes to you is negative. I mean nothing. All the trials and tribulations, and the biggest losses that you ever experience, things that make you say, "If I had known about this, I would never have been able to make it through," are gifts to- you. It is like somebody had to--what do you call that when you make the hot iron into a tool?--you have to temper the iron. It is an opportunity that you are given to grow. That is the sole purpose of existence on this planet earth. You will not grow if you sit in a beautiful flower garden, and somebody brings you gorgeous food on a silver platter. But you will grow if you are sick, if you are in pain, if you experience losses, and if you do not put your head in the sand, but take the pain and learn to accept it, not as a curse or a punishment, but as a gift to you with a very, very specific purpose." (Kubler-Ross, 1969) As a result of my studies, I have concluded that underneath every particular psychological condition, an unresolved grief reality can be found. In other words, unresolved grief is at the root of almost every personality disorder, psychiatric illness or dysfunctional relationship. If we, as helping professionals are aware of this, we can provide more effective assistance to those we so faithfully serve. By equipping ourselves with the right tools, we will be able to meet the needs of those experiencing grief, death and dying situations. More personally, we will be better equipped to assist ourselves through the process and have a personal testimony of its positive effects.
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BIBLIOGRAPHY/REFERENCES
Abata, Russel M. (1991). Help for Pain and Suffering. Missouri: Liguori Publications. American Psychological Association (2001). Publication Manual of the American Psychological Association (5 th Edition). Washington, DC: Author. Augusburger, David W. (1986). Pastoral Counceling Across Cultures. Philadelphia: Westminster Press. Bowlby, J. (1980). Attachment and Loss: Loss, sadness, and depression, (Vol. III) New York: Basic Books. Brite, Mary. (1993). Hearts in Motion Minds at Rest: Living through Loss of a Loved one. Ohio: Barbour and Company. Chapin, Shelley. (1991). Within The Shadow: A Biblical Look at Suffering, Death, and the Process of Grieving. Illinois: Scripture Press. Davidson, Glen W. (1984). Understanding Mourning: A Guide for Those Who Grieve. Minneapolis: Augsburg Publishing House. Dayringer, Richard. (1982). Pastor and Patient. New York: Jason Aronson. Graham, B. (1987). Facing Death and the Life After. Minneapolis: Grason. Grant W, Thompson M, and Clarke T. (1983). From Image to Likeness. New Jersey: Paulist Press. Hunter Rodney J. (1990). Dictionary of Pastoral Care and Counseling. Nashville: Abingdon Press. Jackson E. (1988). You and Your Grief. New York: Bantum Books. James J. and Cherry F (1988). The Grief Recovery Handbook. New York: Harper and Row. Kelsey Morton. (1986). Christianity as Psychology. Minneapolis: Augsburg Publishing House. Kreeft, Peter. (1986). Making Sense Out of Suffering. Michigan: Servant Books. Kubler-Ross, Elisabeth. (1977). On Death and Dying. New York: Collier Books MacMillan Publishing Co. Kubler-Ross, Elisabeth. (1977). Questions and Answers on Death and Dying. New York: MacMillan Pubishing Co. Kubler-Ross, E. (1997). On death and dying. New York: Scribner Kubler-Ross, E. (1991). On life after death. Berkeley, CA: Ten Speed Press. Kubler-Ross, E. (1997). Questions and answers on death and dying. New York: Simon & Schuster Trade. LaHayne, Tim. (1974). Ten Steps to Victory Over Depression. Michigan: Zondervan Publishing House. Lewis, C.S. (1988). A Grief Observed. New York: Bantum Books. Oates, Wayne E. (1987). Pastoral Care and Counseling in Grief and Separation. Philadelphia: Fortress Press. Parkes, C.M. (1972). Bereavement: Studies of Grief in Adult Life New York, NY: International Universities Press, Rando, Therese A. (1993). Treatment of Complicated Mourning. Illinois: Research Press. Sanford, John A. (1992). Healing Body and Soul. Kentucky: Westminister. Sanford, John A. (1990). Evil: The Shadow Side of Reality, New York: Crossroad. Schultz, Karl A. (1992). Where is God When You Need Him, New York: Alba House. Schwartz David J. (1965). The Magic of Thinking Big. New York: Simon and Schuster, Inc. Schwiebert, Pat and Kirk, Paul (1990). When Hello Means Goodbye, Oregon: Perinatal Loss. Stone, Howard W. (1980). Crisis Counseling. Philadelphia: Fortress Press. Switzer, D. (1970). The Dynamics of Grief. Nashville: The Abingdon Press. Tatelbaum, Judy (1980). The Courage to Grieve. New York: Harper & Row. Tournier, P. (1983). The Healings of Persons. San Francisco: Harper & Row. Williams Tom. (1987). Post-Traumatic Stress Disorders: A Handbook for Clinicians. Ohio: Disabled American Veterans. Westburg, G. (1981) Good Grief. Philidelphia: Fortress Press. Wolfelt, A. (1988). Death and Grief: A Guide for Clergy. Indiana: Accelerated Development Publishers. Worden, W.J. (2002). Grief counseling and grief therapy. A handobook for the mental health practitioner (3rd ed). New York: Springer Publishing Company, Inc. Yancey, Philip. (1990). Where is God When it Hurts. Michigan: Zondervan Publishing House. Young R. (1971). Analytical Concordance to the Bible. Grand Rapids: Eerdmans Publishing Co. Young R. and Meiburg, A. (1960) Spiritual Therapy. New York: Harper & Row. Zunn L. and Zunin, H. (1992) The Art of Condolence. New York: Harper Collins Publishers, Inc. Journals:
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Allumbaugh, D. L., & Hoyt, W. T. (1999). Effectiveness of grief therapy: A meta-analysis. Journal of Counseling Psychology, 46, 370-380. Brown, M. and C. Burns. (1987) Human Response to Loss, Nurse Practitioner, 12 (5), 63-66. Engel, G. (1963) Grief and Grieving, American Journal of Nursing, 64:9, 93-8. Farrugia, D. (1996). The experience of a family when a child dies. The Family Journal: Counseling and Therapy for Couples and Families, 4, 30-36. Freeman, S. J., & Ward, S. (1998). Death and bereavement: What counselors should know. Journal of Mental Health Counseling, 20, 216-226. Lindemann, E. (1944) Symptomology and Management of Acute Grief American Journal of Psychiatry, 101, 141-148. Schwab, R. (1997). Parental mourning and children's behavior. Journal of Counseling & Development, 75, 258267. Pistole, M.C. (1996). After love: Attachment styles and grief themes. The Family Journal: Counseling and Therapy for Couples and Families, 4, 199-207
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APPENDIX 1 The following are five theories which represent various forms of the stages of grief:
The Experience of Loss: Making Sense of It
RESPONSE TO LOSS (Bowlby) 1. Protest (shock; disbelief; depression) 2. Despair 3.Detachment (letting go; reorganization)
STAGES OF DYING (Kubler-Ross) 1.
Denial and Isolation
2. 3.
Anger Bargaining
4.
Depression
5.
Acceptance
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COURSE EVALUATION SHEET Please complete this evaluation form. Your constructive feedback will assist with the assessment of the CME program at National Naval Medical Center. Title of Course: GRIEF & THE CAREGIVING PROFESSIONAL (GRIEF: A DEATH AND DYING PATHOLOGICAL REALITY) Date and Time of Session: ______________________________________________________________________________________ Can you now use the information/skill to safely and properly detect, observe, evaluate studied subjects within the range of material presented? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _________________________________________ Please rate the session using numerical values given below: 1=POOR
2=FAIR
3=AVERAGE
4=VERY GOOD 5=OUTSTANDING
CONTENT: Appropriateness of topic for your education needs?_______________________________( ) PRESENTATION was well organized____________________________________________________( ) SPEAKER presented topic effectively____________________________________________________( ) PRACTICALITY: Value of the topic to your daily practice?__________________________________( ) EFFECTIVENESS of learning aids used (A/V materials, handouts)____________________________( ) OBJECTIVES: How well did the material presented meet the objectives of the program?___________( ) OVERALL impression of program?______________________________________________________( ) SPECIFIC COMMENTS, SUGGESTIONS?
Home Phone: ____________ Print Name Work Phone: ____________ Mailing Address: ___________________________________________________________________ E-Mail Address: ___________________________________ Branch of Service: __________ Rank:_____________
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