Free CPD Lecture

Hello, welcome to this bereavement awareness presentation. I am Nicola Hughes and I'm going to run through the aims of this presentation. They are to gain a deeper understanding of bereavement and loss and our objectives today are to reflect on your own thoughts and feelings about grief and how this may affect your helping. We're going to gain an understanding of bereavement theories and how to apply these theories in practice. We're also going to consider the factors affecting bereaved people and their possible reactions and we'll end by discussing assessment options and how we actually work with a bereaved client.

Firstly, a little bit about me. Yes, I'm Nicole Hughes. My first placement was with a bereavement charity and I've worked with bereaved children and their families since 2010. I deliver extensive training to professionals within the community, schools and universities. I have been a group supervisor for a bereavement charity, and I'm currently in private practice as a creative counsellor, clinical supervisor and trainer. I work with individuals, young people and couples, and I do that face-to-face, online and also outdoors. That is a little bit about me.

So, before we get in, I think it's really important to self-assess your knowledge. Maybe you know more than you realize or maybe you know less. That's okay. Today I hope you're going to learn something, but you'll only really know if you assess it. On this scale of one to ten, where one equals, I know nothing about bereavement and ten is I know everything about bereavement, give yourself a score. So, a score between one and ten. This is your scoring system, so it doesn't matter how it relates to anyone else. Write your answer somewhere and we will come back to it at the end.

Just a little overview of what we'll be looking at today and the themes. We'll start off with death and you. I think it's important when we look at any topic that we look at ourselves first. We should always be asking ourselves; how does this affect me or what do I think about death? This may highlight some areas that you need to take to supervision or therapy, and it might also mean that you want to pause this video, take a breath, come back to it later. That's totally fine if that is what happens for you today. We're also going to look at some bereavement theories and I really love this bit. I think I love bereavement theory over all other theory just because it is so useful, it's so practical and I will talk to you more about that as we go along. Today we'll be looking at four different theories. Then we'll go on to look at death and then, this is specifically about working with our clients and how they might experience grief so we can be better informed as a more useful counsellor. Then in the final breath, we will pause and reflect on our learning before we end.

Death and you. How do you feel about death? I believe that we can't be outside and look inside at death. We have to get into it, otherwise we become aloof and detached. Once we are born the only certain thing in life is that we will die. It's humbling, depressing or possibly a challenge. It can be really painful to think about our death, the death we've experienced and the death that is yet to come, but we can be much more helpful if we worked through some of our own stuff regarding this. When I started my bereavement work, I was single with no children, and bereavement work was an absolute honour and joy and it still is. I had very few issues around it, but when I returned to work after my first maternity leave, I really struggled. I did not want to hear about children dying. The fragility of life had never felt more real and sometimes I drive home from work in tears feeling like I was losing grip on my child. In reflection, I don't think I was supported very well on the whole, but I was very honest in my supervision and line management. Needless to say, my second maternity leave came around quite quickly.

Let's talk about euphemisms. A euphemism is a polite word or expression that is used to refer to things which people might find upsetting or embarrassing to talk about. We don't like to use the word dead or dying so we say these things and there's a few words there that you can have a little bit of a look through. Then perhaps maybe you can think about what it is you say when someone has died or when you're writing a code of condolences to a friend, what's the phrase that you use? You probably don't say 'sorry your husband died'. You might do but we tend to use other words. I'm in Yorkshire and people tend to use the word 'passing'. Are there any words on this list that cause you to stir? Personally, I don't like the term 'born sleeping', which I know might be quite controversial and to understand why it's said and perhaps by me saying that now has upset some of you listening today, but it's just not the truth. Babies who are born sleeping are not dead and that's how we use the term. My baby was born asleep and stayed asleep for two hours before she decided to take a look at the world so that is maybe why I don't like it because the truth to me is different. So, why do we use euphemisms? For protection maybe? 'Dead' seems quite harsh, so these words may soften the blow, it's maybe more sensitive and gentler. You want to avoid being rude or offensive to avoid discomfort. It's natural to die, but it makes people uncomfortable. This language may reduce stress, but perhaps it's to offer spiritual comfort to those that believe in afterlife. 'He's not dead, he's with his maker'. Well, denial, it makes it more real to say she's died or maybe your own painful grief feelings. Euphemisms are easier to say, although the word 'euphemism', isn't it? It's a bit of tongue tie. I'm not going to tell you what to say. This is more about an opportunity for you to think about what you say and decide if that's right for you. However, please consider these words, as we've seen aren't always honest and I would urge you never to use these words with children and those with learning difficulties as it is really confusing. A child might say, 'we lost my daddy, but I hope we can find him soon'. Perhaps, 'my grandma is asleep, but I want her to wake up'. This just adds more confusion and more pain to the situation that children are already in.

A little time to reflect. Think about the words you use to refer to death. Reflect on this. Are you avoiding something? Think about how you communicate with clients about death and check out the words your clients use, are they avoiding something? I'm not suggesting you confront that, you might do, but it gives you an indicator, doesn't it? Perhaps if anything's come up for you there, just pause this video and write a few notes so you know to come back to it later, or deal with it now, if that's what you want to do.

One of the reasons I love bereavement theory and teaching it is because it's so versatile. Bereavement theory, as you well know, underpins a lot of the work we do. However, it also means it can trigger a lot of our own experiences in bereavement and loss and I include change in that as well. We can go through a very similar process to bereavement when we've experienced the loss of something or a change of season in our life, so I suggest you pause this video and have a look at the handout I've provided and circle all the losses you've experienced. If you're anything like me, you will be surprised to see what is on there and what actually counts as a loss. Okay, you can go ahead and pause the video now.

I invite you to talk to your supervisor or peer about your list and see what comes up for you. Be honest. How do you think your experience can help your bereavement and how might your experience hinder you? I think, in any of the work we do, we have to be aware that we can be helpful, and we can also hinder.

Let's have a look at these two slides. This is not exhaustive at all, but it might be something you want to go ahead and talk to a peer about more fully, but these are some of the main ones that come up when I deliver this training. Your experience could help your clients. You may have a hope that underpins your work. You have been through it. You know that they can get through it. You might find it easy to empathize with client's raw feelings because you felt raw too and you have the patience to walk a painful and slow journey with your clients because you remember how it feels and how long it can take. Perhaps you can share interim coping strategies to help them get through the day. Your experience may hinder your work. The work may become more about you and your feelings. Can you bracket your story? You might become too emotionally involved, especially if a similar relative has died or the death that you've experienced wasn't that long ago. You may struggle to hear clients frame of reference as you are stuck in your own or you distance yourself because it's too painful. You may want to give advice or share stories that just aren't appropriate. You may want to add your own ideas in there as well.

For further thought, I want to introduce you to the Dying Matters Campaign. You may have heard of them already. They're challenging people to prepare their will for death by considering these five points. Write your will, consider organ donation, record your funeral wishes, plan your future care and support and tell your loved ones your wishes. So, have you considered any of these? I would imagine that if you want to be an organ donor, then you've probably done that, but you might not have written down your future care and support. You might feel like your miles away from that. On one occasion I delivered this training, one of the delegates had sadly experienced two significant deaths in the last six months. She shared that one had written detailed wishes for the funeral and one hadn't. She said it was so much easier to handle the wishes of those that were written down and she saw it as being able to do one last thing for them and their last message to her, whereas the one with no plans was really tricky as there were a lot of family members trying to have their say. When I delivered this training, I was very much of 'well, when I'm dead, I'm not aware of it so you can do what you like with me and celebrate in a way that's fitting for you'. Her experience really challenged me that it could actually be a huge blessing to my family to have some ideas and thoughts written down. It might be something you want to consider as well. It's worth looking at this list with your nearest and dearest and coming up with some plans and being aware of how this makes you feel as you're doing it. I have actually had this discussion with my children aged five and seven, very loosely and age appropriately, we talk about death a lot. We talk about how sad we will be when certain people die and how we will probably cry a lot. I've also explained the difference between cremation and burial to them. They were not impressed with cremation. They were a little bit horrified. They've decided to be buried and hope they die together and if they do, please, can I toss a pack of UNO cards in their coffin so they can play together? I'm not sure they've grasped the concept of death. This might sound like a funny conversation and on one level it is, but on another it's really painful to think about. I had to have a big word with myself afterwards because it's hard to stop your head from going to that place. Later on, my five-year-old said to me she was thinking about what it would be like when different people die and how sad she would be. She said, 'when grandma dies, I'm going to be so sad'. Then she paused and said, 'she's your mom. You are going to be the saddest'. I replied, 'Yes, I will be very sad, and I might cry a lot, but it will be okay, and I will still be strong enough to comfort you and your sadness as well'. You can use these conversations as an opportunity to prepare and comfort those you are close to. We can never truly, really be prepared for the agonizing pain and grief that we experience when somebody dies, but we can make people aware that it happens and what our wishes are. Please see the Dying Matters handout for more information. You might want to print it out. Maybe you want to take a few moments to shake that off before we continue. This work can be personally very draining and emotional.

Definition. Now that we have an awareness of our own experience, let's look at death generally. What is the difference between bereavement, grief and mourning? Terms you'll all be familiar with, but do you actually know how to define them? Definition of bereavement is the death of someone. Grief is what we feel, and mourning is the physical expression. When you lose your job, you aren't very because somebody didn't die, I'm presuming, but you can grieve because that's how you feel about your loss or you might celebrate if you're happy about it, which then the celebration would be an expression of how you feel. I say, that's your mourning.

Grief is a natural process. It does not necessarily require professional intervention. Dealing with the emotions that occur in the grieving process take much time and energy. It does not necessarily require professional intervention. It needs good social support. Many bereavement charities will work with clients six months after the bereavement. I think some of this is to manage waiting lists and some of this is because we don't want to pathologize grief, it is natural. I used to get a lot of calls from social workers and school nurses who were in this parallel process with their clients. They'd call in despair because somebody within a family they were working with had died and I would say it was awful and everyone was crying, and no one knew what to do and it was awful. I've got to help them. I would spend quite a lot of time trying to convince these workers that this was normal. This happens when someone dies, people cry, and you can't get out of bed and you take time off work and its part of the grieving process and we can't take that experience of that part of the journey away from those people. But obviously, these professionals, they were wanting to help, and they wanted to rescue. So, what is our role if we can't take it away? We will come back to that later and answer that question.

Yeah, bereavement theories. I like these theories, because they are really useful for helping clients make sense of what is happening to them and they help us understand the process our clients might be going through. As I go through it, we'll talk about the practical applications and how I use them in my work. The first one, there's no reason why I've chosen them in this order. There are five stages of grief, Elizabeth Kubler Ross and she was a Swiss psychiatrist. She devised the five stages model inspired by her work with terminally ill patients. This model described what they were going through after they've had this diagnosis. She wrote about these in her book Death and Dying. However, the stages also describe the emotional stages experienced by loved ones after the death. This model was greatly criticized as it was assumed grievers went through these stages as a linear process. It made it look simplistic. However, she subsequently written about this in her later book on Grief and Grieving and the references are there on the slides. Some of the things that she said in this book are 'the stages have evolved since their introduction. They were never meant to help tuck messy emotions into neat packages. There is no typical response to loss, as there is no typical loss and our grief is as individual as our lives'. It's a really good book to read, it's quite user friendly, and it's the sort of book you could read if you were grieving or to recommend to clients. I recommend having a look at that. I'm going to go through these stages. Denial; It is not literally not believing they are dead, it's much more symbolic. It's being in a state of shock, that feeling of numbness. She argues that denial is important for survival as it only lets so much emotion. Imagine denial as a sort of gate, only letting so much in and it makes it manageable. There the denial phase and the feelings can surface. Can you imagine being given some devastating news and having the full force of all those emotions on you at once? Just think it would literally knock you over so denial acts as that gatepost, I guess. Then anger, so this doesn't have to be logical or valid. It's a natural reaction to the unfairness of loss. It can be raw and painful to see. Your friends and family don't usually like seeing it. It makes them very uncomfortable. However, we can encourage clients to express their anger and we can give them permission and say, 'it's okay that you're angry'. Bargaining; so clients might say things like, 'if I'd been a better wife or if I hadn't have had the argument or if we'd not gone for that walk that day', it can act as a break between emotions and a bit like denial, I guess, and give the psyche an opportunity to pause or time to just adjust. Then depression; this is not necessarily a sign of mental illness; it is a sign of great loss. Life feels empty and pointless. In grief, depression is a way for nature to keep us protected by shutting down the nervous system so that we can adapt to something we feel we cannot handle. Then acceptance; we accept the reality that our loved one isn't coming back. We will never like this reality and it will never be okay, but we eventually accept it. I think it's really important with acceptance to explain or know that just because we accept something doesn't mean that it is okay.

 

You may have seen this slide before, and it illustrates that it's not a simple process. You go back and forth and all over the place, and this be really reassuring for clients to see. They don't have to fit into a model.

The four tasks of mourning, this is by William Worden. So earlier we wondered what our purpose was when grief was a natural process, which doesn't necessarily need intervention. Now, I think the four tasks can help us see what a client may need. All my clients have needed help with at least one of these tasks, so I keep this in mind as an assessment tool, and I'm listening out for which task needs intervention. We will go through them. The first one to accept the reality of the loss. The client may expect to see them again, forget they've died, be in denial, keep laying the table with a seat setting for them, keep their clothes in the wardrobe. Maybe they think they hear them when they get out of the car at the time that they come home from work. The client needs to emotionally accept, not intellectually accept. This can take some time. Another task is to process the pain of grief. It is not our job to make it better for clients or take away their pain but allow a safe place where all their feelings are acceptable. Many clients are very afraid of feeling the pain. They think it will never end or be too much and they push it down. I think his counsellors, this is where our expertise lies. We're not the doctor or family friend that just wants to, no disrespect to the doctors. Thinking of they the nurses and the social workers that used to call me and used to want to end the pain of these families they're working with and to just try and explain, you can't. You've got to let them feel their pain. Which is really key to what our role is and what we're skilled to do, we allow the pain in the room. We don't make a cup of tea and give a ton of tissues and then there it will be okay. We give time to explore, time to express and that's really what this task is about. So, three, to adjust to a world without the deceased. This could mean many different things, depending on who the person is and who the person is that dies, so it means different things to different people. So, I'm just going to look at this on a few different levels. On n a practical level, a university student might say, 'who is paying my fees or picking me up from uni now my mom or dad has died?' On a psychological level, you may have to form a new identity. To say if dad promotes his son playing football, but then dies, no one is there to take the son to football practice so it might be that that part of the son dies too. It might be that you want to help families think about that, of replacing some of those roles. Then on a social level, you may need to accept your new role and the reorganizing of the family structure. The oldest son may become the male role model or expected to do more. Similarly, for the oldest female, the oldest daughter in the family may take on the morale around the house or maybe your sibling dies so you become an only child. Perhaps you might ask, 'how do I live as a widow now when all my friends are in couples? That would be really, really tricky for people. They may feel that they lose their friends in the process because they can't make sense of how they fit into the friendship groups. Then finally, on a spiritual level, this death may redefine the meaning of life to you because it might not make sense anymore, but it might create a purpose to carry on. I've worked with people who suddenly decide to believe in an afterlife because it gives them comfort to do so. Then the fourth task is to find an enduring connection with the deceased while embarking with new life. The task isn't to give up their relationship, but to help them find an appropriate place for the dead in their emotional lives, a place that would enable them to go on living effectively in the world. A bit of a tricky one to get your head around this and with clients who tend to look at incorporates ending rituals as well. Maybe planting a rosebush in the garden that becomes that connection with the person that has died. What do you think your mom might be thinking or saying now in this situation? So, you sort of keep their thoughts and memories alive of what they might say. These tasks do not need to be in this order. When your client may only present with the needs or help with one or two of them. The theory does argue that if you complete these tasks, it has a healing function.

I will just give you a couple of minutes or seconds to look at the whirlpool of grief. The whirlpool of grief is not a model as such, it's an amalgamation of the stages and tasks, and it gives a pictorial example of what has happened to you when you receive often life changing news. It doesn't just apply to bereavement. It could be any bad news, loss or change. Let me describe it to you. You are on the River of Life and you get some terrible news. You fall into the waterfall and you experience shock, numbness and denial. You can't believe what you are hearing. At some point, you fall into the whirlpool, maybe on the rocks where you experience pain and physical symptoms, or perhaps you end up washed up on the sand banks. You feel lost and emotionally disorganized, like you're falling apart. At some point you'll return to a new river of life. You will mourn and accept the reality of what's happened to you. You can start to reorganize your life and love again and be loved. I use this with clients, and I explain it's very similar to the way that I have just done to you there, and I ask them if that makes sense to them. I ask them if they could tell me where they think they might be. I'm careful to ask them where they would like to be and that really just depends on our relationship with the client. If you do ask the question, don't be surprised if the client can't imagine themselves back in the new river of life. To do that, they feel they are being disloyal to their loved ones. I might ask how they might get there. Are they aware of what this process involves? Sometimes they don't understand, and it gives you an opportunity to say it can involve expressing a lot of difficult feelings. It makes sense to them to cry a lot. Watch out for denial. The client that thinks they are back in the river of life when they have clearly refused to fall into the whirlpool. I might remind clients they can't skip a bit. The journey has to be completed and I might share what I think. Interestingly, when I work with children and their families, quite often the child would be able to pinpoint where the parent was much better than the parent could pinpoint where they were and that would be really useful in the work because the parent would feel that they're just holding back so it doesn't affect the child but the child's fully aware of how their mom and dad are feeling, they just need them to be more honest about it. Use it in those cases too. The whirlpool of grief is very useful because it conveys hope, beginning and an end point, hope that the client will get through it. It shows that it's a process of a journey that they are on and it illustrates why you can't skip a bit. It can mobilize and validate your client's experience. My clients have been so relieved to go through this with me. They see it like a map and give them some security that they aren't going mad and it also allows for some individuality. You can go around and round for as long as you want.

I'm going to look at the Dual Process Model by Stroebe and Schut. I'm not entirely sure that I'm saying that right. That's how I'm going to say it. This theory of grief describes two different ways of behaving. There is the loss orientated and the restoration orientated. As you grieve, you will switch or oscillate between these two different models of being and that's why it's called the Dual Process Model, because two different processes are happening at the same time. Let's look at loss orientated. These are thoughts, feelings and events that make you focus on your grief and pain. It might be remembering, going to the funeral, looking at photos, listening to relevant music, crying. Then there's the restoration orientated. This helps you get on with life and distracts you from grief. It might include paying bills, going shopping, cleaning and cooking, working, taking the kids to school, etc. Usually we wouldn't encourage clients to repress or ignore emotions because it's unhealthy. However, in bereavement, Stroebe and Schut believed that for most people it is actually a normal way of coping with grief. It is in our minds wave in the pain and giving us an opportunity where we can get important tasks done. A little bit like we talked in the stages about the gate that just lets in a little bit at a time. That gates are a bit of a running thing between these different models. If you've ever really sobbed, really properly sobbed, you'll know how exhausting that is and you can't do that all the time, you need a break. By switching orientation, it helps them to integrate the loss and adjust. Sometimes grieving and sometimes getting on with life. We would argue that if we were stuck in grief like Queen Victoria, for example, who always wore black, that it's not healthy or the opposite is not healthy too. Although it's a fairly new model, it's well accepted. Clients are often relieved to know that they're getting on with things is not forgetting the deceased, but totally normal and healthy. Children are really good at this. They will cry and then they'll go out and play without feeling guilty, whereas adults, we tend to juggle with the guilt a bit more. This model is useful because it doesn't just focus on grief but looks at the person's life as a whole. It encourages routine and it gives permission to get on with life for bit.

Tonkin's Model. I have drawn four sets of circles for you there. The circle one is life before grief. Circle two the black is the grief. Actually, if you look at Tonkin's model, the black would take up the whole of life. I just wanted to show that life was behind that. Circle three illustrates what we used to believe, that grief would disappear over time. It would shrink. I put a cross there because that's not how we see it. We see it as the sort of circle for us. The idea of growing around grief acknowledges that grief doesn't always disappear with time. Grief stays the same, but your life gets bigger. It also shows that despite grief not going away, this doesn't mean you will always feel as bad as you do right now because your life will grow around the grief. I guess that's part of the adjustment that we were seeing in the tasks of grief; adjusting to the loss. For many bereaved people, the idea of moving on or forgetting is one of the most problematic parts of grieving, whereas this model suggests it is okay for grief to always be part of your life. This has been such a relief for clients to realize they don't feel bad for how their life is growing because they know that their grief is still there. I've worked with clients who might have joined a group of people who share similar losses and then they feel guilty because they found so much joy and support in life that they wouldn't have found if that person hadn't died, but this is just part of life and it is part of the growing around your grief and your life becoming bigger to accommodate this grief. It can be really helpful to do those circles. They're really easy to do. You could just get a piece of paper and draw those circles on, but also you can find different examples of that online as well.

We've looked at grief in five different ways. I found sharing simple models and ideas with clients are incredibly helpful. It gives them a map of where they are, helps normalize what they're going through and gives them hope that they will get through it. On reflection for you, which resonates with you? Are there any that you don't like? Can you see any that would be useful with the clients you are working right at the moment or clients that you've worked with in the past?

Onto our death and them section. We're going to look specifically at working with our clients. Starting to talk about working with diversity. I want you to know that you don't need to know everything. I used to work in a rich diverse area and I decided naively that to try and learn about all faiths, all the bereavements and all cultures, then I discovered that there are sub-cultures and personal preferences and I realized that I just could never learn everything. Not that that stopped me from learning and taking on board things, but just the reality that I was never going to know everything. Also, how generous my clients were with explaining how things were for them and that storytelling was part of their process. If I'd have come along and gone, 'you know, I know how you guys do things' just would have taken away the opportunity to tell a story and it would have presumed and judged as well. However, saying all that I've attached that includes some of the key differences in terms of some of the different faiths and religions. I would say to approach clients with curiosity and positive regard. People generally like explaining the way they do things, the practices and rituals they take part in. Be aware of your own beliefs and values so that these can be 'bracketed' successfully. What do you believe happens to you when you die? Heaven, nothing. Reincarnation, something else? How strongly do you believe this? Are you okay having someone talk wholeheartedly about their belief of reincarnation when you wholeheartedly believe there is nothing? That might be a challenge. Cultural and religious differences to consider. Faith and religion can play a huge part in bereavement work and some clients might change or reconsider their beliefs while going through this time. I usually ask if I have any afterlife beliefs. How you live your life is often linked to what you believe will happen to you when you die, even if you're not aware of that. If you believe there is no afterlife, this is it and you need to live well. Or maybe when I die, I go to heaven if I've been good, so I need to live a good life to assure that I go to heaven. There's a list of some of the factors that could be very different due to religious or cultural reasons. Although I said you don't need to know everything, it's worth knowing that if you're not aware that an open casket could be in the family, you're working with's lounge, you get a shock. It's just useful to know in some faiths the turnaround time needs to be within twenty-four hours, not a couple of weeks. That are the things that are just really useful for you to know.

I'm just going to go back a page. Some hospitals have bereavement workers or people of certain faiths that work in a bereavement capacity in hospitals and they quite often do training or are available for advice and help. So, if you're really interested in this, it might be useful for you to have a word with them and talk to your local hospital. They are a fount of knowledge and information.

Okay, intervening variables. Let's have a look at some of the factors affecting people who are grieving. There are a lot of variables that will affect the way a person may handle their grief. Their grief is where these factors meet so that faint triangle shape that you can imagine in the middle is where the grief lies. I'm aware that this is making this a little bit textbook and everybody's unique and different and we can't judge assume but I still think it's really useful for us to see and to think about our clients in particular. I'll just go through and explain it and it will make more sense. Our clients, that's a variable. This could include the age of your client at which the death occurred. You're working with a 30-year-old, but the death happened when they were five or three years ago. How old are they now? What's their attachment and coping style? Do they cope really well with things or do they just fall apart? What's their temperament and personality? What past mental health have they had? How resilient are they? All these things are going to affect how they grieve and there isn't a right or wrong to this. There are just facts. Then the person who died, how did they die? Was is sudden? Was it a long illness? Was it expected? Perhaps it was murder or suicide. Who are they to your client? Was it a close relationship? What was the quality of the relationship to your client? How did this deceased person fit into the family structure or if they weren't family, how do they fit into your client's life? Where they adored, well respected grandpa, or an ex-communicated uncle.? I've worked with all these; I'm not making this stuff up. These are real things that happen. Family and environment. How did the family and community respond to this death? Were they supportive? Was there press intrusion or police investigation? What is the grief culture like in the family? Is it something that's being talked about? Do they have permission to grieve? Although we may not ask these questions directly, although they could be part of your assessment process if you wanted them to be, they are useful questions to hold in your minds and wonder about. For example, your client's grandma died due to old age. Your client has grown up in a kind and loving home and expresses emotions easily. You might wonder whether you see that client or not, they might not need counselling. Then a different client, your client's estranged dad dies from an overdose that he has not seen for 10 years. I have some extremes here, but you get the point that these intervening variables do have an impact on how a person will grieve or what your task might be. If you are working with a bereaved client at the moment, perhaps jot those circles down on a piece of paper and list all those different factors and take that as a structure to supervision to explore on if that would be helpful to.

I just want to have a brief word about complicated grief. It's something that comes up. Remember that grief is a natural process. However, prolonged symptoms can mean intervention is necessary. The person feels stuck and struggles to cope with the emotional impact of their grief or grief. Having existing mental health conditions. Perhaps the death was traumatic. Murder, suicide, domestic abuse, or maybe, unfortunately, a result of a combination of difficult circumstances. I would say that complicated grief doesn't necessarily need diagnosing, it just might be something that you're aware of. We could argue that all our bereavement cases are complicated grief because it needs intervention. It's something to think about.

The possible grief reactions. There are two slides here, behavioural, physical, just going to go forward, thoughts and feelings. There's no one way to grieve. When a client tells me their symptoms, they want to know if it's normal. Some of these are more common in children than in adults, but it really just depends. Like Koebler Ross said, there's no one way to grieve. There's no certain set of reactions. These are just a list that I've put together. Often, it's parents that will come with their children, I used to with children, wetting themselves or they're not sleeping. They will be talking about the physical things and the behavioural things a lot more probably than their feelings. They might not have asked them about their feelings because children tend to behave. We notice that more than their feelings, but also with adults as well. Not sleeping, getting anxious, the different thought. They're really just things for you to be aware of.

I'm going to now talk about assessment. When I worked for a children's bereavement charity, we had about three to four pages of assessment questions. The parents really liked being able to talk and be heard and we went into the work fully understanding the facts. I would meet with the parent for a couple of sessions before I was introduced to the child. It's really important in children's work because they can get quite confused around facts. If you just meet the child first, you can end up leaving a session wondering what's happened and that might be okay. You might want to work in that way. Don't think your assessment needs to be about details and mine now isn't and I keep a lot of these points in my mind rather than doing a formal assessment. Let's go through some ideas that you could maybe consider based on what we've talked about already. What are the intervening variables? Remember the variables; our client, personally who died, family and environment. Think of a client and write out their intervening variables. Do you view or understand their grief differently now you've written them out? Then the stages of grief. What feelings is your client reporting to you? Perhaps they're talking about road rage, which they've never had before. They are angry. Maybe something else, constantly sad, crying at everything, crying at adverts on the TV. Then the tasks of grief. What does your client need help with? Is it to accept it's happened, feel the pain, to adjust? Finds the connection. One client has reported recent horrific events to be quite matter of factually and I listened quite unaffected by what she was saying. When she left, I sobbed. What I heard was horrendous. She was in denial and our task was to help her feel the pain of what happened. I meant to say this earlier and forgot, but when I'm sharing case studies, I've changed the information enough that it's not recognizable. I'm not going to say that before each case, just know that I have changed enough. That client's task was to come out of denial, really to feel the feelings. I said earlier, I use the whirlpool of grief a lot. It's a very simple way for the client to see where they are and for us to reflect back what we see as well. It can be really helpful. Then the client's reactions. What is the problem that's bringing them to counselling? I don't think any client ever said to me, 'I'm coming because somebody's died. They usually say, 'I'm having trouble at work' or 'I'm falling out with my partner' or 'I'm really sad' and then as it comes out, somebody's dies. One client I had spent most of the session telling me about her anxiety and workplace stress. Then I asked how long this has been happening and she said, 'since my mom died six months ago'. So, she presented with workplace anxiety but after discovering her mom had died, we never spoke about work again. Just bear that in mind. Also keeping a note of meaningful dates if you want to work in that way. The date that they died marks the anniversary. Being aware of birthdays, Mother's Day, Father's Day, Christmas. We need to be aware of them. Now, I don't bring it up. 'I'm aware that it's Mother's Day next week. How are you feeling?' Just keeping in mind that it might be an issue. I met a residential worker once who had a calendar that was specifically for the dates for all the children in his care. So, he wouldn't always speak about it, but we would expect and be ready for very extreme behaviour on those days, whether it was the day that there was a mom's birthday or a death or a family occasion and without a doubt, a child would usually misbehave on those days. Genogram or ecogram. It's not always necessary. I don't do this very often, actually, only if there was a complex family history and I can't make sense of it. I will ask 'do you mind if we do a family tree just so I can understand who fits where and your family?' Also, you get to see patterns as well. Perhaps quite a few people have died, and you can show those with crosses. The echogram is similar, and you might want to do some more of your own research on this, but echogram is more about the quality of the relationship. I believe you do the echogram in the same way as you do the genogram, but you do thicker lines or dashes depending on the relationship. Then finally, you might ask, why now? It probably relates to their reactions and what's brought them to counselling. Maybe they say they can't go on like this and they need help but why now? Why not last week? Why not six months ago? And why not in the future? What is it that's going on now? Like I say, you don't have to do an assessment. You don't have to have a tick box or a form, but perhaps keep some of these in mind. For me, if I was to pick a few, it would be tasks of grief and whirlpool of grief would be the key ones, but it's just personality and what I find works.

The work. What is bereavement counselling and what are we meant to do? It could be many things. It could be time and space to tell stories using all your counselling skills to listen. It could be a place to remember. I spent a long time listening to people tell me about their lost relationships, about favourite music, day trips, things that were said and I actually really enjoy listening to these stories of things that happened in the past. I can really get involved and hear it. If you think about your clients telling these stories, there's probably not anybody else in their life that's going to listen to those things. The family members know it already or friends don't know it's that's important to allow that space for them. A space to feel uncomfortable feelings. We learned earlier that families aren't great at handling anger and pain. They just want to make it go away and cover it up, not because they aren't compassionate or concerned or caring, but because it just is really uncomfortable. We see pain and we want to make it better. So, therapy is the place to express some of these raw emotions. As a side note, you need to be prepared for this and ready with self-care when it happens. I find it an absolute honour, but it is exhausting. I worked with a girl whose mom was brutally murdered and she spent most sessions very angry and symbolically trying to kill me in whatever we were playing with. Usually I always spoke to a colleague afterwards to help ground myself and be reassured I wasn't hated, but it was really tricky. I think in bereavement work there is a lot less goal setting than in another work, you may not work in that way anyway, but usually in my work there is some sort of 'where are we going? How would you like to feel or be' in a less solution focused way? In grief and bereavement work, I don't really do that. We're on a journey and it can be very slow. I may review the work together, but it's really hard to set goals on grief. If you do, I'd be interested to hear from you. You might want to help with ideas. One client I worked with realized she did not like going to the grave. It was not her place of connection, but her family members expected her to go. So, a significant day was coming up and she was struggling to work out what to do. I asked her what her grandma's favourite flowers were. She was able to tell me instantly. I suggested she buy a bunch and keep them in her home as a reminder of her gran and to honour her and so they could enjoy these flowers together. She loved the idea and reported back how wonderful it was. Although I don't think it's our role to give advice, I do think bereaved clients' needs a little bit of help thinking outside of the box and I quite often help with mourning rituals. Maybe the funeral was too complicated a situation to be a farewell, so I help clients say goodbye. I mentioned earlier, planting a rose bush, writing letters, burning them and it might help with those kinds of ideas, depending on what the client wants. Then finally, if you know me, you'll know I like my creative work. Although I do separate training on this, this is a little sneak peek. You might encourage your clients to bring photographs in and work with those. I use emotional literacy cards a lot. There are loads of different ones you can find because they help clients realize what they are feeling. When we work creatively, the subconscious comes forward. We can really hear what's really going on. That can be just really enlightening when we use a bit of play dough, use stones or pebbles and come out of this with a creative mindset. There's a lot more training available on that, but you can also speak to me about that as well, if you like.

Okay, we're nearly done. The final breath. In this presentation, we've reflected hopefully on your own experiences. You may still need to go away and do a bit more of that. We've learnt about theories, learned about the grieving process. What next for you? Perhaps something's come up and you need your own counselling. Perhaps you need a good bereavement supervisor, maybe do some extra reading and maybe there's some other things you want to do.

Where are you now? We come back to the scale. On a scale of one to 10, how much do you now know about bereavement? Look at your previous number. How much have you learned?

I really hope you've enjoyed this presentation. Remember to go back and reflect fully on the opportunities I gave you, because you're going to say much more from this training if you do and it just consolidates that. I'm available for counselling and clinical supervision, if you'd like more support from me.

I'm going to end with a poem while you reflect on this lovely picture. It's called The Elephant in the Room, and there's a copy for you, if you'd like it. There's an elephant in the room. It is large and squatting, so it's hard to get around it. Yet we squeeze by with, how are you? And I'm fine and a thousand other forms of trivial chatter. We talk about the weather, we talk about work, we talk about everything else except the elephant in the room. There's an elephant in the room. We all know it is there. We are thinking about the elephant as we talk together. It is constantly on our minds. But you see, it is a very big elephant. It has hurt us all, but we do not talk about it. The elephant in the room. Oh, please say her name. Please say Barbara again. Please let's talk about the elephant in the room. For if we talk about her death, perhaps we can talk about her life. Can I say, Barbara to you and not have you look away? For if I can ask, then you are leaving me alone in a room with an elephant. That was by Terry Kesselring.

So finally, for further information, links and resources, please refer to the lecture delivery page below this video. Thank you. And don't forget to claim your SCPD certificates for this presentation.