‘How do we cope with loss or bereavement in a psychologically informed way?’*

17.07.2020: In this week’s Psychologically Informed Environment (PIE) blog for the national youth homeless charity; Centrepoint, I am returning to the topic of ‘loss’ and ‘bereavement’. I originally wrote about this briefly in the early stages of the COVID-19 pandemic, in the context of ‘anger’ and ‘frustration’ (c.f. https://medium.com/@DrHelenMiles/anger-frustration-and-conflict-5d14db41ff38). However as this current situation continues, this issue feels even more relevant because the extremely high UK excess death rate (c.f. https://uk.reuters.com/article/us-health-coronavirus-britain-toll/uk-covid-19-death-toll-nears-56000-including-suspected-cases-reuters-tally-idUKKCN24F0TZ) means that the issue of ‘grief’, loss or bereavement is something that is perhaps closer to home to many of us now. Consequently, over the past few weeks the PIE Team have been working with our colleagues in Human Resources (HR) to devise and deliver some psychologically informed training sessions for our managers about loss and bereavement in order that they can better support their staff, and the homeless young people in their Centrepoint services on this issue.

Talking about death is something that culturally in the UK we perhaps often do not do as much as we should. It sometimes feels like a topic that is too difficult or uncomfortable to discuss, as we prefer to ignore facing the reality of our own mortality and that of those we love. However, it is of course one of the great certainties in life that affects us all, after all the old saying is ‘the only sure things in life are death and taxes! Therefore, creating safe honest spaces to discuss these issues, whether that be in reflective practice or supervision sessions with staff, or key-working sessions with our homeless young people, is important even when it may be difficult because it may trigger us or connect us to our own experiences of loss or bereavement. Moreover, despite loss and bereavement being a universal experience, it is important to remember that we are all individuals, with our own beliefs, histories and experiences. Consequently, there are multiple perspectives around ‘grief’ and how this manifests or is felt within us all, so there is no real ‘right or wrong’ in our discussions with others.

A bereavement can be defined as ‘the reaction to the loss of a close relationship, most notably through someone dying’ (Wayment & Vierthaler, 2002), and our psychological responses following such a loss can include feelings of sadness and despair, anxiety, guilt, anger, a longing for the deceased, sleep disturbances and lack of appetite. Moreover, coping with a bereavement is not just about loss, it is also about adjusting to what is often a major life event and/or a new reality (Stroebe et al, 2005) and thus is a ‘process’ we move through rather than a ‘task’ to be completed.

The issue of how we can cope with the emotion of ‘grief’ following such a bereavement has been considered by psychologists for decades, and probably the most famous model is known as the ‘5 Stages of Grief’ (Kübler-Ross, 1969). This notes that often the first emotions felt after hearing the information that someone you love has died, are those of ‘Denial’ or shock, which can lead to further feelings of confusion, and avoidance or self-isolating behaviours, or even just a desire to ‘carry on as normal’ and pretend that this loss isn’t actually happening. An individual may then experience ‘Anger’ at why this has happened to them, which can also manifest as frustration, irritation or anxiety, before feelings of ‘Depression’, sadness or being overwhelmed by the news can appear. A further emotional experience known as ‘Bargaining’ may occur wherein the grieving individual may try to start to find meaning in their experience, reach out to others and tell their story or share their memories of the loss. Finally, an individual is described as finding ‘Acceptance’ or even meaning in the experience that allows them to start exploring their options for the future and enables them to begin to ‘move on’.

However, this model of ‘grief’ has been criticised as suggesting that there are a series of distinct stages that everyone moves through, or indeed needs to move through to process grief when actually in real life this process is often more messy or complicated than this model suggests. Consequently, this model has been seen more as a lose ‘framework’ to outline the experience to start conversations rather than a defined, rigid or universal experience. In other words, it is far more likely that we process grief in a manner more akin to a ‘roller coaster’ than a linear path, so we experience different emotions or ‘stages’ at different times and in different contexts, or not even experience one of these ‘stages’. Therefore, other ‘models’ of grief have been proposed by psychologists. For example, Stroebe & Schutt (1999) have outlined a ‘Dual Process Model of Coping with Bereavement’. This model outlines how our experience of grief may osculate between being ‘loss-orientated’ (i.e. experiencing the intrusion of grief, dealing with the consequences of grief, breaking bonds or ties, denial and avoidance) and ‘restoration orientated’ (i.e. attending to life changes, distracting oneself from grief, doing new things, developing new roles/identities/relationships). This ‘switching’ between these two states is noted to be exhausting, especially when we are also coping with and dealing with our everyday lives, so it is vitally important to give ourselves time and space for both.

The process of grieving is therefore different for everyone, and is complex as it is often impacted upon by the specific nature of the relationship we may have had with the deceased. This is ‘normal’ and is often not predictable. How many of us for example have thought we were ‘coping’ with the loss of someone in our lives, only to be triggered by a memory (e.g. a piece of music, a recollection of a specific incident, or a reminder of that person) that reduces us to feeling overwhelmed with negative feelings. ‘Grief’ is therefore a painful process, one that it is important not to shy away from or try to block. Rather we need to acknowledge and process the pain we are experiencing and work through it, otherwise we can end up with ‘unresolved grief’, and this can lead to the development of subsequent mental health difficulties such as clinical depression (Zisook & DeVaul, 1983).

Therefore, how can we cope with grief following a significant loss or bereavement? This short video is a great summary: https://youtu.be/gsYL4PC0hyk, which notes the importance firstly of acknowledging our painful emotions and our different responses. Even though we might not feel like it, trying to still do some things that we know make us happy is helpful. Although this often comes with feelings of guilt (i.e. how can we feel happy when we have lost someone important to us?), it is important to maintain our mental health and allow us to process the difficult negative emotions, and is part of being ‘kind to ourselves’. Expressing our emotions, whether that be by talking to others and seeking support (i.e. friends, family or professionals) or even writing them down in a private journal can be a very helpful and cathartic process. Moreover, ensuring that we continue to look after our physical health needs (e.g. sleeping, eating, exercise, self-care) whilst our mind is healing is critical even when it can feel like an insurmountable task.

Taking all of this into account therefore, what might we see in others that are grieving following a loss of bereavement? Being able to talk about our own experiences of grief, will open up those conversations with others, but if we are psychologically aware or informed, we will also notice things in others that may suggest that they are currently dealing with these issues and we can offer them support within our relationships with them. At the moment this is perhaps more likely to be a common shared experience with more people than usual, and therefore it is important we are aware and sensitive to those around us post COVID-19.

The British Psychological Society has therefore recently published some useful guidance on this (c.f. https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20%20Files/Supporting%20yourself%20and%20others.pdf) which highlights some key behavioural, emotional, cognitive and spiritual changes we may notice in a grieving individual. Of course, as noted above these will be different for different individuals and even at different times. However, broadly these include behavioural changes such as fatigue, difficulty sleeping, changes in eating habits, tightness in chest, irritability, appearing subdued or even overworking to compensate. Emotional changes noted include numbness, sadness, anger, guilt, anxiety, fear, loneliness, emptiness or regret. Cognitive (or ‘thinking’) impacts could manifest as confusion, denial, voicing thoughts of unfairness, disbelief, and difficulty concentrating or making decisions (or even decision making being impaired). Finally, spiritual changes noticed could be a loss or reconnection to that individual’s faith or religion, and an increase in their search for meaning, or trying to make sense of or questioning their life situation.

Responding to another person who we therefore notice is grieving is key, and at all times we need to be guided by them. Acknowledging their situation is important and creating the spaces to allow them to speak about it within our relationship with them, if they wish to is helpful but equally accepting if they do not feel that this is something that they want to discuss right now also needs to be respected. Sometimes just letting someone know we are there for them, if and when they are ready to talk, is all we can do (e.g. “I am sorry that has happened; I am here if you want to tell me more about it?”). However, if they do speak to us to witness or hear their experience, then responding in a manner that utilises all our Person Centred Counselling skills (e.g. Rogers, 1959) is key. Firstly, we need to be prepared to sit with them in pain, as highlighted by this short video: https://youtu.be/l2zLCCRT-nE. Of course, this means we also need to ensure that we have the right support, self-care strategies or supervision afterwards for ourselves, as this can be triggering or distressing for us to connect with this pain in others (and ourselves).

Listening without judgement and with unconditional positive regard builds that safe space for others to speak with us, as well as normalising and remaining present with their difficult emotions. For example, noting that “it’s OK or understandable to feel that way” and that you understand that they may need time to process how they feel. Moreover, being empathic is important as empathy drives our connection with others, and this video is a great summary by Brene Brown of the difference between empathy and sympathy, the latter what we can often naturally slip into but is actually less helpful: https://www.youtube.com/watch?v=1Evwgu369Jw. Being empathic in our listening conveys the message; ‘I want to hear you’ rather than sympathy; which often feels like; ‘I want to fix you’. This can be hard, as often we want to ‘solve’ a problem when we listen to another person because of the discomfort their pain can create in us, but of course, ‘grief’ can rarely be solved easily if at all.

All of the above advice about speaking with loss and bereavement does not just apply to our friends, family or colleagues but is also important in how we work with our clients as psychologists, or the homeless young people in our supported accommodation services. Remember that whoever we speak to, they are the ‘experts’ in their own experience and therefore rather than feeling as if we have to have all the answers, we should ask them what they want or think is best or most useful for them right now. This can be the basis of a formal or informal support plan, which can also include what coping strategies would be helpful, who else they can ask for support and how often they might want us to ‘check-in’ with them or offer support. Key is always to trust the relationship we have with the other person, and to give them opportunities to express their feelings or share their memories whether that be verbally or if they are struggling with this through other creative activities (e.g. art, music, letter writing). There are some useful resources here specifically designed for young people that might also be helpful: https://youngminds.org.uk/find-help/feelings-and-symptoms/grief-and-loss/.

Finally, as noted at the start of this blog, whilst there are some commonalities in how we process or cope with grief, we are all unique individuals so our responses will vary. Moreover, our cultural background all interacts with these individual differences and so we need to be aware of this. Luckily we do not need to be ‘experts’ in other cultural responses to loss, we just need to be ‘curious’ towards the other person by perhaps asking; “everyone responds to grief and mourns in a different way, can you tell me what’s important for you?”. Areas to consider but not make assumptions about include rituals around death (e.g. funerals or religious services?), mourning styles (e.g. quiet or more expressive?), the impact and role of family or extended family, and the relationship of their loss to any community trauma that could be triggering (historically or current). Loss and bereavement affects us all, but how we process this grief is highly variable, as is how we may feel talking about death with others. Often if it is something that we are unfamiliar undertaking, it can feel difficult or uncomfortable. However, if we approach another person kindly and compassionately within the context of our existing relationship with them (as per a PIE), the sharing of the pain of grief can positively build relationships as we show we are there to support them even when this may be challenging…

*with contributions from Dr Natalie Seymour & Dr Louise Peters (PIE Clinical Psychologists)

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Dr Helen Miles

Consultant Clinical & Forensic Psychologist & Centrepoint Psychologically Informed Environment (PIE) Lead @orange_madbird