Complicated Grief

July 23, 2009 By

Losing a loved one is one of the most distressing things that most people face. That experience is complicated when the death is sudden, unexpected or “out of order” such as a child dying before a parent. During normal grief and bereavement people go through a set of phases: denial, anger/frustration, bargaining, and depression followed by a gradual fading of these feelings as they accept the loss and move forward. For some people, though, this normal grief reaction becomes much more complicated, painful and debilitating, or complicated. In complicated grief, painful emotions are so long lasting and severe that the person has trouble accepting the death and resuming their own life. Some estimates suggest that as few as 6 percent or as many as 20 percent of bereaved people develop complicated grief.

It is important to note that, during the first few months after a loss, many signs and symptoms of normal grief are the same as those of complicated grief. However, while normal grief symptoms gradually start to fade within six months or so, those of complicated grief get worse or linger for months or even years. Symptoms of complicated grief can include:

    Constant focus on the loss and reminders of the loved one
    Intense longing or pining for the deceased
    Problems accepting the death
    Numbness or detachment
    Bitterness about the loss
    Depression or deep sadness
    Difficulty moving on with life and carrying out normal routines
    Withdrawing from social activities
    Feeling that life holds no meaning or purpose
    Irritability or agitation
    Lack of trust in others

Exactly why two people can go through the same situation and one develops complicated grief while the other does not is not clearly known. We believe that the following risk factors make a person more prone to developing severe symptoms:

    Current or prior history of depression, PTSD or substance abuse
    Lack of a support system or friendships
    Number and degree of stressors in the 6 months prior to the loss
    A sense of responsibility for the death
    An unexpected or violent death
    Suicide of a loved one
    Close or dependent relationship to the deceased person
    Being unprepared for the death
    In the case of a child’s death, the number of remaining children
    Lack of resilience or adaptability to life changes

Additionally, people who experience complicated grief often lack continued support after a few months. Friends and family tell them to “get over it,” or “move on.” If they could they would. In treatment we often find that people with complicated grief symptoms feel an extreme lack of control over everything. They benefit from a combination of narrative and cognitive behavioral therapy to help them make sense of their life and the world again.

Filed Under: Grief Tagged With: , , , , ,

Counseling Patients with Cancer

February 28, 2007 By

Each year millions of Americans are diagnosed with cancer. Nearly 500,000 of those will be diagnosed with breast or prostate cancer. Many of our patients will have, or have had cancer. It is important to understand the range of emotions, causes of distress and interventions available to help them.

There are many things that affect how a patient adjusts to cancer. It is difficult to predict how a person will cope. The following factors influence how a patient adjusts to cancer: The type of cancer, cancer stage, and chance of recovery.
The phase of cancer such as newly diagnosed, being treated, in remission, or recurrent cancer.
Individual coping abilities.
Friends and family available to support the patient.
The patient’s age.
The availability of treatment.
Beliefs about the cause of cancer.

Adjusting to a diagnosis of cancer is an ongoing process in which the patient learns to cope with emotional distress, solve cancer-related problems, and gain control over cancer-related life events. To add to the stress, patients are faced with many challenges that change as the disease and its treatment change. There are, however, certain predictable times when a patient is more likely to experience significant crisis. These include hearing the diagnosis, receiving treatment, completing treatment, hearing that the cancer is in remission, hearing that the cancer has come back, and becoming a cancer survivor. Each of these events involves specific coping tasks, questions about life and death, and common emotional challenges.

Patients are better able to adjust to a cancer diagnosis if they are able to continue fulfilling normal responsibilities, cope with emotional distress, and stay actively involved in activities that are meaningful and important to them. In counseling, patients can learn to develop coping strategies to change problem situations, manage emotional distress, and understand what impact cancer may have on his or her life. Patients who adjust well are usually committed to recovery and actively involved in coping with cancer.

Distress can occur when a person feels that he or she does not have the resources to manage or control the cancer. Patients who have the same diagnosis and are undergoing the same treatment may have very different experiences and ways of expressing distress. Anxiety and depression are common among patients with cancer. It is important, however, to ferret out whether the anxiety and depression are solely emotionally based or are caused/made worse by insomnia, fatigue, pain or side effects of medication.

Anxiety
Anxiety is a normal reaction to cancer and may increase feelings of pain, interfere with one’s ability to sleep, cause nausea, and interfere with the patient’s (and his or her family’s) quality of life. Persons with cancer will find that their feelings of anxiety increase or decrease at different times. Contrary to what one might expect, patients with advanced cancer experience anxiety due not to fear of death, but more often from fear of uncontrolled pain, being left alone, or dependency on others. Many of these factors can be alleviated with treatment. Helping patients identify their own cycles and plan for those times is a useful activity in therapy.

Patients may benefit from other treatment options for anxiety, including: psychotherapy, group therapy, family therapy, participating in self-help groups, hypnosis, and relaxation techniques such as guided imagery, or biofeedback. Medications may be used alone or in combination with these techniques. It is important not to avoid anxiety-relieving medications for fear of becoming addicted. A side benefit of many of the antianxiety medications is that they cause muscle relaxation which can often ease some of the aches and pains patients are experiencing.

Depression
While some patients become anxious, others become depressed, and even others are both anxious and depressed. Depression affects about 15% to 25% of cancer patients. Affecting men and women with cancer equally. People with cancer will experience different levels of distress. Issues which may contribute to depression in cancer patients include:
Fear of death.
Interruption of life plans.
Changes in body image and self-esteem.
Changes in social role and lifestyle.
Money and legal concerns
Guilt at not being around for their children
Regret for delaying diagnosis
Survivor guilt (If the patient survives and his/her friend does not)

People diagnosed with cancer will react to these issues in different ways and may not experience serious distress. It is also important to remember that patients and their family members or caregivers need to be evaluated for depression throughout their treatment. Children are also affected when a parent with cancer develops depression, and often develop emotional and behavioral problems.

There are many misconceptions about cancer and how people cope with it, such as the following:
All people with cancer are depressed.
People with cancer should be shielded from stress
Depression in a person with cancer is normal.
Treatment does not help the depression.
Everyone with cancer faces suffering and a painful death.
Depression and anxiety are always mental health issues

Sadness and grief are normal reactions to the crises faced during cancer, and will be experienced at times by all people. Because sadness is common, it is important to distinguish between normal levels of sadness and depression. An important part of cancer care is the recognition of depression that needs to be treated. This is depression that causes a person to lose pleasure in most activities more often than not for at least two weeks and can be accompanied by sleep and appetite changes, suicidal thoughts, confusion and difficulty concentrating. Counselors with a knowledge of cancer and cancer treatment can help people deal with their depression. Specific goals of these therapies include the following:
Assist people diagnosed with cancer and their families by answering questions about the illness and its treatment, explaining information, correcting misunderstandings, giving reassurance about the situation, and exploring with the patient how the diagnosis relates to previous experiences with cancer.
Assist with problem solving, improve the patient’s coping skills, and help the patient and family to develop additional coping skills. Explore other areas of stress, such as family role and lifestyle changes, and encourage family members to support and share concern with each other.
Ensure that the patient and family understand that support will continue when the focus of treatment changes from trying to cure the cancer to relieving symptoms. The health care team will treat symptoms to help the patient control pain and remain comfortable, and will help the patient and his or her family members maintain dignity.

When the depression or anxiety is being made worse by symptoms or medication, the counselor can advocate for the client, help the client communicate with his/her physician and educate the client about possible interventions.

Fatigue
Fatigue occurs in 14% to 96% of people with cancer, and has physical, psychological, and behavioral causes. People with cancer may describe it in different ways, such as saying they feel tired, sluggish, weak, exhausted, weary, worn-out, heavy, or slow. To be treated effectively, fatigue related to cancer and cancer treatment needs to be distinguished from other kinds of fatigue.

Fatigue can become a very important issue in the life of a person with cancer. It may affect the person’s self-esteem, his or her daily activities and relationships with others, and whether he or she continues treatment. Some of these treatments may include adjusting the dosages of pain medications, administering red blood cell transfusions or blood cell growth factors, diet supplementation with iron and vitamins, use of antidepressants or stimulants, exercise, and helping the patient identify a reasonable schedule so as not to tire too quickly.

Since fatigue is the most common symptom in people receiving outpatient chemotherapy, patients should learn ways to manage the fatigue. According to the American Cancer Society, patients should be taught the following:
The difference between fatigue and depression
Possible medical causes of fatigue (dehydration, electrolyte imbalance, breathing problems, anemia)
To observe their rest and activity patterns during the day and over time
To engage in attention-restoring activities (walking, gardening, bird-watching)
To recognize fatigue that is a side effect of certain therapies and medications
To participate in exercise programs that are realistic
To identify activities which cause fatigue and develop ways to avoid or modify those activities
To identify environmental or activity changes that may help decrease fatigue
The importance of eating enough food and drinking enough fluids
Respiratory therapy may help with breathing problems
To schedule important daily activities during times of less fatigue, and cancel unimportant activities that cause stress
To avoid or change a situation that causes stress
To observe whether treatments being used to help fatigue are working

Pain Management
Pain is another major cause of insomnia, anxiety and depression. Counselors can work with physicians and patients to create a comprehensive pain management plan.

Physical Interventions include:
Muscle/bone pain may be treated with heat (a hot pack or heating pad); cold (flexible ice packs); massage, pressure, and vibration (to improve relaxation); exercise (to strengthen weak muscles, loosen stiff joints, help restore coordination and balance, and strengthen the heart); changing the position of the patient; restricting the movement of painful areas or broken bones; stimulation; controlled low-voltage electrical stimulation; or acupuncture.

Thinking and behavior interventions give patients a sense of control and help them develop coping skills to deal with the disease and its symptoms. Beginning these interventions early in the course of treatment is useful so that patients can learn and practice the skills while they have enough strength and energy.

Thinking and Behavioral interventions include:
Relaxation and imagery: Simple relaxation techniques may be used for episodes of brief pain (for example, during cancer treatment procedures).
Hypnosis: Hypnotic techniques may be used to encourage relaxation and may be combined with other thinking/behavior methods. Hypnosis is effective in relieving pain in people who are able to concentrate and use imagery and who are willing to practice the technique regularly.
Redirecting thinking: Focusing attention on distractors other than pain or negative emotions including counting, praying, or saying things like “I can cope,” music, television, talking, listening to someone read, or looking at something specific. Patients can also learn to monitor and evaluate negative thoughts and replace them with more positive thoughts and images.
Support groups and religious counseling: Since depression tends to increase pain, and pain tends to increase depression, support groups help many patients. Many online support groups for patients and their families can be helpful for those patients who have restricted movement. Visit: http://www.acor.org/

Sleep
Finally, sleep problems can contribute to depression, anxiety and the patient’s ability to manage pain. Sleep disorders that are related to cancer may be treated by eliminating the cancer and side effects of cancer treatment. To promote rest and treat sleep disorders the following may be considered:
Create an environment that decreases sleep interruptions and promotes sleep by:
Lowering noise.
Dimming or turning off lights.
Adjusting room temperature.
Aromatherapy
Keeping bedding, chairs, and pillows clean, dry, and wrinkle-free.
Using bedcovers for warmth.
Placing pillows in a supportive position.
Encouraging the patient to dress in loose, soft clothing.
Encourage regular bowel and bladder habits to minimize sleep interruptions.
Increasing consumption of fluids and fiber during the day.
Taking medication for incontinence before bedtime.
Eating a high-protein snack 2 hours before bedtime.
Avoiding heavy, spicy, or sugary foods 4 to 6 hours before bedtime.
Avoiding drinking alcohol or smoking 4 to 6 hours before bedtime.
Avoiding drinks with caffeine within 12 hours of bedtime
Exercising (which should be completed at least 2 hours before bedtime).
Keeping regular sleeping hours.
Stretching before bed
Journaling to get closure on the day and “vent” stressors
Setting a regular routine so your body is “cued” to get sleepy
Massage
Medications may also be used to help relieve sleep problems.

As a clinician working with a cancer patient, there are many things you can do to aid him/her in leading the highest quality of life. It is important to remember that patients with cancer who are seeking counseling are often in crisis, so write down suggestions or interventions they are to try at home.

Filed Under: Anxiety, Depression, Grief, Mental Health Tagged With: , , , , ,

Post Traumatic Stress Disorder

February 21, 2007 By

Over the past decade, as I have worked with cops, firefighters, abuse victims and children of addicts, I have learned that there are many causes for PTSD. It has also affirmed my belief that PTSD is real and harmful, not only to those who have it, but also to those around them. It impacts the way we act, react, our motivation and our capacity to feel–well, anything.

Terrifying experiences that shatter people’s sense of predictability and invulnerability can profoundly alter their coping skills, relationships and the way they perceive and interact with the world. The criteria for Post Traumatic Stress Disorder (PTSD) are 1) exposure to a traumatic event(s) in which the person witnessed or experienced or were confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and 2) the person’s response involved intense fear, helplessness or horror DSM IV p. 427-28). Gradual Onset Traumatic Stress Disorder can be caused by repeated exposure to “sub-critical incidents” such as child abuse, traffic fatalities, rapes and personal assaults.

Nevertheless, not all people exposed to trauma are “traumatized.” Why? In 1998, Pynoos and Nader proposed a theory to assist in explaining why people have different reactions to the same event. They asserted that people are at greater risk of being negatively impacted by traumatic events if any of the following are present: 1) they have experienced other traumatic events within the preceding 6 months, 2) they were already stressed out or depressed at the time of the event, 3) the situation occurred close to their home or somewhere they considered safe, 4) the victims bear a similarity to a family member or friend and 5) they have little social support.

It has been argued that officers, emergency service personnel, children of addicts and abuse victims experience traumatic events or threats to their safety on an almost daily basis. Being abused, not knowing when or if your parents will come home, repeatedly seeing children murdered, people burned in car fires and devastated victims starts to take its toll. People like idealistic officers who joined the force to change the world and protect the innocent begin to feel like nothing they do makes a difference, they cannot even keep their zone safe (criteria 3). This is especially problematic for officers who live in or near their work zone and often leads to frustration and burnout (criteria 2). Children start to feel that the whole world is uncontrollable and unsafe.

It is still not totally accepted within the law enforcement community for officers to discuss the impact of situations on them. Anger, humor and sarcasm are but a brief outlet for what many officers dream about at night. As their condition worsens, many officers withdraw, because they are fearful of seeking help or support for fear it is a one way ticket to a fitness for duty evaluation or will get out and be an obstacle for future promotions. Several studies in recent years have shown that Post Traumatic Stress Disorder (PTSD) is among the most common of psychiatric disorders.

Another thing that distinguishes people who develop PTSD from those who are just temporarily overwhelmed is that people who develop PTSD become “stuck” on the trauma, keep re-living it in thoughts, feelings, or images. It is this intrusive reliving, rather than the trauma itself that many believe is responsible for what we call PTSD. For example, I have worked with officers who have responded to child abuse calls and had a child of their own who was a similar age (criteria 4). In the course of daily life children get hurt and have bad dreams. As parents they have seen looks of pain and fright on their kids faces. This makes it just that much easier to envision the looks of terror and agony on the face of the child as their parent beat them. Sometimes this visualization gets corrupted and officers suddenly they start to see their child in their mental re-enactment of the trauma, obviously a much more powerful memory. These officers are much more likely to be “traumatized” by the incident and potentially get “stuck.”

Traumatized individuals begin organizing their lives around avoiding the trauma. Avoidance may take many different forms: keeping away from reminders, calling in sick to work, or ingesting drugs or alcohol that numb awareness of distress. The sense of futility, hyperarousal, and other trauma-related changes may permanently change how people deal with stress, alter thier self-concept and interfere with their view of the world as a basically safe and predictable place. In the example above, these people often became even more overprotective of their children, suspicious of others, and had difficulty sleeping, because every time they close their eyes they see the child.

One of the core issues in trauma is the fact that memories of what has happened cannot be integrated into one’s general experience. The lack of people’s ability to make this “fit” into their expectations or the way they think about the world in a way that makes sense keeps the experience stored in the mind on a sensory level. When people encounter smells, sounds or other sensory stimuli that remind them of the event, it may trigger a similar response to what the person originally had: physical sensations (such as panic attacks), visual images (such as flashbacks and nightmares), obsessive ruminations, or behavioral reenactments of elements of the trauma. In the example above, sensory triggers that triggered some of the officers memories were certain cries, hearing or seeing a parent spank their child, returning to the same neighborhood for other calls and, of course, television shows or news reports that involved descriptions of abuse.

The goal of treatment is find a way in which people can acknowledge the reality of what has happened and somehow integrate it into their understanding of the world without having to re-experience the trauma all over again. To be able to tell their story, if you will.

The Symptoms of PTSD
Regardless of the origin of the terror, the brain reacts to overwhelming, threatening, and uncontrollable experiences with conditioned emotional responses. For example, rape victims may respond to conditioned stimuli, such as the approach by an unknown man, as if they were about to be raped again, and experience panic.

Remembrance and intrusion of the trauma is expressed on many different levels, ranging from flashbacks, feelings, physical sensations, nightmares, and interpersonal re-enactments. Interpersonal re-enactments can be especially problematic for the officer leading to over-reaction in situations that remind the officer of previous experiences in which she or he has felt helpless. For example, in the child abuse example above, officers may be much more physically and verbally aggressive toward alleged perpetrators and their reports tend to be much more negative and subjective.

Hyperarousal. While people with PTSD tend to deal with their environment by reducing their range of emotions or numbing, their bodies continue to react to certain physical and emotional stimuli as if there were a continuing threat. This arousal is supposed to alert the person to potential danger, but seems to loose that function in traumatized people. This is sort of like when rookie officers start and a hot call is toned out, they usually have an adrenaline rush. After two or three years, the tones hardly have any impact on them. Since traumatized people are always “keyed up” they often do not pay any attention to that feeling which is supposed to warn them of impending danger.

Numbing of responsiveness. Aware of their difficulties in controlling their emotions, traumatized people seem to spend their energies on avoiding distress. In addition, they lose pleasure in things that previously gave them a sense of satisfaction. They may feel “dead to the world”. This emotional numbing may be expressed as depression, and lack of motivation, or as physical reactions. After being traumatized, many people stop feeling pleasure from involvement in activities, and they feel that they just “go through the motions” of everyday living. Emotional numbness also gets in the way of resolving the trauma in therapy.

Intense emotional reactions and sleep problems. Traumatized people go immediately from incident to reaction without being able to first figure out what makes them so upset. They tend to experience intense fear, anxiety, anger and panic in response to even minor stimuli. This makes them either overreact and intimidate others, or to shut down and freeze. Both adults and children with such hyperarousal will experience sleep problems, because they are unable to settle down enough to go to sleep, and because they are afraid of having nightmares. Many traumatized people report dream-interruption insomnia: they wake themselves up as soon as they start having a dream, for fear that this dream will turn into a trauma-related nightmare. They also are liable to exhibit hypervigilance, exaggerated startle response and restlessness.

Learning difficulties. Being “keyed-up” interferes with the capacity to concentrate and to learn from experience. Traumatized people often have trouble remembering ordinary events. It is helpful to always write things down for them. Often “keyed-up” and having difficulty paying attention, they may display symptoms of attention deficit disorder.

After a trauma, people often regress to earlier modes of coping with stress. In adults, it is expressed in excessive dependence and in a loss of capacity to make thoughtful, independent decisions. In officers, this is often noticed because they suddenly begin making a lot of poor decisions, their reports lose quality and detail and they are unable to focus. In children they may begin wetting their bed, having fears of monsters or having temper tantrums.

Aggression against self and others: Both adults and children who have been traumatized are likely to turn their aggression against others or themselves. Due to their persistent anxiety, traumatized people are almost always “stressed out,” so it does not take much to them set off. This aggression may take many forms ranging from fighting to excessive exercise or obsession about something—anything to keep them from thinking about the trauma.

Psychosomatic reactions. Chronic anxiety and emotional numbing also get in the way of learning to identify and discuss internal states and wishes. May traumatized people report a high frequency of headaches, back and neck aches, gastro-intestinal problems etceteras. Since the stress is being held inside, the body begins to become distressed.

Summary
After a trauma, people realize the limited scope of their safety, power and control in the world, and life can never be exactly the same. The traumatic experience becomes part of a person’s life. Sorting out exactly what happened and sharing one’s reactions with others can make a great deal of difference a person’s recovery. Putting the reactions and thoughts related to the trauma into words is essential in the resolution of post traumatic reactions. This should, however, be done with a professional specializing in PTSD due to the wide range of reactions people have when they start confronting and integrating the memories of the trauma.

Failure to approach trauma related material gradually is likely to make things worse. Often, talking about the trauma is not enough: trauma survivors need to take some action that symbolizes triumph over helplessness and despair. The Holocaust Memorial in Jerusalem and the Vietnam Memorial in Washington, DC, are good examples of symbols for survivors to mourn the dead and establish the historical and cultural meaning of the traumatic events. There are several events for survivors of traumas that officers can also take part in. These events remind survivors of the fact that there are others who have shared similar experiences. Other symbolic actions may take the form of writing a book, taking political action or helping other victims.

PTSD is real, and can be resolved with time, patience and compassion.

For more information on treating PTSD, see All CEUs

Filed Under: Anxiety, Grief, Mental Health, Trauma Tagged With: , , , , ,