Grief and trauma

Guest Lecture By:

Amara Naeem

Department of Clinical Psychology

School of Professional Psychology, UMT Lahore
 Overview

 Definitions

 Difference b/w Grief and Trauma

 Theoretical model

 Biopsychosocial-spiritual model

 Stages of Grief

 Types of Grievers

 Assessment Modalities

 Strategies to overcome loss

 ‘The journey of grief is a path we
must walk, where each step is a
memory, and every tear is a tribute to
the love we’ll forever hold dear’
 Understanding Human Connections and Bonds

• What is a relationship?

• Why do we need relationships? Why do we need bonds and connections in life?

• ‘No man is an island, entire of itself.’

• Relationships makes life meaningful
• Vital for survival
• Emotional support
• Reduce loneliness- sense of belonging
• Sense of purpose of meaning
• Self-esteem and identity
• Learning and growth
• Coping mechanisms
• Fundamental importance in childhood
 Attachment Theory (John Bowlby)

• Multidimensional model
• Dynamic- not static
• Theory encapsulates bio-psycho-social-belief system and an
interactive model
• The corner stone is not just how we are but how we act, react and
relate to our ecology-expanded from childhood to later years of life
 Attachment Theory (John Bowlby 1950’s)

• Attachment behaviours- attaining or retaining behaviours

• Triggered by separation or threatened separation from attachment figures
• Internal working model- a model of the world in which the self and
significant others and their interrelationships are represented and encode the
particular patterns of experiences by the child in terms of feeling safe, secure
and provided for (with love and affection)
• Secure attachment, insecure attachment, disorganized attachment
• Long term affects of attachment
 Journey of Grief

• What is Loss?
• The fact that you no longer have something or have less of
something.
• A disadvantage caused by someone leaving or by something
being taken away.
• The end of a relationship
• The death of a person
Types of Loss

• Death • Miscarriage
• Job • Illness-health
• Relationships • Olde age-dependence
• Self • Financial
• Failures • Retirement
• Transitions-growing up • Trust
• Physical • Promotion
• Possessions
 What is Grief?

• Grief is a natural response to loss.

• It’s the emotional suffering you feel when something or someone
you love is taken away.
• Even subtle losses in life can trigger a sense of grief.
• The pain of grief can also disrupt your physical health, making it
difficult to sleep, eat, or even think straight.
• The more significant the loss, the more intense your grief will be.
 The Grieving Process

• Grieving is a highly individual experience; there's no right or wrong way to

grieve.
• Inevitably, the grieving process takes time. Healing happens gradually; it can't
be forced or hurried—and there is no “normal” timetable for grieving.
• Some people start to feel better in weeks or months. For others, the grieving
process is measured in years.
 Myths and facts about Grief and Grieving
• Myth: The pain will go away faster if you ignore it
• Fact: Trying to ignore your pain or keep it from surfacing will only make it worse in the long run. For real healing, it is necessary to
face your grief and actively deal with it.
• Myth: It's important to “be strong” in the face of loss.
• Fact: Feeling sad, frightened, or lonely is a normal reaction to loss. Crying doesn't mean you are weak. You don't need to “protect”
your family or friends by putting on a brave front. Showing your true feelings can help them and you.
• Myth: If you don't cry, it means you aren't sorry about the loss.
• Fact: Crying is a normal response to sadness, but it's not the only one. Those who don't cry may feel the pain just as deeply as others.
They may simply have other ways of showing it.
• Myth: Grieving should last about a year.
• Fact: There is no specific time frame for grieving. How long it takes differs from person to person.
• Myth: Moving on with your life means forgetting about your loss.
• Fact: Moving on means you've accepted your loss—but that's not the same as forgetting. You can move on with your life and keep
the memory of someone or something you lost as an important part of you. In fact, as we move through life, these memories can
become more and more integral to defining the people we are.
 Stages of Grief?

• Elizabeth Kubler-Ross describes Denial

the five stages of grief in her book

On Death and Dying.
Acceptance Anger
• Stages are non-linear Stages
of
• Stages are not rules
Grief
• No particular order

Depression Bargaining
 Stage 1: Denial
• You may have difficulty accepting that a loss is real.
• ‘I feel fine’, ‘This cant be happening to me’
• The first reaction is to deny the reality of the situation
• It is a normal reaction to rationalise overwhelming emotions
• It is a defence mechanism that buffers the immediate shock
• We block out the words and hide from the facts
• This is a temporary response that carries us through the first wave of pain
• Feelings of Numbness and Shock
• In the denial stage, you are not living in "actual reality," rather, you are
living in a "preferable" reality.
 Stage 2: Anger
• The anger may be aimed at
• Inanimate objects
• Complete strangers
• Friends or family
(people who couldn’t save a loved one, God, yourself- or even no one in particular)
• Anger may be directed at our dying or deceased loved one
• Rationally, we know the person is not to be blamed
• Emotionally, however, we may resent the person for causing us pain or for leaving
us

We feel guilty for being angry and this makes us more angry
 Stage 3: Bargaining

• The normal reaction to feelings of helplessness and vulnerability is often a

need to regain control. Seemingly endless strips of what ifs:-
• if only we had sought medical attention sooner
• if only we got second opinion from another doctor
• if only we had tried to be a better person towards them
• Secretly, we may make a deal without higher power in an attempt to postpone
the inevitable
• This is a weaker line of defence to protect us from the painful reality
• Defense mechanisms? Rejection, sublimation….
 Stage 4: Depression
• In those moments, we tend to pull inward as the sadness grows.
• Find oneself retreating, being less sociable, and reaching out less to others
about what we are going through.
• Although this is a very natural stage in the grieving process, dealing with
depression after the loss of a loved one can be extremely isolating and one of
the most difficult stages.
• First type: Practical implications, sadness and regret predominate, visiting
graveyard, may feel foggy, heavy, and confused.
• Second type: More subtle in a sense, more private. Bid farewell to loved
one
 Stage 5: Acceptance
• Emotions may begin to stabilize.
• Come to terms with the fact that the "new" reality is your partner
• A time of adjustment and readjustment: the good days tend to outnumber the
bad days.

‘Reaching this stage of mourning is a gift not affordable to

everyone’
• Opportunity to make our peace. We are no longer resisting the reality of our
situation
• This stage is marked by withdrawal and calm
 Types of Grief
• Complicated grief: It is long-lasting grief that occurs after a loss. It causes
intense emotions and consuming thoughts that don’t fade over time and can
affect your daily life.
• Also called Prolonged Grief Disorder (PGD) (DSM-5-TR)
Symptoms of prolonged grief disorder (APA, 2022) include:
• Identity disruption (such as feeling as though part of oneself has died).
• Marked sense of disbelief about the death.
• Avoidance of reminders that the person is dead.
• Intense emotional pain (such as anger, bitterness, sorrow) related to the
death.
• Difficulty with reintegration (such as problems engaging with friends,
pursuing interests, planning for the future).
• Emotional numbness (absence or marked reduction of emotional
experience).
• Feeling that life is meaningless.
• Intense loneliness (feeling alone or detached from others).

The person’s bereavement lasts longer than might be expected based on

social, cultural, or religious norms
 Complicated Grief

• It is suggested that individuals who are susceptible too complicated

grief are ones where there is already:
• a mood disorder present,
• there is low social support,
• difficult relational experiences and
• high dependency on the deceased
 Grief vs Depression

Grief Depression
• It is typically preceded by laws • Depression can develop anytime
• The sadness present in grief is • It is characterised by a journal sense.
typically related to the loss or of worthlessness despair and lack of
death. joy.
• symptoms of grief may improve • Depression often needs treatment to
on their own time. recover
 Other Types of Grief
• Anticipatory Grief- terminal illness, processing grief beforehand can prepare you
to face the loss when the time comes.
• Abbreviated Grief- Abbreviated grief may follow anticipatory grief. You can
grieve a loss quickly (emotional labor).
• Delayed Grief- busy handling the practical matters that accompany loss (like
funerals and wills) that your body can’t grieve until you’ve handled these
responsibilities.
• Inhibited Grief- repressing emotions, manifested as physical symptoms.
• Cumulative Grief- Grieving multiple losses simultaneously e.g., war, natural
disasters.
 Psychological and Behavioural Reactions

• Grief
• Guilt
• Increased use of alcohol and drug
• Isolation or withdrawal
• Nightmares another sleep disturbances
• Panic
• Questioning faith and religion
• Sleeping too much (hypersomnia)
• Social withdrawal
• Order and logic not necessary- sometimes it just needs to come out

Fight Flight Freeze Fawn

• An unhealthy • Leaving the • Playing • People pleasing

trauma situation possum behaviour
response, entirely. • Dissociation • Codependent
Narcissistic • Panic and • Isolation relationship
tendencies constant fear • Brain fog • No boundaries
• Workaholic • Perceived • Loss of self
tendencies laziness • Violent
relationships
 Types of Grievers

The Intuitive Griever The Instrumental Griever

• An externalized experienced • An internal experience
characterized by extreme sadness characterized by mental separation
and pain as well as outward from the loss as well as an
experience characterized by outward experience characterized
emotional expression (e.g. tears) by a lack of emotion.
• Experience prolonged period of • More prone to thoughts of grief
confusion, inability to concentrate, • Problem solving ability
disorganization and disorientation. • Brief period of cognitive
dysfunction
 Assessment

• Counseling Interview
• Adult attachment questionaire
• Complicated Grief Assessment
• Thematic Apperception Test (TAT)
This is considered to be one of
the most important pictures,
especially for depressed
patients, as it deals with themes
of aggression, impulsive control,
guilt and depression.

For instance, If a patient

describes the ambiguous object
as a gun, it’s highly likely that
the person might harm oneself
(Intra-aggression) or another
person (Extra-Aggression).
 Assessment

• Counseling Interview
• Adult attachment questionaire
• Complicated Grief Assessment
• Thematic Apperception Test (TAT)
 Strategies to Overcome Grief
• Need for intervention
• Willingness of the client
• Challenges on part of the therapist
• Understanding grief triggers
• Extra-curricular activities- artwork, exercise, eat well
• Play out unfinished business
• Empty chair technique
• Ring theory
 Grief Counseling

• Acceptance of loss- visit graveyard witness physical loss acknowledging pain

visiting the place where the accident happened
• Emotional expression- giving words to sorrow, journal, letter
• Adjustment to new reality-learn to live without, independent decision
making more actions taken
• Emotional relocation- not reminiscing but moving forward
• Giving closure- saying goodbye
• Reorient life- get used to of the change, celebrate anniversary
 Intervention

• Reconstructing meaning: universality of grief, continued connections,

caregivers help
• Narrative therapy: focuses on meaning making, redefine relationships,
letters, journals, documents
• People are not the problem
• Problems are to be externalized
• Deconstruct problems
• Re-write own story
• Distance from pain
Grief is as much part of attachment as
loss is a part of gaining
death is a part of living
You cannot have one without the other!

Prof. Dr. Zahid Mahmood