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Summer Week 6 (Last week! Keep going, we are almost done!!!)

Okay, y’all, we have covered so much in terms of assessment and interventions, step by step.
This week we cover special high-risk considerations in both of your texts. These include the
death of a child as well as some clinical challenges you may encounter as you intervene. The
second part of your Rando chapter for this week focuses on AIDS- related deaths and the
challenges which face mourners. Much of the information about AIDS has changed BUT the
dynamics of disenfranchisement continue and so are important for us to consider. The
disenfranchisement may no longer be part and parcel with AIDS related deaths, but there will be
more such illnesses, more situations that foster social isolation rather than support. So we need
to be aware of how to intervene to best support mourners. So for those reasons, I believe we
should still read through that section, focusing on what we can still glean and apply to our work
with grieving and traumatically bereaved clients. It is difficult to read about the death of
children, as it is often one of our more feared losses. Nevertheless, we need to be informed on
how to assess and then how to intervene. So, let’s roll up our sleeves…
Rando chapter 13 and Traumatic Bereavement chapter 14.
Part I: Risks and Therapeutic Implications Associated with Death of a Child.
Death of a child
 P 611 Research findings document that when compared to other types of bereavement,
parental mourning is particularly intense, complicated, and long-lasting, with major and
unparalleled symptom fluctuations occurring over time.
 Age of the child
o In general, the age of the child is irrelevant in this type of death.
o Regardless of the child’s age, parents have lost:
 Hopes
 Dreams
 expectations
 Fantasies
 And wishes for that child.
 Parts of themselves
 Each other
 Their family and their future
 Their assumptive worlds have been violated.
o Although age is generally irrelevant, age does define some of the specific issues.
Identify some and give examples:
 When death is a miscarriage, stillbirth or infant death, what are the issues
that can complicate mourning?
 Reminded they can have other children (not helpful)
 The attachment bond is ignored (loss is socially negated)
 When an infant dies outsiders view loss as minimal (mistakenly)
 Loss is negated and mourning becomes disenfranchised.
 And adult child dies,
 Parents are overlooked
 Primary attention given to that childs spouse and children
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 These issue contribute to 5 special bereavement problems in

parents who lose adult children p 613
o Compromise of successful accommodation of the loss
o Exclusion from the concern of others
o Existence of multiple factors contributing to complicated
grief and mourning
o Significant lack of control
o Presence of numerous and difficult secondary losses

 Psychological relationship between parent and child

o P 613 The unique psychological relationship between parent and child contributes
to the appearance that bereaved parents’ mourning is atypical, abnormal, or
pathological when in fact it is typical for the circumstance.
o The very aspects of the relationship between parent and child that define its
intimacy and uniqueness are the same factors that intensify bereavement
following death. These factors can be grouped into the following 4 categories.

o Feelings hopes meanings projected onto the child

 First child is an extension of the parents
 Second, child is a product of_ones self and ones partner:
 Feelings about the child come from the past, present_and future.

o Inherently assumed and socially assigned responsibilities

 More inherently assumed and socially assigned responsibilities exist in
the parent-child relationship than in any other relationship. Most of them
are totally unrealistic
 Parents are burdened by unachievable ideals yet they internalize these
unrealistic expectations and therefore measure themselves against
impossible standards.
 Guilt is a normal consequence after any loss when there is a failure of the
mourner to meetself-expectations.
o Incorporation of roles into parental identity
o Closeness and intensity of the relationship
 Factors exacerbating mourning for a child
o Bereaved parents encounter 10 specific dilemmas as a consequence of the loss of
a child. These are associated with the following areas:
o Loss of the parenthood function
o Loss of parts of the self
o Secondary losses
o Assault on parental identity
o Loss of a sense of immortality
o Violation of the assumptive world
o Loss of the family subsystems
o Related high risk variables
o Loss of a future caretaker
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o Intensified responses (8)

 Guilt is especially intense due to inappropriate and unrealistic parental
expectations, falling short of ones self-image, the assault on parental
identity, surviving one child, and feelings that one contributed to the death
or could have prevented it but did not
 anger is intensified because of what the loss of a child means in the terms
of the parental role the secondary losses and the fact that it is unnatural for
a child to predecease a parent
 pain of separation is heightened because of the incomparable closeness of
the relationship with the child
 learning and searching a few by the dynamics of the laws which demand
that the parent find and recover the lost child
 the search for meaning is accelerated due to the unnaturalness of the death,
parental sense of guilt and failure, and the assault on the assumptive world
caused by the nonsensical nature of the loss
 despair is magnified by the meaningless and unnaturalness of the loss

 upsurges of acute grief are greater and more numerous than for other types
of bereavement
 Issues in the marital dyad
o In addition to individual mourning issues, mourning the death of a child offers a
number of common marital complications.
 Each parent has sustained a different loss
 A-synchronicity of grief
 Communication impairments
 Sexual relationship
 Changes in parents as individuals necessitates changes in the marital
relationship:
 Issues in the family system
o Other dependent children
o Resentment
o Idealization of dead child
o Over protection
 Social issues
o Bereaved parents suffer enormously because their loss represents the worst fears
of others. P 624 bottom
o It is so strongly taboo, that there is not an English word for it
 Children with dead parents: orphans
 Spouse with dead spouse: widow/widower
 Parents whose child is dead:??? No word
 Parental bereavement: An exception to General Conceptualizations of mourning
o Failure to general conceptualizations to describe parental bereavement
 Difficulty recognizing the loss because:
 Violates their basic function and defies the laws of nature
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 multiply victimizes them and savagely assault their sense of self

and their abilities
 if other children survive continuing in the parental role makes it
easier to deny that the child has died
 social negation of the loss often exists
 with the loss of pregnancies and the deaths of young infants and
adult children residing outside of their parental home, no dramatic
act sense is apparent to signal the loss and confirm its realities
 Difficulty reacting to the separation because
 this type of loss results in intensified pain of a longer duration
 interferences often exist with the ability to identify, differentially,
and express psychological reactions to the laws
 more secondary losses take place in this type of bereavement
especially those relating to the self
 the experience of pain is subverted by the lack of social support the
loss of the spouse as the most therapeutic resource and
inappropriate social expectations
 Recollecting and Re-experiencing the deceased and the relationship is
more difficult because:
 if the child is unborn or an infant there is little or nothing concrete
to review or remember realistically
 negative feelings are not socially accepted in parents and the
morning of the negative aspects of the relationship is thus
complicated or made impossible
 Relinquishing the old attachments to the deceased and the old assumptive
world because:
 Attachments to the deceased child also include attachments to the
self making it difficult to distinguish what belongs to the child and
to the parent and to detach from the child
 given the unique nature of the parental role the parent child
relationship is less amenable than any other relinquishment of
attachments
 relinquishing attachments to the old assumptive world mandates
that complete revision of the most fundamental assumptions
underpinnings ones adult identity
 Revision of the assumptive world usually demands some
reassignment of roles to indicate the loss and to confirm the change
 in the loss of a pregnancy invert or adult child who lives outside of
the home no dramatic absence signals that the death has occurred
 identification is more problematic because of the role of a parent to
child and because of inherent difficulty in identifying with a young
child when the mourner is an adult
 Compromised in ability to move adaptively into the new world without
forgetting the old because:
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 Number and severity of violations of the assumptive world often

lead bereaved parents stunned
 developing a new relationship with the disease may be difficult
because of the parental relationship demands role behaviors that
are not as amendable
 as a method of maintaining a connection with the deceased
identification may be problematic for parents of young children if
the behaviors with which they would identify would be
inappropriate to adult functioning
 the consequences of social disenfranchisement interfere with any
adaptive movement into the new world and the adoption of
required new ways of being
 and much of the world remains the same it is difficult to form a
new identity or adopt new ways of being in the world because one
still functions on the same parental wall
 More difficulty reinvesting because:
 reinvesting in a similar relationship is more feasible when the
relationship is with a spouse peer or parent then when the
relationship is with a child
 although many parents are often inappropriately urged to have a
new child as a way of dealing with the pain of the older child's
death others are treated in the opposite fashion
o Vulnerability to complicated mourning and to erroneous dx of pathology (3
issues)
 P. 628 First, bereaved parents have the greatest number of factors known
to promote failure to mourn in any individual, as identified by Lazare.
 P 629 Specifically, they must contend with 5 of the 6 issues Lazare
contends interfere with mourning
 Guilt
 Loss of an extension of the self
 Reawakening of an old loss
 Multiple loss
 And idiosyncratic resistances to mourning
 P 629 Of the 5 social reasons Lazare identifies as contributing to failure to
mourn, bereaved parents usually must deal with 4(especially, although not
exclusively, if the child who dies is an infant or an adult):
 Social negation of the loss
 Socially unspeakable loss,
 Social isolation
 And/or geographic distance from social support
 And assumption of the role of the strong one.
 P 628 SECOND, the death of a child involves the greatest number of
factors known to affect any individual’s bereavement. (see Table 2.1)
Personal factors aside, the most salient of the potentially negative
situational influences on parental mourning are (12):
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 the unique nature and meaning of the loss sustained in the

relationship severed
 Qualities of the relationship lost
 roles the deceased occupied in the mourners family or social
system
 characteristics of the deceased
 amount of unfinished business between the mourner and the
deceased
 mourner's perception of the deceased fulfillment in life
 number type and quality of secondary losses
 nature of any ongoing relationship with the deceased
 presence of concurrent stresses or crises
 timeliness
 mourners perception of preventability
 mourner social support system and the recognition validation
acceptance and assistance provided by its members
 p 629 THIRD, a number of characteristics and determinants associated
with typical parental bereavement are the same as those generally
associated with particular syndromes of complicated mourning.
Characteristics aligned with the conflicted mourning syndrome are not
usually associated with parental loss in general, although in specific cases
they certainly could be. However significant overlap does exist with
regard to :
 absent mourning
 delayed mourning
 inhibited morning
 Distorted mourning of either type (excessive angry or excessive
guilty)
 Unanticipated mourning and
 Chronic mourning/
 Need for a new model of parental mourning and new criteria for pathology
 P 630 The traditional criteria for pathology are inapplicable here
(with parental bereavement
 The simple fact is that what is considered abnormal or pathological
in other losses is typical after the death of a child, in the sense that
it is experienced by the majority of bereaved parents.
 Failure to delineate a new, more appropriate model of mourning
and to determine what constitutes pathology within this group has
resulted in the development of inappropriate and unrealistic
expectations for bereaved parents, who cannot and must not be
expected to have the same bereavement experiences as other
mourners.
 Treatment concerns
o P 630 Regardless of treatment approach chosen, interventions must be designed to
address: Each of the issues specific to this type of bereavement
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o In constructing treatment, the worker will need to: p 630 take into account the
unique issues involved in this type of loss and adjust treatment plans and
expectations accordingly
o Psycho educational and normative information to : help them appropriately frame
and understand their experiences, comprehend specifically what has been lost, and
know how to dose their exposure to the pain
o In terms of the marital relationship: the caregiver must help parents recognize the
differences between and within themselves and to readjust the relationship to
accommodate these
o Compassionate Friends is: self help support group for their particular loss
Part II: AIDS-Related Death, with a focus on Dynamics of Disenfranchisement
 Doka conceptualizes AIDS as the Great Disenfranchiser. This status of
disenfranchisement is at issue. What does it mean and how do we intervene.
 Stigmatization and disenfranchisement (p 635)
o Stigmatization and disenfranchisement are malignant processes that contribute to
the high risk factor of a perceived lack of Social support p 635
o Personal _confrontations with negative social responses can complicate
mourning considerably
o Many families are cut off from social support
 Distancing by other family members
 Family’s determination not to “tell” so secret-keeping, lack of
communication, closing off the family system.
 Illness-related complications p 638
 Length of an illness is a significant variable in mourning. (Death from an
overly lengthy illness is an identified high-risk factor.
 P 640 Factors exacerbating parental mourning
o Parental mourning is exacerbated by the frequent (perceived) need to maintain
secrecy.
o Disenfranchisement by or extended family members can further deplete
psychosocial resources.
 Conflict between biological and chosen family p 641-643
o Who will provide care?
o Who will determine funeral arrangements
o What happens to possessions (things)
 Social isolation and disenfranchisement p 644
o P 645 The rituals of mourning may not address the needs of the gay community.
 Bereavement overload in the gay community
Part III: Treatment Challenges
Potentially challenging aspects of the treatment
The treatment approach described by this book is an example of General Systems Theory and
evidences its axioms:
 A system (treatment regimen is a whole of transacting parts (treatment components)
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 A system (treatment regimen) is greater than the sum of its parts

 As the individual treatment components are presented, descriptions of elements that may
be difficult to implement will be addressed.
 Development of self-capacities
o Resistance: p 232
 Adult clients with interpersonal trauma histories:
 May be reasonably capable and effective in the world
 BUT they may have great difficulties
o Regulating their internal states by tolerating strong feelings,
o maintaining a sense of self worth
o Gathering support from internal psychological experience
of positive others.
o (underdeveloped self-capacities)
 These clients are often termed “resistant”
 One way of understanding resistance is that it signals something a
therapist does not yet understand about the client
 It may require a modification of the treatment to meet the client’s needs.
o Behaviors that are common in clients with complex trauma:
 Clients who strongly resist emotions
 Avoid relationships
 React strongly to seemingly small slights
o What is the difference between effective trauma processing via exposure and
re-traumatization?:
 Adequacy of a client's self capacities
 Therefore building or strengthening the client’s self-capacities is key.
 Trauma processing
o Cognitive processing
 Cognitive restructuring work with automatic thoughts and the beliefs that
underlie them is a significant part of this approach. (p 233)
o Emotional processing
 Focus on loss and mourning
o use randos 6 R 's to guide clients through the morning processes
o maybe challenging for some therapists
 Structured treatment
o Relational focus with a structured treatment approach
 Psychoeducation and Independent Activities
o Essential to the success of this treatment approach
o both processes lead a therapist into the role of educator and coach in a way that
may be uncomfortable to those who practice from a more receptive intuitive
relational or psychodynamic stance
 Focus on termination
Guidelines for identifying treatment challenges
Responding to clinical hurdles
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 Requires sound clinical judgment based in theory science and experience

 The four “e” strategies (explore, empathize, educate, and encourage((reinforce).
o Staying on task
 Explore - To understand why the client is behaving as she is
 Empathize - Try to identify with the client and imagine what it's like to
lose a loved one and expectedly and traumatically
 Educate - reminding the client of the rationale for this treatment approach
and the particular elements of it can help her to renew her commitment
 Encourage - taking the time to acknowledge highlight and praise the client
success at facing a painful feeling, completing a treatment task, and being
fully present in sessions can provide essential support to clients
o Lack of Treatment Progress
 Explore - the client continues to seem stalled in the ways that brought him
into treatment in the first place it may be helpful to explore this together -
in exploring the client's understanding of his lack of movement do you
notice any resistance to getting better
 Empathize - empathize with the difficult feelings a client may be
experiencing as well as with the strategy he may be using to avoid such
feelings
 Educate - after exploring where the client is stuck and empathizing with
him educate him about what you have observed and what strategies might
you might use to address the challenges
 Encourage - encourage or reinforce what the client has been doing that
will help him move through the morning process
o Worsening symptoms
 Explore - Taking an inventory of the client symptoms and their intensity
 Empathize - using clinical judgment and knowledge of how the client has
been moving through the treatment to help you decide how and when to
express empathy
 Educate - holding on to the knowledge that is expectable part of this
treatment and to share this understanding with the client if they notice an
increase in intrusive symptoms anxiety or depression
 Encourage - Reinforcing a client's progress and holding hope for the future
 Attend to safety
 addressing A worsening of symptoms entails careful attention to a
client safety
Challenges arising from working in a different paradigm: stronger and weaker suits
 Stronger suits
o Areas of knowledge or information, process areas of techniques or information,
clinical populations, and skills areas like assessment or treatment
 Weaker suits
o areas to which we have not been exposed as therapists in which we have not had a
lot of interest which we have not had chance to practice and use or in which we
simply lack skill
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 How will this apply to you? building a weaker suit requires self and arrest and openness
to learning. practicing this treatment approach provides an opportunity for us to expand
our therapeutic toolbox while also learning about ourselves and the process of
transformation through grief
Y’all, you have worked so hard and learned so much about working with clients who are
bereaved as well as traumatically bereaved, communities who are grieving from some sort of
disaster, and special populations as they face grief. You have learned assessment, and a host of
intervention strategies, including their specific theoretical foundations. In anyone’s book, that is
a lot! To end our week (and our very fast summer semester), it is time to turn the mirror towards
ourselves and learn assessment and strategies for ourselves, as we work with grieving clients
and communities. So, for the last time, let’s roll up our sleeves and get to work.
Part III: Self-Awareness, Self-Assessment, and Self-Care for the Clinician
First, let’s review something we discussed early on in the semester. There are basically 3
reasons that this type of population (grieving clients) is difficult.
 It brings up our actual losses
 It brings up our feared losses
 It heightens our own personal death awareness
Those being identified, we can discuss concerns for the worker’s well-being (Rando Chapter 14
and explore the effects of this work on workers (Traumatic Bereavement text ch 14).
RANDO
Working with the ill, the dying and the bereaved have inherent personal and professional dangers
for the social worker. Research shows us that this work is:
 Inherently intimate
 Powerful in eliciting worker’s own feelings, thoughts, memories and fantasies about loss
 Commanding in its life-and-death nature.
P 651 “This type of work demands a deep emotional response from the worker. Both in giving
and withholding this type of emotional response can severely tax the worker.”
When mourning is uncomplicated, workers face difficult professional issues; when mourning is
COMPLICATED, these issues are intensified and new ones arise.
 Failure to attend to such matters can result in workers’ distress in all dimensions: (7)
o Psychological
o Spiritual
o Behavioral
o Social
o Physical
o Occupational
o economic
 Workers are advised to practice:
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o continual active grieving for those they lose through death, illness or termination
of treatment
o implement personal and organizational stress management strategies designed for
work in this field
Presented here are 2 preliminary concerns:
 Caregiver characteristics that are necessary to provide treatment of complicated mourning
 Therapeutic errors workers are prone to make in this area of practice (pp 651 and 652)
CAREGIVER CHARACTERISTICS
 P 652 Scurfield (My personal friend and colleague at Southern Miss) notes that
“_Extraordinary events and the reactions to them require extraordinary efforts in
treatment by both the client and the caregiver
 Specifically, Scurfield identifies 3 essential caregiver qualities:
o a willingness and sensitivity to probe quite directly into the various aspects of the
traumatic experience
o the ability to face honestly one's own reactions and those of the survivor to such
probes
o the sensitivity to navigate the murky boundaries between uncovering that which
the survivor has been trying, often desperately, to avoid and full integration of the
traumatic experience within the survivors current existence
Professional Knowledge and Skills (5)
 is this person truly evidencing complicated mourning
 is the type or style of treatment I provide for complicated mornings suited to this
particular individual
 are there contradictions for treating this situation as I usually would treat someone in a
situation like this
 do concomitants of the complicated mourning exist that require additional types of
intervention
 can I provide access to the complete array of treatment required by the mourner
Caregiver Personality (4)
 what personal attributes and qualities are necessary to treat complicated mourning
 is there any chance I am a codependent caregiver
 am I personally and professionally able to work with an individual who has been through
this type of loss
 and my personally and professionally able to work with this particular mourner
Success in Confronting One’s Own Prior Losses (4)
 where am I with my own losses and my morning over them
 is there unfinished business or any other indication that suggested is appropriate for me
to be doing this work with this person now
 am I able to differentiate my own issues and needs from the mourners
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 do I have the ability to set appropriate limits with this particular morning given my own
prior loss history
Ability to Care for Oneself as a Caregiver (5)
 what are my expectations and limitations for myself in this work and are they appropriate
 what are the most stressful aspects of work with complicated mourning
 what am I doing to help myself cope with the stressful aspects of my work
 what are my personal warning signs indicating I am being stressed
 how do I come to appropriate closure nurture and replenish myself and work with
complicated mourning
Part IV: COMMON THERAPEUTIC ERRORS
 There are errors of OMISSION and errors of COMMISSION
o Some of the most problematic acts of OMISSION are (7)
 failing to conduct a comprehensive and in-depth assessment at the
beginning of treatment, assess for fluctuations and changes in mourning
throughout treatment, and design treatment to respond specifically to the
mourners idiosyncratic needs
 failing to incorporate into treatment psychosocial and secondary losses etc
 failing to comprehend be sensitive to improperly treat the mourners
resistance and undertaking the work processes of mourning and or
underlying concerns or issues beneath apparent reactions
 failing to take the mourner beyond the passive processes of grief and to
the active processes of mourning
 focusing too much on the generic aspects of grief and mourning and too
little on the other specific issues relating to the mourners idiosyncratic
situation
 failing to integrate the treatment of complicated mourning with
psychotherapeutic and or medical treatment mandated for any mental or
physical disorders that may coincide with or develop subsequent to
complicated mourning
 failing to proceed past an issue to a certain wear and how it has interfered
with the successful completion of the R processes and morning and are
intervening at the appropriate time to enable the completion
o Some of the most potentially dangerous acts of COMMISSION are (7)
 pushing the mourner too fast
 pushing the Warner to sever all connection with the deceased without
assisting in the appropriate establishment of a new relationship
 colluding with the mourner to avoid the requisite R processes of mourning
 becoming involved to degree that the mourners proper treatment and
successful mourning are compromised
 becoming caught up in specialized techniques to treat complicated
mourning or focusing on complications to the extent that a sense of the
mourner as a person is lost
 befriending the mourner in response to the victimization
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in an effort to deep pathologize bereavement focusing on the

uncomplicated or normal aspects and overlooking the complicated ones
o How does the worker guard against making such errors? proper information about
uncomplicated and complicated grief
CAREGIVER STRESSORS
 3 main types of caregiver stressors exist:
o mourner related stressors
o death related stressors
o stressors related to the difficulty of treating complicated mourning
COUNTERTRANSFERENCE (p 249)
 What it is: p 249 all of your responses to particular client
 Factors influencing your countertransference: personality coping style and strategies
experiences with your own losses family history and current life stressors
 Sources:
o Regardless the source awareness is essential to using these responses
constructively to help the client
 Managing Countertransference Responses ( 252)
Mourner-related stressors/ Responses related to Client Adaptations (p 250)
 These involve: the symptoms or syndromes of complicated mourning manifested by the
mourner and factors associated with the individual premorbid relationship and social
system
 “The mourners’ responses can prompt not only frustration in the worker, but also fear, if
rage or aggression are part of the picture” p 657
 How is contending with the mourner’s guilt be problematic?
 P 658 “Those whose mourning is absent, delayed or inhibited often can be persuasively
articulate about not needing to emote or deal with mourning at all. Those whose
mourning is chronic may be quite convincing about their inability to stop.” How can
these situations be challenging for the worker? can lead to stress for the caregiver if they
challenge therapeutic beliefs and cause cognitive dissonance
Responses related to client adaptations: p 250
 Example: a client may present with psychosomatic difficulties but no reported
emotional problems
Death-related stressors/ Responses related to the Death P 250
 Pertain to: the characteristics of this specific depth to which the caregiver is exposed
o Specifically these stressors are associated with
 Mode of death
 the degree to which the death was anticipated
 the number of deaths involved
 the extent of the trauma
 whether the loss was of a child or related to aids
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 Problems caused by death-related stressors

o What types of deaths are over-represented in complicated mourning: sudden
traumatic violent mutilating preventable senseless horrifying
o Genuineness and empathy create vulnerability in the caregiver, which in turn
compromises the ability to land therapeutic support

o High risk deaths often generate in the worker, as well as in the mourner
 High anxiety and threat
 increase vulnerability
 heightened insecurity
 intensified feelings of helplessness
 Strong sense of _loss of control
o The mourner’s search for meaning can be agonizing to the worker because:
condition of the injustice in these types of deaths can leave the caregiver cynical
and hardened
 Caregiver responses to traumatic death
o Why is this especially difficult for workers? to the extent that the caregiver is
exposed to the details of traumatic death or to his own traumatic experiences
secondary to the mourners emotional reactions traumatic material and fears the
caregiver becomes vulnerable to the stress response syndrome
o P 660 “It is for such reasons [secondary traumatization of the worker] that the
need has been identified to provide safety in treatment not only for the victimized
individual, but also for the caregiver. Safety is necessary because the worker is a
witness to atrocity who is exposed to experiences that can raise intense emotional
reactions such as terror, grief, rage, and excitement. This can evoke in the worker
wishes to deny, rescue, blame, and punish.”

o Caregivers mush manage countertransference reactions that arise from work with
those lacking a clear feeling of guilt. Countertransference with these individuals
stresses the worker’s tolerance to its limit

Responses related to the Death P 250

 Therapists often feel revulsion: fear that such things could happen to them.
 How is this problematic?
Stressors Associated with Treatment Difficulty/ Responses Related to the Therapy (p 250)
 Just doing this work is stressful for the worker
 The tasks of therapy are more challenging with clients experiencing complicated or
traumatic bereavement than for clients experiencing uncomplicated mourning.
 Specific mourner liabilities (list below)
o Prior or concurrent losses or stresses
o Mental or physical disorders
o Mourner problems with:
 Anger
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 Ambivalence
 Guilt
 Dependency
 codependency
o Perceived lack of social support
place inordinate demands on caregiver and on the treatment process. P 662

 List the 8 problems commonly experienced as stressful:

o Grief and mourning reactions are greater and persist longer in complicated mourning
than an uncomplicated morning in many cases
o horrific gruesome senseless or preventable losses will likely intensify prolong and
complicate treatment at the same time that they make the caregiver want to avoid the
mourner or the issues involved
o complicated mourning is associated relatively more often than uncomplicated
mourning with suicide potential and acting out potential
o the time it takes to work through some of these issues can be difficult for the mourner
to endure while witnessing the suffering that occurs in the interim
o cases of complicated mourning involving prior or concurrent losses or stresses or
mental and physical illness necessarily require more complex intervention and altered
expectations and goals
o treatment of complicated mourning is often distressing to the caregiver because of the
frequent need to promote the mourners painful confrontation with loss and or trauma
o working with chronic mourners can be particularly stressful discouraging and
frustrating for caregivers because this population is known to be especially
recalicitrant
o counter transference feelings of anger resentment and rejection can develop in the
caregiver when the mourner begins to make progress and rely on others besides the
caregiver
Responses Related to the Therapy (p 250)
 Example: one therapist struggled with teaching feeling skills. when she worked with a client
who was much older than she was her struggle became more pronounced. she experienced
herself as condescending and thus tended to minimize these aspects of the treatment. after
exploring her responses with a colleague she came to understand that her client often did not
get the support he needed because others saw him as unusually self-sufficient
Responses Related to the Therapist (p 251)
 Your particular responses may depend on such factors as your theoretical orientation,
personal style, history, and current life circumstances, similarities between you and the
client_.
 Differentiate between empathy and personal distress, and shared trauma:
o Empathy: a process in which one imagines the experience is happening to the other

o Personal distress: arising when one imagines the experience is happening to oneself
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o Shared Trauma: personal traumatic experiences can come to into play when therapists
and clients have endured the same traumatic events at the same time

Part V: VICARIOUS TRAUMATIZATION

 Defined: specific ways in which working with survivors of sudden traumatic death
overtime and across clients can negatively affect therapists

 Differentiate between countertransference and VT: counter transference refers to our

responses as therapist to individual clients and Vt describes our responses across clients
over time

 Sources of VT
o The clients
o The therapist
 Identifying VT
o how is this work affecting me in ways that resemble trauma if in a milder form
 Addressing VT
o Coping with VT
 educating oneself and others about the effects of traumatic events
obtaining assistance and support from others using humor active coping
and planning countering isolation and developing mindful self-awareness
expanding perspective to embrace complexity engaging in active optimism
and holistic self-care maintaining clear boundary and creating meaning
processing with peers or others and exercising
o Transforming VT
 P 663 McCann and Perlman advocate a series of strategies
 Use strategies appropriate to working with uncomplicated
bereavement, and the following:
 Support groups. These support groups should be focused around:
o Normalizing…
o Applying constructivist …..(address why this approach is
helpful)
o Providing safe ….
 Countertransference reactions must be presumed to indicate
inevitable to reflect caregiers own unresolved issues despite what:
fact that caregivers psychic conflicts and unresolved victimizations
in early childhood certaintly contribute to VT
 Workers must understand how the assumptive world
 If workers learn more about their own particular psychological
needs, then: they will be more effective in processing traumatic
material and limiting its impact on the assumptive world and
functioning
 What does I t mean to “challenge the dark side of humanity
observed in this work” p 664 develop the essential components of
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optimism and hopelessness in the face of tragedy by

acknowledging and confirming the many positive experiences and
effects work with traumatized individuals can have
 Drawing personal meaning from knowing one is
involved in an important social problem and making
a contribution to ameliorate some of the destructive
impact of violence on human beings
 having enhanced awareness with the social and
political conditions that lead to violence which can
lead the caregiver to greater social activism
 Developing heightened sensitivity and enhanced
empathy for victim suffering which may result in a
deeper sense of connection with others
 increasing feelings of self esteem from helping
trauma victims regain a sense of wholeness and
meaning
 developing a deep sense of hopefulness about the
capacity of human beings to endure overcome and
even transform their traumatic experience
 achieving more realistic view of the world through
the integration of the dark sides of humanity with
healing images
 P 664 “Just as mourners have a choice about how ultimately to
respond to their loss, so also do workers who work with these
mourners.”
o Thus, all the sources of caregiver stress noted here could
Become sources of positive consequences_
o The traumatic nature of a death can just as easily depress
one worker as it can intensify The determination in another
to live life as meaningful as possible
o The notion of exercising individual choice does not imply
that the stress of working with complicated mourning is
insignificant.
o However, by choosing How to manage stress one can
minimize its deleterious effects and maximize its benefits
for the ultimate good of the mourner as well as oneself.”
Part VI: STRATEGIES FOR REDUCING CAREGIVER STRESS
 To use resources available most successfully, it is important to identify the sources of
stress and determine the following. Which ones are
o Generic in treating _Any complicated morning_ p 663
o Inherent in the specific work at hand
o personally idiosyncratic.
o Additionally, worker must identify personal vulnerabilities to the work
o Build in ways to deal with them.
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 What must the worker do alone and with others and why? P 663 to process the
reactions elicited by this type of work and to understand that one must acknowledge
expressed and work through painful experiences if one is to prevent or ameliorate
some of the potentially damaging effects of this work
 Please take the Checklist on page 261-262. This is just for your own use, but it is helpful.
Yes, I know you are in graduate school, working, and many in an internship, and have
significant others in your life and maybe dependents, as well. Still, you brush your teeth
for good oral hygiene, you eat to fuel your body, so you do the necessary self-care-for-
survival items. And life is more than survival. It is living, and to live well, (and certainly
to be of optimal benefit to our clients) we need to do just that: Live WELL. So take the
checklist and see where it leads.
 Training and Consultation: Supporting yourself in the work
o Training and Continuing Education
 Helpful to build our weaker suits (add training in less familiar areas.
 To use the treatment approach offered in this Trauma Readings the
following trainings can be beneficial
 CBT
 Treatment of _complex trauma, grief and bereavement
 Relational psychotherapy
 And EMDR. The authors have repeatedly mentioned EMDR as a
viable alternative. And, as we have mentioned, EMDR drastically
reduces the risk to the therapist of secondary traumatization
(Vicarious traumatization).

o Clinical Consultation
 Self awareness and good clinical consultation are essential for all
therapists, especially those of us working with traumatically bereaved
clients.
 When might it be necessary for you to refer a client elsewhere for
services?
 The client may experience this referral as yet another loss
 How might you phrase the referral? The nature of your loss evokes
something from my own experience that would make it difficult
for me to give you the help you deserve. I'd like to refer you to a
colleague who I think can be more helpful to you
 A decision to refer is best made when in the treatment proves?
 Is it best to have a consultation with a colleague to help develop a
referral plan
 Give an example of how a consultant (supervisor) can help identify the
worker’s blind spots? ( p 262-263)
 Good trauma therapy consultation should have the following qualities:
(please list and describe these qualities)
 Respectful:
 Collaborative
 Experienced:
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 Generous
 Peer support can be supportive. Describe how. Provide information,
support, and opportunities for reflection on the work
REWARDS OF THE WORK (P 264)
 Satisfaction that comes from facilitating positive change in a client
o Some have struggled for years
o Honor to be entrusted with our clients’ pain fear, grief, and vulnerability
 Gratifying to master a complex treatment approach: Learning stimulates us and keeps us
engaged in our professional lives and we can integrate the information and skills gained
from working this way into our work with other clients expanding the benefits to others
 Vicarious resilience
o The parallel process
 As our clients struggle for meaning
 We also face questions of meaning in our own lives
 Our clients’ ability to endure terrible losses can inspire a kind of vicarious
resilience