Helping Patients and Families Cope

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Transcript Helping Patients and Families Cope

New Hampshire Psychological
Association Meeting – May 6, 2011
Gerald P. Koocher, PhD, ABPP
Simmons College
 Accepting the reality of the loss
 Grieving: experiencing the pain and
emotion associated with the loss
 Adjusting to the new reality
 Commemoration: relocating
representation of the deceased in
one’s own life
What did we learn from…
 our culture?
 our family of origin?
 our personal loss experiences?
What does this particular loss mean?
 to my support system (social and economic)
 in light of my quest for meaning (attributions and
sense of self)
Supported by National Institute of Mental
Grant No. R01 MH41791
Gerald P. Koocher, Ph.D. and Beth Kemler, Ph.D.
Principal Investigator and Co-Principal Investigator
Perceived social support
Week 1
Mean social support
Week 6
Time elapsed since death
External social support rises sharply after the
loss event and then declines
 Intra-familial support can be variable
Mutual Escape
Distancer and Pursuer
Group 1
3 months
9 months
Group 2
Comparison Group
Part I – 90 minutes
 Family members tell their stories
▪ Assure that all speak for themselves
 Exploration of coping
▪ Circular questioning about perceptions of self
and others
 Education about grief
▪ Child versus Adult patterns
How to do it and why:
To assist the telling of the story, the intervener asks
specific questions pertaining to
 the times of the diagnosis or accident,
 the funeral, and the period following the funeral.
The purpose of the questions is to provide some
structure for eliciting everyone's story, as well as to
make clear each person's conception (or
misconception) regarding causality, blame, and
cognitive understanding of the death
Part I – 90 minutes (continued)
 Acknowledge pain and discomfort of
discussing the loss again
 Give parents reading material
▪ The Bereft Parent (Schiff)
 Assign Homework for Session II
▪ Each family member to choose memory object for
next session, but avoid discussing the choice at
The parental subsystem remains critical one in grief affecting
the entire family system.
Parents may differ on how to handle discussing death within
the family, especially with the surviving siblings.
Another frequent source of tension may result from
asynchrony in the style and/or timing of parental grieving.
Parents may disagree on how to deal with behavioral issues in
the surviving children.
 How open and direct to be around the topic of death, how much
autonomy to allow, limit setting, etc.
Part II: parents only- additional 30 minutes
 Explore dyadic issues
▪ Sources of tension in the relationship (e.g.,
sexual disruption, replacement child, etc.)
 Discuss losses in family of origin context
▪ How were you taught to deal with loss?
 Review personal loss histories
▪ What important losses have you suffered
Part I: parents only - first 30 minutes
 Explore interval since first session
 Address any recent concerns
 Normalize the distress of reawakening grief
 Provide encouragement for coping efforts
made to date
Part II: family meeting- 90 minutes
 Two Exercises:
▪ Remembering the deceased child
▪ Family letter writing
Remembering the deceased child
 What reminder has each person brought?
▪ Discuss the meaning of the item.
 How is the child remembered.
▪ Where are the reminders at home?
 Assess idealization.
▪ Are negative memories tolerated?
▪ What has been done with the child’s room and belongings?
▪ Explore cemetery visits.
 Discuss how the family has changed.
Family letter writing activity
 May be literal or figurative, written or taped.
 Young siblings can draw pictures.
 Goal: create emotional object to take home.
 Content:
▪ Things left unsaid
▪ Memories shared
▪ Unanswered questions
Anticipating anniversary phenomena.
 Which will be most difficult for whom?
 Review normal grief and “warning signs.”
 Discuss re-involvement in the world for each
Explore meaning-making for each person.
 Philosophy of life
 Hope for the future
Plan family activity outside the home.
Dealing with relatives and friends.
Dealing with PIG (people in general) and their
helpful or NOT comments
Staying withdrawn from
family and friends
 Persistent blame or guilt
 Feelings of wanting to die
 Persistent anxiety;
especially when separating
from parents or surviving
 Unusual and persistent
performance problems at
work or school
New patterns of
aggressive behavior
 Accident proneness
 Acting as though nothing
happened, or happier than
 Persistent physical
 Extended use of Rx or nonRx drugs and alcohol
Five aspects
 Physical
 Emotional
 Behavioral
 Interpersonal
 Attitudinal
Chronic Frustration
 Emotional and physical
Malice and aversion toward patients
Reduced productivity and effectiveness at work
Role ambiguity
 Vague or inconsistent expectations/demands
Discrepancy between real/ideal work
Unrealistic pre-employment expectations
Lack of support at work
The Asshole Factor
 (temporary and certified status)
 Demeaning, bullying, hypercritical…all too
common in medicine
▪ Example- medical error reporting
 The No Asshole Rule: Building a Civilized
Workplace and Surviving One That Isn't -- by
Robert I. Sutton
Role clarity
Positive feedback and recognition
Enhanced staff autonomy
Providing for stress recovery at work
Social support at work
Perfectionistic personality
Losses in the family
Chronic helplessness
Permeable boundaries
Substance abuse
 The Savior Complex
 External control orientation (I-E Scale)
Sense of personal accomplishment
Realistic criteria
 Including patient outcome expectations
Accurate awareness of personal strengths
and weaknesses
Internal control orientation (I-E Scale)
Hart, C., Harrison, A., & Hart, C. (2006). Breaking Bad News. In
Mental health care for nurses: Applying mental health skills in the
general hospital. (pp. 82-94): Blackwell Publishing: Malden.
Most important: how do we know that the patient
will perceive the news as 'bad'?
 A patient may receive definite news--whether or not it is
perceived by clinicians as 'bad'--as conferring a degree of
certainty and feel grateful for this, particularly if it
confirms a long held suspicion or belief.
Equally important: information that the bearer may
have thought of as relatively unimportant may have
a severe impact on the patient and/or family
Someone who knows the patient/family.
The person who has all the information available,
to cover any questions the patient or family may
 Who is that? The primary care physician, as the person
with overall responsibility for the patient's treatment,
a team, a 'specialist' in such matters as breaking bad
Communicating bad news is most closely
associated with having to tell patients about a
terminal prognosis.
Try not to
yourself with
 Just because
you have bad
news should
not prevent you
from offering
“You have a serious illness of an undisclosed nature.”
Try to
and respect
of the
 Deliver
line first,
The "good
does not help
if the news is
only really
Have a plan or help
the recipient to
engage in
developing one.
When stress is high
written information
can help.
Set up ongoing
support and
Be human,
and be