Helping Patients and Families Cope

Report
New Hampshire Psychological
Association Meeting – May 6, 2011
Gerald P. Koocher, PhD, ABPP
Simmons College
www.pedpsych.org
 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
Health
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

Congruence
Complementary
Mutual Escape
Distancer and Pursuer
T1
Group 1
T2
3 months
9 months
Group 2
T1
T1
Comparison Group
T2
T2

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
home.

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
previously?

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
person.

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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
children
 Unusual and persistent
performance problems at
work or school

New patterns of
aggressive behavior
 Accident proneness
 Acting as though nothing
happened, or happier than
normal
 Persistent physical
complaints
 Extended use of Rx or nonRx drugs and alcohol


Five aspects
 Physical
 Emotional
 Behavioral
 Interpersonal
 Attitudinal

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Anger/Hostility
Chronic Frustration
Depression
Apathy
Exhaustion
 Emotional and physical


Malice and aversion toward patients
Reduced productivity and effectiveness at work

Role ambiguity
 Vague or inconsistent expectations/demands

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Conflicts
Discrepancy between real/ideal work
functions
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

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Role clarity
Positive feedback and recognition
Enhanced staff autonomy
Providing for stress recovery at work
Social support at work

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Perfectionistic personality
Losses in the family
Chronic helplessness
Permeable boundaries
Substance abuse
Expectations
 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
members.


Someone who knows the patient/family.
The person who has all the information available,
to cover any questions the patient or family may
ask.
 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
news?

Communicating bad news is most closely
associated with having to tell patients about a
terminal prognosis.

Try not to
protect
yourself with
distancing.
 Just because
you have bad
news should
not prevent you
from offering
support.
“You have a serious illness of an undisclosed nature.”

Try to
understand
and respect
the
perspective
of the
recipient.
 Deliver
the
bottom
line first,
then
explain.

The "good
news/bad
news
approach
does not help
if the news is
only really
bad.

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
availability.

Be human,
and be
present.

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