Grief as a Skill - SOPHIA (PDF)

St. Catherine University St. Catherine University SOPHIA SOPHIA Master of Social Work Clinical Research Papers School of Social Work 5-2017 Grief as a Skill Grief as a Skill Michael Sadowsky St. Catherine University, [email protected] Follow this and additional works at: https://sophia.stkate.edu/msw_papers Part of the Social Work Commons Recommended Citation Recommended Citation Sadowsky, Michael. (2017). Grief as a Skill. Retrieved from Sophia, the St. Catherine University repository website: https://sophia.stkate.edu/msw_papers/787 This Clinical research paper is brought to you for free and open access by the School of Social Work at SOPHIA. It has been accepted for inclusion in Master of Social Work Clinical Research Papers by an authorized administrator of SOPHIA. For more information, please contact [email protected]  Running head: GRIEF AS A SKILL Grief as a Skill by Michael Sadowsky, B. A. MSW Clinical Research Paper Presented to the Faculty of the School of Social Work St. Catherine University and the University of St. Thomas St. Paul, Minnesota in Partial fulfillment of the Requirements for the Degree of Master of Social Work Committee Members Rajean P. Moone, Ph.D., LNHA (Chair) Heidi Haley-Franklin, LICSW Janet Dahlem, MA The Clinical Research Project is a graduation requirement for MSW students at St. Catherine University/University of St. Thomas School of Social Work in St. Paul, Minnesota and is conducted within a nine-month time frame to demonstrate facility with basic social research methods. Students must independently conceptualize a research problem, formulate a research design that is approved by a research committee and the university Institutional Review Board, implement the project, and publicly present the findings of the study. This project is neither a Master’s thesis nor a dissertation.  GRIEF AS A SKILL 2 Abstract This qualitative research study examined seven professionals’ views on grief and loss and opinions regarding reframing grief as a skill. Seven semi-structured interviews were conducted to provide data for this research study. Analytic induction was used for data analysis, with the research question being “how is grief a skill?” Major themes included grief being something that is done instead of an affliction or just emotions. Barriers to grieving was a theme, such as: grief not being taught and being sheltered from death, cultural norms that discourage grief or socialize grief out of people. Another theme was the ways that grief is a skill, which involve willingness to authentically experience grief and all it brings, being changed by grief, and learning new skills to better cope with loss and grief. The last major theme was how grief can increase skillfulness as human beings. This included many changes, including deepened understanding of self, deepened understanding of and empathy for others, and deeper understanding of life itself, including a deepened appreciation and gratitude for life, finding meaning in loss, increased meaning and purpose in life, an ability to tolerate suffering and change, and other potential changes. These findings support previous studies about grief outcomes, but also add the dimension of exploring grief as a skill that can be learned. Further research will help workers in various helping fields who wish to work more holistically with clients who are experiencing major life changes, clients who are bereaved, or clients with end-of-life issues. In each of these cases, this research provides a useful framework to better assist clients with these difficult situations, as well as potentially providing a useful orientation towards grief for individuals, communities, and cultures.  GRIEF AS A SKILL 3 Acknowledgements This research was very personal. It is a result of many years of incubation, followed by an intensive nine months of research, digesting, and writing. It has been inspired and aided by many teachers, mentors, and companions, both professional and personal, who are far too numerous to name in a humble acknowledgements section. While I lament not being able to thank you all here, I do continue to carry you all with me. In this space, I would like to thank my committee members Heidi Haley-Franken and Janet Dahlem for their continued encouragement and pep talks, as well as for challenging me to improve this research. I thank Merra Young for modeling a holistic view of working with the bereaved, and I am honored by the interest she has shown in my own work and learning. I would like to thank my friends and fellow classmates for support and commiseration, and for the needed pub nights we regularly had. Thank you to my family for your positive thoughts, unconditional support, dinners, mailed packages of cookies and treats, and for tolerating my obnoxious absence from your lives while graduate school ate my life. Thank you Aubrey for the encouragement, understanding, comfort, screaming sheep videos, and for giving me needed laughs. Thank you to the Regans. Tom and Patti for your deep friendship, support and mentorship. And to the whole Regan clan, for accepting me as one of your own, for helping me learn the skill of how to hold joy and sorrow at the same time, and for continuing to go on this heartbroken but soulful life journey with me. Marlowe  GRIEF AS A SKILL 4 Table of Contents Preface............................................................................................................................................. 8 Introduction................................................................................................................................... 10 Literature Review.......................................................................................................................... 13 A brief history of grief .............................................................................................................. 13 Types and consequences of grief .............................................................................................. 14 Physical effects of grief ............................................................................................................ 16 Non-Western culture, grief, and ritual ...................................................................................... 20 Social Support........................................................................................................................... 23 Models and treatments for working with grief ......................................................................... 25 Mindfulness-based interventions .............................................................................................. 28 Grief, acceptance, and meaning-making................................................................................... 30 The role of suffering ................................................................................................................. 33 Can grief be learned? ................................................................................................................ 34 Summary and research question ............................................................................................... 36 Conceptual Framework................................................................................................................. 38 Methods......................................................................................................................................... 43 Research design ........................................................................................................................ 43 Sample....................................................................................................................................... 43  GRIEF AS A SKILL 5 Protection of Human Participants............................................................................................. 45 Data Collection ......................................................................................................................... 46 Data Analysis............................................................................................................................ 46 Results........................................................................................................................................... 48 What is Grief?........................................................................................................................... 48 Why Grief is so problematic? ................................................................................................... 50 Grief Difficulties/What Doesn’t Help with Grief ..................................................................... 55 Growth from Grief.................................................................................................................... 59 Meaning in the Context of Grief............................................................................................... 65 Spirituality................................................................................................................................. 70 Grief in Western Culture........................................................................................................... 73 Helpful Ways to Approach Grief.............................................................................................. 78 Helpful Clinician Actions. ........................................................................................................ 82 Critiques and Cautions Regarding the Research Question ....................................................... 85 Ways that Grief is a Skill.......................................................................................................... 87 Discussion..................................................................................................................................... 95 Grief is Something that is Done................................................................................................ 95 Barriers to Skillful Grieving ..................................................................................................... 96 Skillful ways to approach grief................................................................................................. 99 How Grief Makes People more Skillful Human Beings......................................................... 103  GRIEF AS A SKILL 6 Strengths and Limitations ....................................................................................................... 108 Implications for Social Work Practice and Holistic Health Care ........................................... 109 Implications for Policy............................................................................................................ 111 Implications for Future Research............................................................................................ 112 References................................................................................................................................... 113 Appendix A................................................................................................................................. 123 Appendix B................................................................................................................................. 126  GRIEF AS A SKILL 7 List of Tables Table 1. Participant Statements Suggesting Dominant Theme of What Is Grief? ........................................................................................................................................ 48 Table 2. Participant Statements Suggesting a Dominant Theme of Why Grief Is So Problematic................................................................................................................. 52 Table 3. Participant Statements Suggesting a Sub-Theme of What Doesn’t Help With Grief ............................................................................................................................ 57 Table 4. Participant Statements Suggesting a Dominant Theme of Growth From Grief.............................................................................................................................................. 61 Table 5. Participant Statements Suggesting a Dominant Theme of Meaning in the Context of Grief.................................................................................................................. 67 Table 6. Participant Statements Suggesting a Sub-Theme of Spirituality.................................... 71 Table 7. Participant Statements Suggesting a Sub-Theme of Grief in Western Culture ............................................................................................................................ 75 Table 8. Participant Statements Suggesting a Dominant Theme of Helpful Ways to Approach Grief ............................................................................................................... 80 Table 9. Participant Statements Suggesting a Sub-Theme of Helpful Clinician Actions .......................................................................................................................... 83 Table 10. Participant Statements Suggesting a Dominant Theme of Critiques and Cautions Regarding the Research Question ........................................................... 86 Table 11. Participant Statements Suggesting a Dominant Theme of Ways that Grief is a Skill.............................................................................................................. 90  GRIEF AS A SKILL 8 Preface The Young Man found himself on the bank of the Souris River, north of Minot, ND. The sun was setting, in that melancholy, gorgeous, almost endless way that it does on the Prairie, with oranges fading into red, red fading into pink, pink fading into all kinds of purples and blues. And blues…It was the only time He’d be able to call his mother. Hours had passed since He’d found out. He’d stayed home to finish up final projects for the college, while She had left in the early afternoon to make it to Her brother’s birthday weekend. He planned to join in a day, after one last intense bout with homework before the semester was vanquished. That next day of joining came, but not as expected. Hours after She left, after a final I love you, a polite officer and chaplain visited. It was broad daylight, and no clear cause. She swerved, overcorrected, and the car rolled. A nurse who coincidentally drove by on the rural highway performed CPR on Her while paramedics rushed from dozens of miles away. Son, She was dead, and is there anything we can do for you? Have a nice day now…This darkness, heavy as a judgment. Yeah, now He should call his mother. Who knows how deep and isolating this hole will become if He doesn’t do it right now? When she picked up, after some time, He was able to get out a “mom….[She’s]…” before the shock left Him mostly incoherent. Many thoughts and activities played out in the course of the next few days. He and His mother drove to Her parent’s home, and He asked aloud how one could comfort the mother of a child lost, when oneself was experiencing loss. He met Her sobbing parents, Her numb siblings, Her aunt and uncle. He ate hotdishes, meat and cheese trays, and other foods left by neighbors and friends. He slept in Her teenage bed alone, waiting for miracles and ghosts. He heard rumours of an illegal steep drop from road asphalt to side curb, which may have contributed to the accident, and volunteered his time to document the scene of the accident, as well as the bloodied and extensively battered vehicle, before any insurance or vehicle company could compromise the evidence. He saw Her battered body, and later Her slightly more made-up body at the funeral. He had a last moment with Her before the casket was closed, and pressed a special necklace and stone into her hands. Soon after, family and friends tossed dirt upon the casket, hoping for some kind of closure. And what to make of this whole thing? He had experienced loss before, in many forms. A family constantly on the move, leaving friends behind in early life moving from state to state. The loss and seeming betrayal of a best friend in grade school. The loss of a close and cherished uncle, who used to play basketball and trade baseball cards with Him and His brother and cousin. This uncle died by suicide; the loss so unspeakable that decades later the family can barely speak his name. The sorrow so unbearable to the grandfather, this uncles father, who witnessed and cleaned up the suicide scene; this sorrow that absolutely contributed to this grandfather falling to pieces at the mention of his son, and soon to his onset into dementia; this sorrow that absolutely scarred and shattered His own father, the older brother of this uncle. He Himself had experienced the loss of a grade school friend who died in a car accident in high school as a result of alcohol, and sat defiantly in the pew of a church who attempted to evangelize the death into a commercialized way to sell ‘coming to Jesus’ by asking all attendees to come forward to receive a rebirth, rather than focusing the life and loss of the deceased. He’d soon after experienced the death of another friend by suicide; a gunshot to the head after drunkenly crashing his truck. This friend had always seemed depressed and suicidal. Drunken nights with other friends attempted to make sense of the tragic even, and sometimes romanticize the whole thing, philosophizing  GRIEF AS A SKILL 9 suicide as a rejection of social control…intense ways for young men to attempt to contend with the violent loss of a comrade, and what it meant to their own lives. But what to make of this new loss? This Young Man had never felt so close to another human being. This Young Man had never felt so accepted by another human being. This Young Man planned to marry this other human being someday. His primary identity had become increasingly inter-webbed with Hers. He was lucky in life, and doing all the right things. What comes next? What happens to a lucky, clever, and hard-working life that is suddenly shattered by loss? This Guy was told many things, and found no comfort. The gentlest of great uncles offered “time heals.” This Guy defiantly replied back “no, time makes you forget.” He was told that the loss was part of “God’s plan,” and defiantly replied that he wouldn’t tolerate living in a universe where any “God” would arbitrarily and gruesomely kill a person for some purpose. Gone, now, was any beliefs in predetermination. When inquiring on his parent’s insurance for antidepressants, he was asked “Do you really want to try those?” His feelings of sadness and depression were disenfranchised, turned into a sign of luxury and misunderstanding. This Guy moved to another state after Her death. He couldn’t bear to be in the same apartment where They lived, the same town where They built a life, attend the same college where They had both attended productions. He attempted to start over, and would pursue international journalism, planned to study in China, and planned keep moving. Instead, He would get a job on a cruise ship and explore the continent. He would date another person and try to start a new life. He was determined to not let this grief thing beat him, to slow down His life. Several months later, He was laying in the fetal position on the floor, on the day He had taken his first Zoloft dose that was found during work at an abandoned medical clinic. He was contemplating suicide and fighting for life. Logically being able to contemplate suicide was the only thing that kept Him alive during that ordeal. Anger at the disenfranchisement of His grief came later… So what? Why does all this matter? Well, this Guy intuitively caught on to something despite his intentions to avoid and move on. He instinctively remembered birthdates and other personal dates. He naturally developed personal rituals and remember what came before. He tried valiantly to move past the loss, only to be tugged back in by personal emotions—and by others who graciously and less-graciously informed him that the life and death of Her was still very real and very present. After a time, it seemed clear to Him that you don’t cut ties and simply move on from the dead. And what to do with who are lost? They don’t validate and support us in the present…or do they? A lost car key doesn’t explain what it does to us, but instead what we do to the key. Some would suggest that the loss of a loved one is similar, and that this explains much more what we do to them [who are lost] than they do to us. Who loses who? Maybe we can continue our bonds with those who are lost in meaningful ways? And rather than push grief away, could we be instead be tenderized by the experience? Grief, although always deeply unwelcome, forces us—if we allow it—to a place of realizing the price of love, the value of life, the inherent non-entitlement of being alive, and what it costs for us to be alive in the way we are. Perhaps if we can comprehend the backdrop of the whole gulag of being alive, we can realize what a great gift we’ve been given. And realizing this great gift, perhaps we can continue to leave a legacy for future generations who may understand this, and who are grief-soaked, but gratitude-affirmed. Such a dream….  GRIEF AS A SKILL 10 Introduction Is grief something that happens to you, or something you do?...my [experience] has shown me that grief is not an inner feeling, not a complex little knot of inner feelings, not a coaxial cable of feelings…that is what sorrow, depression, loss and the rest are…grief is not a synonym for those things. Grief doesn’t come from nowhere, an intrusion into the natural order of things. Grief is the natural order of things…Grief: a sign of life stirring toward itself (Jenkinson, 2015, p. 367). Society’s relationship to grief in the modern Western world is an uneasy one. This current society is often described as Modernist, which values reason, observation, continued progress, and--in medicine and psychology--has given rise to the “machine metaphor” for understanding human health and functioning (Stroebe, Gerge, Gergen & Stroebe, 1992). In this view, the belief is in an optimal and universal way of human functioning, with differences perceived as abnormal. Grief can be a very intense and disturbing experience for humans, and therefore seen as an interference with optimal functioning. As a consequence, the process of grief is often forestalled, medicated and pathologized, with people often avoiding the subject, and a quick recovery emphasized (Cornell, 2014). Modern care for mourning individuals in North America tends to pathologize grief, with medication and talk therapy as commonly used treatments. Grief is considered an intrusion in our lives, and a deeply unwelcome event. Due to this, the primary focus of care is on what grief does to people, and how to prevent or alleviate the pain and difficult emotions that come with mourning. This view of grief has a lot of momentum: with the DSM V’s recent removal of the grief exception from Major Depressive Disorder, the door has been further opened to treating grief as a mental illness in need of medication rather than as a normal reaction to loss (Wakefield  GRIEF AS A SKILL 11 & Schmitz, 2012). While it’s understandable that grief has come to be understood this way in a culture with a dominant biomedical model of human health, it is not a universal experience or understanding of grief among all cultures, past or present, and may be a sign that our culture is actually grief-illiterate. The realities of death and grief are often avoided, or seen as losses or tragedies that are to be gotten over as quickly as possible. The biomedical model, with its emphasis on curing, views death as an inherent failure of life (Byock, 2002). Taken together, many Western individuals themselves are death-phobic or find themselves living in a death-phobic society. Death is an inevitability for all humans, and while there’s a natural inclination to avoid this reality, other research, cultural practices, and wisdom posit that being willing to approach grief and loss may be a more useful approach to dealing with the deeply unwelcome realities of death (Cacciatore, 2013; Horrigan, 2003; Stroebe, et al., 1992; Thieleman, 2015). Previous societies derived much of their cultural identity from the way they grieved, as do some modern societies. Current thinking about grief therapy is stirring towards assisting in meaning-making in bereaved clients, and other experimental research suggests that engaging with death in a variety of ways may deepen peoples’ appreciation of life (Heine, Proulx, & Vohs, 2006; Kablenz, 2015; Mendes, Goncalves, & Neimeyer, 2012). The purpose of this qualitative research study was to explore societal and professional concepts of grief, and proposed redefining grief as a skill which can be learned, and which may add value to life. As Joan Halifax argues, contemplating and preparing for death is not morbid, but that “the actual preparation for death releases you into an appreciation for life and living” (Horrigan, 2003). Grief is an experience in which we encounter the stark reality of the mortality of loved ones, and by proxy, we must confront rumors and echoes of our own mortality. While  GRIEF AS A SKILL 12 encountering mortality is an unsettling proposal in many ways, Stephan Jenkinson argues that death is “the cradle of [our] love of life” (Davis, interview with S. Jenkinson, n.d.). If this love of life is to grow, and if we become informed about death through grief, it seems necessary to foster the skill of grief in order to expand our ability to love life. To better understand how grief can come to be known as a skill, a literature review exploring many facets of grief is presented. This literature review outlines a brief history of grief, types and consequences of grief, physical effects of grief, treatments of grief, non-Western responses to grief, social support and grief, the role of suffering, and explores whether grief can be learned. Next, the conceptual frameworks for this research is presented, which reflects social work values of strengths and empowerment, as well as a holistic health model of care which emphasizes attention to mind, body and spirit. Following this, qualitative discoveries of the research are outlined. Lastly, findings from the study and implications are discussed.  GRIEF AS A SKILL 13 Literature Review A brief history of grief For hundreds of years there have been psychological studies and musings to understanding grief, with grief being attributed to many different external and internal causes (Granek, 2010). Freud wrestled with the concept of grief, and while concluding that there was a normal grieving process, he came to believe that grieving could become pathological (Granek, 2010). As part of an unhealthy grieving process, Freud (as cited by Granek, 2010) thought that hostile feelings toward the deceased were turned inward and resulted in “melancholia,” or depression (Freud, 1917). Elisabeth Kubler-Ross helped bring discussion of grief into popular culture with the publication of her famous stages of grief model. This model presentw five stages a bereaved person must pass through, which include denial, anger, bargaining, depression, and acceptance (Kubler-Ross, 1969). While these stages—or any stage model of grief—have been debated, it’s inarguable that Kubler-Ross’s publications had a profound effect on the way grief was understood and researched. Like most phenomena with a long history of study, descriptions and understandings have become increasingly more nuanced and complex. Where Freud had begun to articulate a broad phenomenon called “melancholy,” modern descriptions of grief have grown to encompass many different types of grief, including normal, pathological, complicated, extended, acute, chronic, and many others (Prosser-Dodds, 2013). Many models and treatments have been proposed and used, many with success, yet grief continues to be a profound and confounding part of the human experience. Some research suggests that there is no universal timeframe for the cessation of grief, and that there is wide variation in the expression of individual grief (Currier, Neimeyer, &  GRIEF AS A SKILL 14 Berman, 2008). Consequently, grief treatments and understanding of grief will continue to evolve. Types and consequences of grief Many negative health benefits are associated with bereavement. Among those studied are higher risk of mortality, compromised physical, social, emotional, and mental health, and higher consumption of medical care (Kersting & Kroker, 2010). Women are at higher risk of bereavement due to their longer life spans (Kersting & Kroker, 2010). Guilt and self-hatred have been documented as outcomes of grief. Miller discussed how bereaved persons often feel rage toward the deceased loved one, which then manifested as feelings of guilt for these feelings, self- hatred for having these feelings, and ultimately an experience of melancholia (1970). Complicated Grief is a psychological phenomenon with more intense symptoms than is usually expected in the Western world. Symptoms associated with Complicated Grief include persistent yearning and longing for the loved one who died, preoccupation with thoughts and memories of this person that are disruptive to living life, avoidance of reminders of the death, self-blame, bitterness, or anger associated with the death, an inability to get satisfaction or joy from meaningful activities or relationships with others, and a deep, persistent sadness (Horowitz et al., 1997). There’s a strong connection between complicated grief and complicated spiritual grief. It’s not uncommon for a bereaved person to have a spiritual crisis following a profound loss (Burke et al., 2011). Indicators of such a spiritual crisis include “the bereaved individual’s sense of discord, conflict, and distance from God, and/or from members of his or her spiritual community” (Burke et al., 2014). In a qualitative study by Burke et al., participants reported a wide range of spiritual related changes after bereavement, such as feeling punished, betrayed,