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What about the Old Folk?
Bereavement Services in general
Member Name: mdp97jes
Bereavement Services in general
Date: 08/07/02, updated on 08/07/02 (1686 review reads)
Advantages: helps come to terms with feelings, provides support
Disadvantages: may be upsetting at the time
Having spent time working with the elderly in a nursing home and on care of the elderly wards in hospitals I have become very aware of the lack of counselling provision for the elderly, in particular bereavement counselling. As we become older we expect that people we are close to are going to die, but that does not mean that it is any easier to cope with. For many elderly people the death of a spouse is devastating, they may have been married for over fifty years and been very dependent on each other. Most of us know how distressing it is to have a relationship end after a few years, it is hard to imagine the pain of losing someone after a lifetime together. "The tragedy of true love is that one must die before the other" (Somerset Maughan cited in Scrutton 1995). I have seen people who are so traumatised by the death of a spouse that they become confused, lose the ability to do things for themselves or lose their own will to live. "The death of a life long partner can precipitate a grief reaction from which some elderly never entirely recover" (Shoenberg 1980). As well as the distress caused by losing someone close, the elderly person begins to realise that they themselves may not have long to live and for some this is very frightening. Another upsetting thing is that the elderly person may be on their own, as, they have no family or the family does not live near by or does not have time for the elderly relative. We have moved away from the days when the extended family all lived close together and looked after their elderly relatives.
"The death of someone you share your life with is known to be one of the severest forms of stress. In later life it can mean the end of a loving relationship which has lasted for many years; in older age , too, there may be added problems - lack of mobility, the problem of living alone, your own infirmity or ill-health, the distance you live from the family, or the possibility that you may have no
family left at all" (Help the Aged 1995).
Most people view counselling as going to a formal setting to see a qualified counsellor and talk through problems for an hour a week for a set period of time. This op aims to demonstrate how I feel counselling skills can be used to help the bereaved elderly. They rarely need formal counselling just a listening ear and the chance to reminise and cry. I will explain how I think the use of effective listening and the role of reminiscence therapy can benefit the bereaved elderly person.
~The Process of Grief and Bereavement~
"The process of grief is an individual journey. Although loses appear to have similar qualities, and there are universal dimensions of grief, each individual has unique issues to cope with and resolve. No two people grieve in the same manner or to the same timetable" (Humphrey & Zimpfer 1996).
There are four stages of grief,
~ Shock and Disbelief
~ Depression and Apathy
~ Expression of Grief
~ Signs of Recovery
Everyone experiences these stages in varying levels of severity and may cope better with some stages than others. It is not a straightforward process and people may go backwards and forwards between stages. There are many emotions that accompany the stages of grief such as, anger, misery and depression.
Parkes (1975) described seven phases of bereavement;
~ Realisation - moving from denial towards acceptance of the loss
~ Alarm reaction - anxiety, restlessness and fear
~ An urge to search for the lost person
~ Anger and guilt
~ Feelings of internal loss of self
~ Identification phenomena - the adoption of traits, mannerisms or symptoms of the lost person
~ Pathological variants of grief - excessive or prolonged reactions.
~Counselling the Bereaved Elderly Person~
"To really listen to a person is the most
caring action of all" (Burnard 1995). "Reminiscence can play an important part in ameliorating personal distress, and can be adapted when counselling older people through such matters as retirement, dependence, depression, ill health, as well as coming to terms with bereavement and death" (Scrutton 1989).
My first experience with a bereaved elderly person came when I was working on a hospital ward for the elderly. One of the ladies (Mrs X) I was looking after had told me that her husband was in another hospital and she wanted to know how he was and if she could talk to him on the phone, unfortunately she had not been told how ill her husband was. A short while later we received a call to say that her husband had died. The nurse in charge told Mrs X of her husbands death and then asked me if I would sit with Mrs X. My initial thoughts were 'what shall I say to her' and 'what if I start to cry.' The nurse said 'you don't need to say much, just sit with her.'
"Listening and attending are by far the most important aspects of the counselling process. Often the best counselling is that which involves the counsellor only listening to the other person. Unfortunately, most of us feel that we are obliged to talk! Unfortunately, too, it is 'over talking' by the counsellor that is the least productive. If we can train ourselves to give our full attention to and really listen to the other person, we can do much to help them" (Burnard 1995).
I sat with Mrs X for two hours just listening to her and allowing her to cry. I kept her supplied with tissues, held her hand and reassured her that she was not silly crying. "Physical contact can provide bereaved people with considerable reassurance. Sitting close, touching, holding hands, an embrace, passing a tissue, crying together, are all simple gestures which demonstrate care and sympathy, and often do so better than any words" (Scrutton
1995). It must be remembered that despite this close contact is not accepted by everyone and the situation should be assessed for each individual. "Crying alone may be useful but it may not be as effacious as crying with someone and receiving support" (Worden 1995).
Silences can be very effective as long as they do not make anyone feel uncomfortable, we usually assume that if there is a silence we need to fill it, but in fact this may make the counselling less effective as it can interrupt thoughts.
"Using silence appropriately is a very effective way of encouraging people to open up and continue exploring their thoughts and feelings. Research has shown that during silences, speakers are typically clarifying their thoughts and going deeper into their feelings" (Hornby 1993).
Mrs X spent a lot of the time talking about her husband, firstly about his illness and how she wished she could have been with him and then about how they met and about things they had done together. I think this was more upsetting for me than for her, she seemed quite happy whilst she was remembering, it was me who was fighting back the tears. Another hard part was when Mrs X kept saying that she wanted to die too, she had no family, they chose not to have children. It was very difficult to know what to say to her at this point, I could quite appreciate that she did not want to be alone and felt that she had nothing to live for. I conveyed that I understood how she felt, I did not feel that the feelings needed to be challenged as Mrs X was not contemplating suicide, she was afraid of being alone.
When I had to leave Mrs X she thanked me for my support, I was very touched by this, as gratitude was the last thing I would have expected from someone who has just lost their husband. It made me feel that I had helped her in some way, but I was afraid that it may be the only support that she would receive and that she may suffer more in the
days that followed when the death of her husband became more real.
This experience is a good example of how listening can be helpful to bereaved people. "Listening is particularly important in the early stages of mourning. Communication with bereaved people need not involve much talking by the counsellor, as this can sometimes inhibit self expression" (Scrutton 1995). There is perhaps something to be learned from Davis who says "nature gave man two ears, but only one tongue, which is a gentle hint that he should listen more than he talks" (Davis 1972 cited in Tschudin 1995). Good listening involves many skills including;
~ Not interrupting
~ Not being judgemental
~ Being accepting
~ Not undervaluing the problem
~ Giving time to talk
~ Avoiding giving advice
~ Clarifying obscurities
~ Giving full attention
Listening is not just hearing what the person says, but observing body language, such a facial expressions, posture and gestures, these can tell us much more than words about how someone is feeling. "Listening refers to hearing what the client is saying. Hearing encompasses not only the words that are being used, but also the non-verbal aspects of the encounter" (Burnard 1992).
Grieving can last for many years and in addition to loss of a spouse elderly people may have many other losses to mourn; family, friends and even pets. "Grief is not an illness or psychological problem" (Parry 1990), but needs to be worked through to avoid problems occuring as a result. A good example of this is Mrs W an elderly lady who lives in a nursing home. Mrs W's sister died at 13 and even seventy years on Mrs W still feels the loss especially at special times of the year such as Christmas. Ten years after the death of her sister Mrs W watched her beloved grandmother die. In more recent years Mrs W nursed her mother, husband and close cousin t
hrough their final illnesses. Left without any close family Mrs W became very attached to her pet cat and was very distressed when the cat became ill and had to be put to sleep. Finally a few weeks ago Mrs W's closest friend in the nursing home died after a long illness. Although some of these bereavements happened many years ago Mrs W has never fully recovered from one before another has happened, so the grief mounts up. Mrs W's own health is now failing and she is trying to come to terms with the fact that her own death may not be far away. "Experiencing the loss of contemporaries such as spouse, friends or siblings may heighten one's personal death awareness. This increase in the awareness of personal mortality can lead to existential anxiety" (Worden 1995).
Mrs W finds great comfort in being able to reminise and I have spent long periods of time with her listening to her stories and allowing her to talk about the people that she has lost and how they died. "Literally speaking, to reminisce means to recall memories of past events (Norris 1987) This practice is discouraged by many people as they feel it makes people dwell on the past, but I feel and it has been shown that reminiscence can help people come to terms with their loses and realise what they have achieved during their life. These people do not have much of a future to look forward to, so if they find comfort in the past then it cannot be a bad thing. We all find comfort in reminiscing even when we are young.
Reminiscence involves attentive listening, it can be hard at times to show your interest, especially if you feel that you may upset the person further. I have found that asking the occasional question conveys your interest and encourages the person to continue. "The information that a helper is looking for should relate to the story and the actual problem, there is no merit in having much information which is not relevant . Prompting may be
useful in getting the right information, but prying is not theraputic" (Stewart 1992). Usually the person gets comfort from the interest rather than becoming more upset. Although the person should not be unduly distressed, the experience of being upset can be beneficial. "A major premise of grief counselling is to help clients experience pain in order to heal, rather than to avoid or deny it" (Humphrey & Zimpfer 1996). Obviously some consideration should be given to questions, but I am begining to find it quite easy to pick up on things that are said and do not have to think as much about what I say. "The skills that the helper needs are those of giving permission to talk, encouraging the continuation of the story telling being unafraid of what might emerge, and listening for that which matters and has meaning in the persons life" (Tschudin 1995). Often just a nod or saying yes is enough to show your interest.
Norris (1989) feels that there is real value in giving time to allow the elderly to reminisce in a one to one relationship. He says;
"The very existence of a one to one relationship in which the old person is provided with the opportunity to reminisce can powerfully communicate a recognition of the identity and importance of the individual" (Norris 1989).
He also says;
"A one to one situation is a highly personalised opportunity for an old person and an interested listener to develop a strong rapport and mutual trust (Norris 1989).
I felt that these statements describe very well the relationship that formed over a period of time between Mrs W and myself, she has not told anyone else how she feels or lets others see her upset. I feel that recognising the value of allowing reminiscence enables me to care for the emotional needs of residents and patients as well as their physical needs.
"Recognising reminiscence as an important part of the process of adapting to ol
d age can [also] help the carer appreciate the value of giving time and space to listen to the elderly person talking about their past (Norris 1989),
Bereavement counselling and reminiscence lend themselves very well to Rogers client centred therapy developed in the 1940's. Rogers believes "the client has the answers to most of his own problems, and can find them, given the right sort of space and time" (Brumfitt 1986). In client centred therapy the counsellor does not try to impose change upon the client and does not provide answers.
"At its heart, person-centred counselling is a way of using the relationship between the client and counsellor to facilitate the development of the client. If the counsellor is able to offer the client a relationship characterised by the 'core conditions' of empathy, acceptance and congruence, and if the client is able to perceive and appreciate these qualities, then the client will feel safe enough to begin to disclose aspects of the self that are painful, shameful and hidden" (Palmer et al 1996).
In client-centred therapy it is important to remember that life is what the client says it is like, if the counsellor does not believe this then this can minimise the significance of the clients pain. Client-centred counselling should demonstrate that the client is at the forefront of the counsellors concerns.
Rogerian therapy also puts the focus on the here and now and not on looking back or forward. This being so many would argue that reminiscence does not fit in with Rogerian thinking, but in fact it does.
"Although the content of reminiscence refers to the past the actual process of reminiscing involves a current interaction between the old person and his interested listener. Therefore the benefits of reminiscing lie in the immediate effect that it has upon the old person and his listener, rather than what is said" (Norris 1989).
Empathy is an
important but difficult skill required in counselling, it is particularly important in bereavement counselling as it means that the counsellor understands the client, by seeing things from their point of view and is not judgemental. Bolton considers empathy to be "the most important quality for enriching interpersonal communication and fostering personal growth" (Bolton 1979). Empathic understanding is the ability to;
"assume, in so far as he is able, the internal frame of reference of the client, to perceive the world as the client sees it, to perceive the client himself as he is seen by himself, to lay aside all perceptions from the external frame of reference while doing so, and to communicate something of this empathic understanding to the client" (Rogers 1951).
Empathy can be very difficult to achieve, especially as most of us have not experienced the death of someone very close, known that our own life is nearing an end or felt the loneliness experienced by the elderly. We can use our own experiences to help us empathise, for example the ending of a close relationship or death of a relative. Whilst these experiences can help us to empathise we need to make sure that our own feelings, such as anger or bitterness at the ending of a relationship are not allowed to influence the interaction.
I hope that this has demonstrated some of the need for counselling skills in those working with the elderly. The use of counselling skills could help reduce some of the tragic reactions that occur as a result of bereavement, such as confusion, depression and loss of independence. "Many become confused, and their confusion dated from the time when death was inappropriately handled by carers" (Scrutton 1989). The feelings of a bereaved person should not be ignored, they should be accepted and a listening ear should be offered. "The most valuable support in the early months of bereavement is give
n by a good listener, especially one who is not too closely involved with the family's emotional distress" (Collick 1987).
"Often just using active listening with people helps them to express feelings and examine various thoughts, which leads to them understanding their situation better and to finding solutions to their difficulties" (Homby 1993).
Reminiscence is a very helpful way of helping the bereaved to come to terms with their loss and should not be dismissed as a sign of mental illness or as something that will cause distress. Finally "whatever else we may be able to offer to those in need, one very important gift is that of time" (Speck 1978)
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