Grief

Begin Here If
  • A client has experienced the death of a loved one and is experiencing any of the following grief symptoms:
    • Trouble functioning in daily activities such as work or school.
    • Loss of interest in hunting or gathering activities.
    • Increased social isolation or withdrawing from loved ones.
    • A client has lost the presence of a loved one who is still alive, such as through a breakup or incarceration, or has lost something significant, such as a job or place to live, and is experiencing grief symptoms.
Do NOT Begin Here If
  • The person is considering suicide or talks about wanting to go be with the person who died. See Chapter D-6: Suicidal Thoughts and Plans.
  • The person is abusing substances to obtain increased energy, elevated mood, or control over psychological pain. See Chapter D-2: Substance Use and Abuse.
  • The person is in medical danger due to any of these factors.
Note: Refer to CHA/P or other medical care provider for evaluation and treatment.

Introduction

Definitions

  • Grief is deep sorrow or distress caused by any form of loss, such as death, a breakup, loss of work, or loss of a place to live. Grief encompasses a range of feelings, such as sadness, anger, and pleasant feelings about memories of the lost person or experience.
  • Bereaved means to be deeply saddened by someone’s death. Family members and close friends who have lost a loved one are often referred to as “the bereaved.”
  • Mourning is the outward expression of the loss of a loved one and involves culturally determined rituals that help make sense of the end of a loved one’s life and give structure to a period often marked by disorientation and confusion.
  • Prolonged grief is a reaction to loss that lasts more than six months and results in the person experiencing an ongoing longing for the deceased loved one. See DSM-5 for more information.
  • Complicated grief is a chronic, stronger state of constant mourning. With typical grief, symptoms gradually fade. With complicated grief (also called complex grief), the symptoms of grief linger and worsen. The feelings of loss are devastating and don’t improve even after one full year, and the bereaved person may speak as though the deceased is still alive. Complicated grief is so painful, long-lasting, and severe that the person has trouble accepting the loss and resuming her own life. Certain factors related to a person's death and the closeness of the community can increase the risk of developing complicated grief:
    • Death by suicide.
    • Sudden or unexpected death.
    • Murder or violent death.
    • Terminal illness and death of an esteemed elder.
    • Death of a child.
    • Death related to substance use.
    • Death that occurs during a period of relationship tension, conflict, or estrangment.

Grief becomes a concern if the grief-stricken person starts to believe that they cannot have a meaningful existence without the deceased loved one. At times, people who are experiencing immense grief wish they had died along with the loved one and may consider suicide.

Note: If a client is considering suicide, speak to your supervisor immediately and see Chapter D-6: Suicidal Thoughts and Plans.

Guiding Principles for a BHA/P

Grief and loss can affect people immediately as well as months or even years later. Losing a loved one is one of the most distressing yet common experiences people face. Most people experiencing normal grief and bereavement have a period of sorrow, numbness, and even guilt and anger. Gradually these feelings ease, and it's possible to accept loss and move forward.

Grieving is normal, not a sign of weakness or failure. Grief also cannot be ignored; ignoring grief can prolong the feeling of being stuck. People who are grieving need to experience and express their feelings in the way that feels right for them, which may be based on traditional and cultural teachings and/or highly individual.

Everyone grieves in a unique way. The death of a loved one can cause a wide range of feelings and behavioral reactions. Many are natural, normal, and even necessary. There is no right or wrong way to grieve.

Sometimes, grief can be overwhelming. The intensity of the emotion can cause the bereaved person to feel numb and removed from daily life. This feeling often comes in waves; it is not constant. The bereaved person may find it hard to carry on with regular duties while grieving.

Grief in small communities can be magnified. The small size of villages and the interconnectedness of people across each individual village and the state can magnify the experience of grief. With high rates of suicide in Alaskan villages as well as this sense of community-wide connection, many residents of remote Alaska experience loss and death more frequently than normal. Debriefing within the affected village after suicide and other traumatic deaths is important in helping people to deal with not only the current loss, but the frequency of death.

We live in a diverse state. Each region within Alaska, each culture, and each village has different rituals and ways to deal with death. It is important to respect the values and rituals of each community and its members.

  • If you do not work in a particular village, it is important for you to get an invitation from the Tribe or a tribal representative before going there to assist with a crisis response.
  • Talk with elders, tribal administrators, and mayors before responding to a suicide, murder, violent death, or death of a child.
  • Support individuals and families as they cope with the death by listening to and validating their feelings.

Complicated grief can affect a person physically, mentally and socially, leaving the person unable to carry out normal routines or find pleasure in life. A person experiencing complicated grief may become detached from the activities of the village/community. In addition, a person my experience an increased risk of physicalillnesses.

Take time to look at all areas of the person’s life as they explore the feelings they are experiencing.

The Kubler-Ross Model of Grieving offers a helpful way to understand the typical phases of grief. These five phases are not usually experienced in a clean succession. Instead, people may move between them over time and even experience more than one in the same day or hour. The order and timing of these phases will be unique to each person.

  • Denial. This phase is important because it helps bereaved people get through the initial pain of the loss by pacing their grief. Denial is characterized by a feeling of meaninglessness and numbness.
  • Anger. This emotion is the first step in facing and healing from the loss. Anger must be faced and accepted, not ignored, for healing to continue. Bereaved people may be angry at the person who died, people in their lives, people who were in the life of the deceased, God, or death itself.
  • Bargaining. In the stage of “if only” or “what if,” people may bargain with themselves, their memories, or God, seeking ways they could’ve prevented the loss or can bring back the person they lost.
  • Depression. This stage is not a sign of mental illness, but a healthy response to moving into the present and feeling the depth of loss. It is important not to dismiss this stage as something to be escaped or fixed, but to instead help bereaved people feel supported through it.
  • Acceptance. This stage is not the same as being fine with the loss; most people will never feel like the loss was okay. Instead, it means accepting the reality of the loss as the new, permanent normal and living accordingly by reassigning roles and making new connections.

Differences in the timing and phases of grief are normal. However, if a person is unable to move through one or more of these stages after a considerable amount of time, the person may have complicated grief. Individuals who experience complicated grief may benefit from being referred to a clinician for mental health treatment.

There are many factors that can influence how someone experiences grief, including:

  • The closeness of the relationship.
  • The length of the relationship.
  • Physical or emotional health prior to the death.
  • Previous life experiences with grief.
  • The person’s support system.
  • The culture’s approach to grief.
  • How the person died.

Children and youth may experience and express grief differently.

  • Some small children may not show the same outward signs as older family members, yet express their thoughts and feelings through drawing, coloring, or imaginative play.
  • Some children may want to talk about death, while others may simply need a safe place to cry.
  • Some youth may ask lots of questions about the death and where the person is now, and others may prefer to write about their experiences in a journal or blog.
  • Similar to adults, children and youth may have trouble sleeping, especially in the first few weeks or months after the death.
  • Teens may look to their peers for support and respond to family with irritability or anger.
  • Teens may have a lot of curiosity about the details of what happened.

Support your minor clients:

  • Acknowledge their presence, opinions, thoughts, and feelings.
  • Be patient and open-minded. Support them in discovering their own grieving process.
  • Spend time with them, listen, and answer their questions.
  • Let them know it is normal for them to have mixed feelings about the person’s death.
  • After obtaining releases of information, check in with other adults involved in their life, such as teachers, school aides, or coaches, to see if they have noticed any changes and encourage them to offer support as they are able.
For elder clients, the experience of grief can be compounded by their stage in life, which may involve:
  • Health problems.
  • Loss of independence.
  • Loss of their emotional support system, because their own elders and friends have passed and adult children may not be fully available.
  • Personal struggles with mortality.

Information You Need for This Visit

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history related to the recent loss and overall changes in behavior.

Treatment Plan, if one exists.

Signs, Symptoms, and Risk Indicators

Physical and behavioral

  • Reoccurring, unexplainable stomachaches or headaches
  • Trouble sleeping, including being scared to go to sleep
  • Changes in appetite
  • Recurring nightmares about the death and its details
  • Feeling tired all of the time
  • Desire to sleep a lot to avoid facing life without a loved one
  • Isolating from friends and/or family
  • Increased substance use following the death
  • Loss of interest in activities they usually enjoy (berry picking, hunting, bingo)
  • Increase in attention-seeking behaviors

Emotions/mood

  • Shock or denial
  • Feeling numb or helpless
  • A feeling of “going through the motions”
  • Obsessive focus on the person’s death or reminders of the deceased loved one
  • Frequent crying spells
  • Repetitive revisiting the memory of the person's death
  • Not being able to talk about the person or the death
  • Feeling guilty; saying “It was my fault” or “I could have prevented this”
  • Afraid to be alone
  • Not wanting to stay home alone
  • Worrying about when she will experience another death
  • Wanting to be dead so she can be with the person who died
  • Difficulty concentrating on work, school, or other daily activities
  • General sense of confusion or disorientation
  • Extreme sorrow for an extended period
  • Feeling like life isn’t worth living without the loved one
  • Bitterness or anger
  • Depression
  • Withdrawal and apathy
  • Anxiety
  • Alcohol or substance abuse

Risk factors for developing complicated grief

  • Death
    • An unexpected death, such as in a snow machine, ATV, boating, other unforeseen life events
    • A suicide or especially violent death
    • Suicide of a loved one
    • Death of a child
  • Relationship Concern or Changes
    • Childhood separation from parents or loved ones
    • Dependent or extremely close relationship with the deceased loved one
  • Other
    • History of depression or other mental health issues
    • General lack of flexibility or adaptability to life changes after the person's death
    • Traumatic childhood experiences, such as abuse or neglect
    • Lack of support system
  • Childhood separation from parents or loved ones

Evaluation Questions

These questions are geared towards a client who is grieving a person who died. You can adapt these questions for clients who are grieving people they have lost from their own lives for other reasons, such as long-term incarceration or divorce, or for those who are grieving the loss of an important element of their lives, such as a job or home.

General and personal concerns

  • What was your relationship to the deceased person?
  • When did the death happen?
  • Do you know how the death happened?
  • Was it expected or unexpected?
  • How have you been affected by the person’s death?
  • Have you experienced other deaths within the past year?
  • Have you had any other recent changes or major life events?
  • How often do you think about the person who died?
  • What was life like for you before the person died? How has it changed?

Emotional concerns

  • Have you experienced other deaths that occurred in a similar manner to the current death?
  • Do you have thoughts of wanting to go be with the deceased person?
  • Do you wish you were dead instead of the person you lost?
  • Do you feel like you no longer understand your role or identity?
  • Do you feel as though your future is completely different now?
  • Is it difficult to find hope?
  • Do you feel unable to show or experience joy of any kind?

Physical and behavioral concerns:

  • Have you been grieving for a long time, but have not found a “new normal” in your life to help you start feeling better?
  • Do you feel like there have been so many changes in your life since your loved one died that you will never be able to adjust?

Interventions and Referrals

Routinely review Chapter C-4: Common Treatment Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

Individual Counseling.In many cases, clients will benefit from support and validation of their emotional responses. Helping them identify and understand confusing and/or intense emotional reactions will be highly beneficial. It is also critical to normalize their reactions and to support healthy and safe coping strategies. During the initial stages of grief, it may be important to support clients’ efforts to sleep and eat regularly, take care of their physical health, and access their social supports.

If you are working with a client who has lost someone to suicide, be aware that there may be a complex set of reactions related to the sudden and traumatic nature of the loss. These reactions might include:

  • Disbelief. Sometimes, family or friends may doubt or deny that their loved one’s death was truly a suicide.
  • Asking “why?”
  • Shame, which is often related to the stigma that surrounds suicide in some communities.
  • Blame, which may focus on people, events or circumstances that are believed to have contributed to the suicide.
  • Guilt
  • Abandonment or rejection related to the perception that the deceased individual “chose” death over continuing to be with their loved ones.
  • Anger
  • Fear that others are at risk of dying by suicide.
  • It is also important to understand that individuals who have lost a loved one to suicide may be at higher risk of suicide themselves. If you are concerned about the safety of any person you are working with, consult your supervisor immediately and reference Suicidal Thoughts and Plans.

In addition to supportive counseling, there are specific treatment strategies shown to be effective for grief. For people experiencing complicated grief, Cognitive Behavioral Therapy (CBT) has the largest evidence base for positive clinical outcomes. This is an approach that you should only utilize with appropriate training; consult with you supervisor regarding the appropriateness of using CBT prior to initiating the treatment. A supplement to CBT that can also be helpful is creative expression, such as writing, storytelling, and drawing. These activities can be utilized at many developmental stages to help grieving clients process and express their emotional experience.

Note: Although creative expression is a helpful tool to process grief, seek consultation and guidance with your clinical supervisor regarding this intervention. Also, unless you have specific training or supervision in play or art therapy, avoid offering interpretations or insights based on the client's work.

Community Intervention for Grief. As a BHA, you may be asked to provide community-level support following a traumatic loss (for example, the death of an elder, the death of a child, or unexpected death due to violence or suicide). As stated above, it is important to insure that these interventions are:

  • requested by the tribe and/or other community entities.
  • respectful of the community’s grieving traditions.
  • available to first responders, like health aides and/or the search & rescue team.
    Note: Recognize that while BHAs may be asked to provide support to first responders and called on to support the deceased's immediate family, BHAs are also first responders. BHAs are encouraged to ask for support when they need it and to practice daily self-care.
  • Suicide Postvention Services. At times, BHAs are asked to provide postvention services for a community following the suicide of a community member. Suicide Postvention services include a range of activities meant to assist the bereaved, first responders, and larger community after a suicide. The goals of suicide postvention are:
    • To help individuals heal (see above section on individual counseling)
    • To facilitate community conversations about safety and healing
    • To reduce the negative impact of suicide exposure
    • To prevent suicides among people at higher risk after exposure to a suicide

National guidelines for suicide postvention services were published in 2015, and these may be helpful to you if you are called upon to work with individuals or communities in the aftermath of a suicide. When participating in a suicide postvention response at the community level:

  • In group and/or community level discussions, help people to avoid specific descriptions of the details of a recent suicide (for example, how it was carried out, what the scene looked like, etc). At an individual level, family members or first responders may need to talk about these details—but sharing these details more widely in the community may put others at risk of additional traumatization.
  • In group settings, watch for people who may be experiencing particularly intense reactions, and make arrangements to provide individual support for them. This could include an offer for individual counseling, an offer of other resources, or talking with their loved ones about monitoring their safety.
  • Importantly, a community response following a suicide should be carefully planned and coordinated with community agencies. If you are asked to participate in a suicide postvention response, work closely with your supervisor and colleagues to design and implement an approach that meets the unique needs of the community.
  • Suicide postvention work is emotionally challenging, especially if you have your own history of losing a loved one to suicide. If you are asked to participate in a community suicide postvention response, work as part of a team, talk about your own reactions with your team, and practice good self-care.

Reporting and Documentation

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. In cases of grief, precise documentation is recommended. Report instances of the following, consistent with your organization's policies and procedures:

  • Child abuse or neglect.
  • Suicidal thoughts or plans.
  • Intentions to cause harm or injury to the self or others.