Loss and Grief in Social Work - Case Study Example

Loss and Grief in Social Work In the famous book, ‘A Grief Observed’ written by C. S. Lewis, as he was bereaving the loss of his beloved wife quoted,“No one ever told me that grief felt so like fear” (Lewis, 1961) Grief is often associated with death of a loved one. However, the author believes that loss is not the only event in life that triggers grief. Climacteric events like illness, divorce and redundancy can also stimulate similar reactions. In this paper, the author attempts to understand grief through a life-changing accident that affects a care giver. The case is reviewed from the viewpoint of different authors and its intricacies analyzed, even while an intervention methodology is developed to be administered through the counselling process. The Beginning It was a warm Saturday afternoon when Mrs. Abraham1 first walked into my office. She had been running late on her appointment and seemed quite haggard. I assumed from her orderly manners and constant apologies that she was not someone who enjoyed being late. Despite her evident tiredness, she smiled brightly at me as she entered my office and sat herself demurely on the sofa. She had been recommended to me by a close friend who had known her family for ages. Having come to America 20 years ago; Mrs. Abraham and her husband made up the ideal migrant family. They worked hard, stayed out of trouble, had strong socio-cultural ties and ensured that their two children got the best education their joint incomes could provide. Psychoanalyst, John Bowlby’s evolutionary theory of attachment hypothesised that attachment behaviours are intuitive. He explained how children were born with a tendency to demonstrate certain inherent behaviour traits (example, crying, crawling, smiling, etc.) which helped ensure propinquity with its mother (mother figure). Such social releasing behaviours would in the long term help create a reciprocal relationship which would act as a model for future social relationships. Any separation from this relationship would universally result in grief. This grief he observed could manifest itself either through physical symptoms like, tightness in the chest, loss of appetite, shortness of breath, restlessness, lack of concentration and insomnia or through feelings of loneliness and isolation, combined with feelings of anger, fear and guilt (Patricia & Nancy, 2008). Nature of the Problem Mrs. Abraham had lived a perfect life till about 2 months ago. Both her husband and she had steady jobs and earned comfortable incomes. Her son, Dex (20 years) had recently been accepted at the Department of Computer Science in the University of Texas at Austin. Her daughter, Kiara (15 years) was still in school and was an A-grade student. It was this world; Mrs. Abraham stated that the accident destroyed. Dex had gone out with his friends for a night out, enjoying his last few days before he was to leave for college, when his bike was hit by a drunk driver. He had stopped his bike at a red light crossing and was waiting for the light to turn green, when an over speeding car hit him from the back and sent him flying 70 feet across to the sidewalk. His cervical spine hit the sidewalk with such force that his C3 was completely shattered, leaving him quadriplegic. For Mrs. Abraham to see her grown son lie still in bed with tubes attached to every part of his body and doctors claiming that he would never be able to walk again had been too much to handle. However, she kept her pain to herself and waited on her son for 2 long months as he recovered in the hospital. But, constant worries about her son’s future, the overlying depression at home and instant dip in family savings had left her anxious. Whenever she had tried to discuss this with her husband, he had resolutely refused to discuss the future and wished that they live each day as it came. This she observed left her short tempered and irritated. She also complained of constant sweating, shortness of breath, headaches and insomnia. Pauline Boss in her article ‘Ambiguous Loss: Living with Frozen Grief’ explains, “...not knowing whether a loved person is absent or present, dead or alive...is the most difficult kind of loss to resolve...the certainty we hunger for in human relationships is most poignantly unachievable when a person we care about is neither clearly absent nor clearly present in our lives.” (Lauren & Moira , 2007). Such a loss has been described by her as ambiguous loss In the above case study too we can see the clear manifestation of such a loss. Here Dex’s condition as a quadriplegic result in unresolved grief, since his presence in the family with respect to his roles and identity is now missing. Though he may be physically present in the family environment, his unexpected and catastrophic psychological distancing would leave the family anxious and depressed. What is most frustrating of such an experience is the uncertainty of whether such a situation is temporary or permanent. The capricious nature of ambiguous loss takes away from the care givers validation and supports that would have been extended to them, had they suffered from an ordinary loss. Grief according to William J Worden is the pain which we associate with any loss. He looked at grief as a process rather than a state. Comparing grief to the healing process, he looked at it as a mechanism which brought back balance into life (Worden, 1991) However, if the loss sustained by a care giver is not recognized by society as a loss, it would not provide the care giver with mechanisms to withstand the resultant grief. This is what Doka & Davidson describe as disenfranchised grief (DeSpelder,1998). Mrs. Abraham may find her grief for Dex’s quadriplegic state, disenfranchised. Society labels her loss socially insignificant and unnecessary to grieve. Such a state sans social support mechanisms can often leave an individual with episodic pangs of anxiety and feelings of panic. This was clearly visible in the state of Mrs. Abraham. As observed by Baum Mourning “requires legitimization, validation, and presence...grieving can occur and progress only in contact with others” (Baum, 2003). Interview with Mrs. Abraham Mrs. Abraham sat at the edge of the sofa leaning towards me. Her bright smile did not reach her tired eyes and her constant fidgeting with the bag was a reminder of her unease. She began by talking about her family and of how happy they once were. She described naughty instances from Dex’s childhood and seemed very proud of her son. An incident of how her son once took apart the ironing machine with a screw driver and then did not know how to put it back together again, left her teary-eyed. Kiara’s fascination with the mirror was another thing she repeated at two different occasions. She then described her son’s accident in detail and of all that transpired on that day. Her anxiety over her son’s life, her pain at seeing him paralysed, her inability to control her emotions were all replayed in great detail. Over the course of the next few interviews, each of her grieves was listed out and listened to patiently. She first talked about her anxiety for her son’s future. She described how while she had been waiting on her son in the hospital, one day she saw a fly sitting across Dex’s face. He was irritated by its presence but however much he shook his head, the fly refused to budge. At this point she broke into tears and said that she felt helpless to know that the son she had raised for 20 years was now unable to swat a fly off his own face. “I am revolted by the sight of that wheelchair in my house”, she said. To think of her son as a bed ridden, infirm man was just not acceptable to her. How would he provide for himself now? What about his shattered dreams and aspirations? Who would marry him? How could he now support them in their old age? These questions plagued her mind. She also spoke about her distancing relationship with her husband. Post the accident, Mr. Abraham had lost himself in work. He would regularly take leave from work whenever the necessity arose but apart from that refused to discuss with her anything regarding their son or the accident. “It’s almost as if, it (the accident) hasn’t happened for him”, she said. She also noted that while her husband had been an occasional drinker earlier, his drinking patterns had increased of late. Though he never got drunk, she now saw him more often with a glass whiskey in hand, especially in the evenings. He wasn’t abusive but his callousness drove her up the wall, she said. During a few interviews she also raised doubts about her deteriorating financial situation. Their family which had once lived comfortably had now exhausted all their savings. The medical expenses had cost a fortune leaving Mrs. Abraham scared of how they could survive the future. Kiara’s education, Dex’s further medical expenses, increased household expenses had all to be accounted for in the face of her resignation so as to look after Dex at home. This constant worrying she said had been affecting her. Every day when she stood next to Dex’s bed to feed him, to bathe him or to just simply turn him over, she could now feel anger rising. Nowadays, she felt, she needed very short triggers to lose her temper. She also complained of constant sweating, shortness of breath, headaches and insomnia. Upon the social worker’s advice she visited a doctor who concluded she had Anxiety Attack Disorder. She has now been prescribed medication for the same. Sigmund Freud’s paper on ‘Mourning and Melancholia’ (1917) was the first methodical study on loss. He perceived grief as the cognitive process through which loss was dissolved. His study focussed on ‘melancholia’ and described its features as “...a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love, inhibition of all activity, and a lowering of the self-regarding feelings to a degree that finds utterance in self-reproaches and self-revilings, and culminates in a delusional expectation of punishment (Freud, 1917)” According to Freud, for a person to recover from loss, loving memories of the lost person need to be converted into futureless memories in the eyes of the mourner. That is to say, s/he would need to take out energy from the lost person and put it into another person (Miles & Demi, 1994) However, the definitive end that Freud intends to put for grief by reinvestment of energy from one person to another is impossible to achieve in the case of Mrs. Abraham because the loss of her son is ambiguous, progressive and ceaseless. The care giving that she administers to her son daily puts her in the way of chronic sorrow. Her non-linear, prolonged and complicated grief coupled with low physical and mental health status and an anxious attachment push her further into disillusion. Thus, putting Freud’s theory to work in this case would be of absolutely no use. Patricia B (2009) states five levels of losses, which are particularly handy in understanding loss situations as a whole 1. The primary level of loss – Such a loss is very evident and generally dominates people’s perception of a loss situation. For example, Dex’s accident which results in paralysis from his shoulder down. 2. The secondary level of loss – These are derivative or concrete losses that follow directly from and usually after the primary loss. For example, loss of financial savings to cover the hospital bills following the accident. 3. The holistic level of loss – These are abstract losses and are connected to primary and secondary losses, such as loss of dreams, future, status and security. For example, loss of Dex’s aspirations of becoming a computer engineer and all other future dreams his family held for him (marriage, income to support family, etc). 4. The self-conceptual level of loss – According to Weenolsen, a primary loss can lead to changes in how one perceives oneself, here the concept of self could get lost. For example, post the accident Mrs. Abraham had to let go of her job to take care of her son fulltime. Due to various psycho-social reasons there was also a marked change in her behaviour. All this coupled with her distancing from her husband could result in low self-esteem leading to further deterioration in her psycho-socio status. 5. The metaphorical level of loss – A significant loss can lead a person to question his values, beliefs and other philosophical views. For example, the accident may challenge Mrs. Abraham’s assumptions that children outlive their parents. She may have always believed that parents are able to protect their children from harm or that in her old age Dex would take care of her and her husband, however, this may no longer hold true. If we look at these losses carefully we will be able to understand more clearly why Mrs. Abraham was affected so deeply. Awareness of their grief could help the social worker make sense of their responses and address all levels of their loss (Pamela, 2002) William J Worden built his work on Freud’s theory of mourning and the attachment theory given by Bowlby. His book, ‘Grief Counselling and Grief Therapy’ published in 1991 gave a clear distinction between grief counselling and grief therapy. He believed grief counselling was about helping people transform, uncomplicated or normal grief to tasks of grieving in a moderately fair time frame. However, grief therapy is applied in situations where a complicated reaction to grief is personified through prolonged grief, masked behavioural or somatic symptom and/or exaggerated response to grief. Grief theory, according to Worden, utilized specific techniques that helped people with abnormal or complicated grief reactions to resolve the conflicts of separation (Worden, 1991) Since, Worden’s work does not address only linear grieves, it is his ‘Tasks of Mourning’ that is widely used today in counselling processes around the world to address bereavement. The framework he provides to address grief are: 1. to accept the reality of the loss 2. to work through the pain of grief 3. to adjust to an environment where the deceased is missing 4. to emotionally relocate the deceased and move on with life (Worden, 1991) Though these tasks are related to grief following death, counsellors or therapists personalize and use them in varying degrees within the therapeutic process for different kinds of grief. Prigerson & Jacobs (2001), in their Yale Bereavement Study of 233 bereaved individuals, living in Connecticut found that acceptance was the most common feeling among the bereaved and it came early in the grieving process. Another surprising element that the study revealed was that the main negative feeling attached to loss wasnt sadness or anger but yearning. Though, the study excluded people with complicated grief disorders and those who had lost their loved ones to unnatural causes, it still broke ground by shattering the age old myths surrounding traditional grief theories. If we look at the interviews with Mrs. Abraham we can note threads of similar yearnings. A yearning to return back to the normalcy she once enjoyed, the yearning for a wholesome child, the yearning for a life of financial security are all expressed in her thoughts. Applying Grief Therapy While working on therapy with Mrs. Abraham it was essential to explain to her that the counselling process was not intended to sever bonds with her grief; grief was not some electronic switch that could be pressed on and off at convenience. The effort here was to integrate the ambiguous loss of her son as a part of her life and to continue the bonds of attachment. During the initial few sessions, she was allowed to vent her denial, anger and depression after which her losses were broke down and its multifaceted nature revealed. Her physical losses like the loss of savings and symbolic losses like the loss of her son’s aspirations were revealed as an ongoing process. She was asked to recognize, investigate and find meaning in her losses, only then could she truly be one with her loss. This process helped her to accept the new world that had replaced her earlier one. Dex’s accident had shaped into her feelings of powerlessness. Her assumptions that children outlive their parents, parents are able to protect their children from harm and that Dex would take care of her and her husband in their old age, were all shattered. Mrs. Abraham used words in her interview sessions to reflect and find a new meaning for Dex’s role in her life. She began accepting the reality that it could be possible that her son would never stand on his two feet again, the fact that hospitals would be a regular feature in her life now and that a wheelchair was an essential requirement and she had to get used to seeing it. With this acceptance the social worker worked on reconstructing her belief system, thus making her less afraid of the unknown future. The financial situation which was a huge cause of worry for her was discussed. The social worker helped her realize that though she may have quit her job to look after her son, there were a lot of small businesses or online works that she could take up to earn money while sitting at home. The social worker based on her assessment found that Mrs. Abraham had excellent writing skills; she then connected her to online websites where she could earn money for content writing. The financial loss due to hospital bills now became a part of her of life since she was able to counter earn and manage them. Another important aspect of Mrs. Abraham’s life was the disenfranchised grief. She always felt that her husband and society at large did not approve of her grieving for her son. The fact that she could not share her grief openly left her irritated and short tempered. The social worker to counter this issue asked Mr. Abraham to accompany her to therapy. During the session, Mr. Abraham at first maintained a stoic silence and listened to his wife’s accusations, when she had finished he quietly took her hand, kissed it and said, “I’m sorry”. He explained to her how though he had been in considerable pain; he had found it difficult to talk to anyone about his son’s loss. It was for this reason that he had begun to work late hours. Increased use of alcohol was another attempt at releasing his pent up pain. The social worker explained to Mr. Abraham that unless he acknowledged his grief and began working on it, it would lead him nowhere. She recommended that they both attend group therapy with parents of quadriplegic children. The therapy sessions were once every Saturday and she believed that conversations with other parents suffering the same loss may give them the support and reassurance they need. It was also recommended that Mrs. Abraham, her husband and daughter attend the Supportive Family Training for Quadriplegic patients to help them understand how to care for Dex. This would ensure that the burden of caring would ease from the shoulders of Mrs. Abraham alone and would become a collective family responsibility. In social work counselling though we may work with clients using grief therapies, our dependence on therapies is limited enough to accommodate the strengthens, capacities and diversity of response that people adopt when they are faced with grief. Values and ethics governing social work place immense importance on self-determination, empowerment, inherent dignity and commitment to client experience and meaning, thus, putting clients before theories. References Baum, N. (2003). The male way of mourning divorce: When, what and how. Clinical Social Work Journal, Vol 31, No.1, p. 37-50 DeSpelder, L. (1998). Developing cultural competency. In K.J. Doka & J.D. Davidson (Eds.), Living with grief: Who we are. How we grieve (pp. 97-106). Washington D.C.: Hospice Foundation of America. Freud, S. (1917). Mourning and Melancholia. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works, 237-258 Lauren J B & Moira O (2007) The Fundamental Paradox In The Grief Literature: A Critical Reflection, OMEGA, Vol. 55 , No.3, 199-218 Lewis, C.S (1961) A Grief Observed, New York: Harper & Row Miles M S& Demi A S (1994), Historical andcontemporary theories of grief. 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