Colin Parkes - Grieveing and Mourning: The Psychology of Bereavement

the first speaker of the day will be um dr colin murray parks who is so i think this country can claim uh to have much the best care for the dying and for the bereaved of any in the developed world and that is the result of work done by a handful of people um in the especially in 60s 70s 80s and up to the present day who've really reshaped these fields uh one of whom is colin murray parks he is the director of the life president of cruise bereavement uh officer of the british empire medical doctor a flight lieutenant of the royal air force as we discovered recently and uh also my grandfather as it happens so uh with that sidelight just like to uh hand over the floor to here thank you sam that uh i must say it's a great privilege to share the platform with such distinguished colleagues and i'm grateful to the universities of oxford cambridge and warsaw for hosting this important meeting i remember feeling very anxious when i first knocked on the door of a newly bereaved widow i said this picture is not of her uh i wanted her to ask me to help me with my research into the psychology of bereavement i was afraid she would either angrily slam the door in my face or burst into tears in either case i would have done more harm than good what i discovered was that once i convinced her that i wasn't carrying out bogus research or trying to snare her into a particular psychological or religious trap of some kind that she was only too pleased to share with me thoughts about um about the most important thing that had happened in her life which was occupying her mind and i she did cry in the course of the next few hours while we were talking there were several points where she broke down and immediately apologized i said it was most natural thing in the world to cry about when someone you love dies it was more of a tribute to them than a reason to feel embarrassed and when eventually we'd finished our interviewing as i was leaving the house she said i think it's wonderful what you're doing and that was such an unexpected response because i felt so grateful to you for sharing so much with me and i realized then that she was on the same quest as i was we were both trying to make sense of the most painful and shattering experience in her life and she was glad to find someone with whom she could share that confusion and in the hope that we could somehow begin to make sense of it and that was a response that i found again and again among the bereaved people whom i interviewed in the course of the next few years i've gradually become much less self-conscious about about talking about death and bereavement and it's it's it although like a lot of taboo subjects once you break the turbo once you show uh a reminder for instance of one patient who was dying at some christmas hospice and she said it's strange thing is it it's safe to die here the thing that made it safe to die was the fact you could actually talk about it you could actually share with others uh the experience good or bad whatever and that turning point in her life was the most important opportunity for her to share thoughts and feelings many of these people said you know you're the first person i've been able to talk to like this and they discovered that they couldn't speak to their families for fear of upsetting each other they were all bereaved uh they couldn't they didn't want to burden their friends because they felt that they might lose all their friends if they kept crying on their shoulders there was this feeling the laugh and the world loves with you weep and you weep alone and it's that kind of thing that makes people reluctant to share at a time when they desperately need to share having somebody it doesn't have to be a researcher it can be anyone who respects that person is prepared to listen can perhaps give them permission to do exactly what i was doing i've dealt on this dilemma because it illustrates one of the most important and challenging aspects of bereavement the emotional turmoil the fact that particularly a bereavement which is um people are unprepared for either because it's sudden and unexpected or because although it should have been expected somehow people have avoided facing up to it and either of these things leaves people in an emotional turmoil recent research by by strobe and and school at the university of utrecht has been focusing on two different process psychological processes which both seem to be part of the process of grieving um they call it the dual process model they point out that particularly in the early days of bereavement people tend to oscillate between the pangs of grief intense feelings of pining and yearning for the lost person um one of the most painful and intense emotions that any of us can feel um but people don't grieve all the time even even the most profound bereavement becomes the time when the tears die down and when you have to get on with the business of or arranging funerals looking after the kids doing things which gradually mean facing up to what turns out to be a very different world and it's that different world which is part of the problem so um the loss orientation when you're in a sense looking back yearning and panning for a lost person as is on the one hand and that's oscillating with episodes of a less passionate sort of struggle but nevertheless quite an important one in revising one's assumptions about the world i'm going to say a bit more about both of these because i think it's very important get to us to get clear what we mean by these two different orientations two different ways of thinking it's not that they're in competition except that it's in a way they are incompetent there's a sense in which when you're looking back and pining you can't be looking after the kids uh there is a sense that this oscillation nobody can manage two enormous tasks at the same time and what tends to happen is people oscillate back and forth between them problems arise if people get stuck in one or the other and i'll say more about this later um let's just move forward uh here we are these are the oscillations i'm going to start off by talking a bit more about the loss orientation in this picture we can see four different faces of grief this was taken at the funeral following the omar bomb which as you probably remember was one of the most uh horrific uh bombs during the course of the troubles in northern ireland and 38 people were killed outright and many more many more than that were seriously injured and the day afterwards the whole community was feeling pretty shattered as you can see in his book the expression of the emotions in man and animals which is by charles darwin written in 1873 a year after the descent of man um it's interesting that this is one of his books it is very little quoted and yet i think it's very important he talks about the grief muscles as he calls them which produce the distinctive expression of the pang of grief as we can see the lady on the left here perhaps shows it most clearly furrowing of the brows uh drawing down of the corners of the mouth um nobody seeing that expression would be in any doubt that this was someone in in great distress um the other two ladies are also showing signs of distress not perhaps quite the same uh it's the only the guy who's showing a a very stiff upper lip if you like and that in itself is interesting because it says something about the cultural factors between men and women that perhaps make it difficult for men to show feelings in quite the same way as women we'll come back to talk more about this darwin suggested that the expression of grief is a muted form of the expression that we see in young children and infants when frightened or separated from their mothers from any length of time i like showing pictures of my grandchildren this isn't sam uh this is dylan i i've got one of sam which i used to use but that's in black and white but i thought the important thing about here is the color because what's what dylan is doing is expelling air through a closed larynx when he does this he makes a very loud noise which is amplified by the loudspeaker of his mouth very effective at the same time this expelling air through a closed larynx produces a sharp rise in jugular venous pressure which makes him red in the face and he's screwing up his eyes in order to counteract that pressure if he didn't he would get hemorrhages into his conjunctivity um i'm not saying this is a sign of intelligence in all my grandchildren uh this is instinctive behavior affair if there is any such thing you don't have to teach a child to do this having said that right from the outset you know all forms of instinctive behavior are modified by learning pretty soon after they begin to exhibit themselves so before very long almost the first thing a mother says it says to a child is don't cry and we're trying to flag them down and gradually teaching them to uh not to be quite so outspoken as as dylan is here but again you can look back here again you can see the similarities even little clenched fists um in this occasion that's my arm around round dylan uh i picked him up because he was making such a noise but i picked him up and the and the noise got louder and he was hammering away with his fists barbie noticed this that uh when the mother goes to pick up the child it doesn't immediately have any effect you know the first you have to put up with that noise for a while and he suggests that in terms of genetic survival the child who punishes mother for going away and deserting him is less likely to do it again and it is obviously you know you one could see why in the environment of evolution when there were real dangers around for children even newborn babies perhaps especially newborn babies because they're very vulnerable but um a baby that can actually call for help and get help sooner than the next baby has a better chance of surviving or did not perhaps quite so much today um let me see crying isn't the only behavior that has survival value before long babies in the first year or two of life are beginning to search if they're looking for mother their eyes will scan the room and as they get grow more as their motor development develops they are moving likely to crawl towards wherever they expect her to be so searching seems to be again a natural thing which perhaps increases the chances of the baby finding the mother by the time we reach adult life we know that deaths irreversible and crying aloud won't get back the person we've lost it's not only irrational it's socially embarrassing and yet i found time and again newly bereaved people have a powerful impulse to do just that to cry aloud to search one woman said dwight where are you and francis beck in her diary of a widow right sir another sorry that was francis beck in my own study i found measures i was trying to measure the amount of crying preoccupation with thoughts of the dead person and memories of the dead person all correlated together the more grief-stricken they were the more these three things crying searching uh came together um preoccupation in short very people carried in their heads a clear picture of the spouse they moved recently around places associated with him or her they found it difficult to pay attention to other tasks some of them one of them said i walk around searching for him or i'm just searching for nothing not in a way you know this is illogical but you still feel impelled to do it it's as if i'm drawn towards him and i'm quoting various brief people who i've interviewed six of the widows whom i interviewed had been to spiritualist meetings in the hope of meeting the dead person and several of them had received messages that seemed to confirm their hopes in recent years it's been possible for the first time and this is i think actually going to prove the most important development for the first time we can actually see what's going on in the brain while people are thinking the functional magnetic resonance imagery it's called fmri scanning traces temperature changes in the brain caused by neurons firing which show the exact place in the brain that's in use at any given moment we still have a way to go to understand all the complex changes that follow bereavement but i'll give you an example from a recent study that shows that when people with prolonged grief are shown pictures of the the lost person um their reward center the perhaps the most important one of the most important parts of our brains the nucleus accumbens as it's called let's have a picture of it please oh god here we go um round in the full brain here um is an area that is sometimes called the pleasure pleasure area it seems to be something to do with goals when you're searching for something and you think you've found it that bit lights up it happens with drug addicts if they're missing their drug and you show them a picture of a syringe or of the medication the things that they use which they're searching for the nucleus the comebacks lights up if a mother's separated from her child again the nucleus incumbents will will light up um it seems for a moment as if you've found what you're looking for having said that the nuclear circumstances immediately attached very quickly by uh neurons going to the prefrontal area which is where the whole thing's analyzed and another message goes back to the nucleus to come and says it's only a photograph and almost as soon as you thought it you've got another thought saying no it's not them it's not what you're looking for so for many people although some of them do get uh are aware that for a moment they think they've found what they're looking for most of the time they've done no it's more painful because they think they found it in the habit if you follow me so the uh the pleasure is immediately cancelled out by the opposite if you follow me i'm i'm gone into this in some detail because i think it really confirms what i've been saying about the way we're instinctively driven to do some something which however illogical um drive it's sometimes referred to by psychologists as having a mental set for something your brain is set to perceive that lost person even though you know that it's a waste of time and you don't want to do it in other words this is an unconscious it's it's it's a taking part automatically in a part of your brain which is is outside immediate conscious control but nevertheless providing the feedback from other parts of your brain which which in a sense cancel out what you've just been perceiving now i wanted to go on to talk a bit about love grief is the price of love you can't have love without grief and grief without love love uh grief implies that there's somebody or something to which you're attached and john bolby is uh one of my mentors whom i uh worked with at the tavistock clinic for 13 years and then remained in close touch with him during the rest of his life so i had a great deal to do with john and it was great privilege working with him at a time when the studies of attachment were going on at the tavistock clinic and in the institute of human relations which is a research or was the research arm of the tabby crying and searching as soon as the infant is able are two of the ways by which small children regain contract contact with their parents when separated and john added clinging smiling and following as ways of maintaining proximity and he referred to these attachment behaviors crying searching following smiling babbling clinging all of these things are emerging in the course of that first year of life by the end of the first year of life uh once and i i haven't time to go into it show you a lot of pictures of these but you get the idea of a repertoire if you like of behaviors which tend to maintain the attachment between parents and children these are the behavior of the child but the parents themselves are also responding at a very deep level to this attachment to the child and affected by these things um let's go back for a moment to uh and i want to talk now a bit more about the restoration orientation if i can there we go um we all perhaps one of our most important possessions is this is an assumptive world the assumptive world is the world that we assume to exist on the basis of our knowledge of the world or our experience of the world up to this moment in time uh john belby referred to it as a a world model it's a model of the world i like to i i prefer the term assumptive world because it rather brings home repeatedly the the recognition that our view of the world is an assumptive words the world we assume to be true each of us has a different assumption of the world because our experience of life is different i mean i know things like tables and chairs and doors and windows we all share these but an awful lot of things that we don't share particularly things about value about the kind of people we are the kind of people others are 101 different assumptions which we assume to be true and you could say if you like that some of our most basic assumptions i believe many of our beliefs held most profoundly but perhaps with great variation from one person to another and without the same underpinning of a constant feedback that says yes this is the real world you're experiencing i want to make a distinction between the assumptive world and the real world i'm not saying everything in the assumptive world is is not real but i think we need to be a in there's a great danger that we assume that just because it's true or but that's because we think it's true it must be you follow me i'm sorry to be i'm not talking very articulately at this moment but it's a difficult thing one needs to be constantly bearing in mind the difference between the assumptions we make about the world and the real world which we infer as a result from those assumptions so um we share this to some extent with others especially those we love if you've ever noticed i i've certainly noticed this with my three daughters they were always in i went through a period when they were always in love there'd be somebody they were they would when they fell in love they wouldn't talk or think about anything else and they've had this wonderful experience of life as a sort of um expanding world they oh we went to that concert i never realized about how what how good beethoven was until we went to that concert together you know the feeling was that this wasn't a wonderful experience as one's view of the world was being shared with someone else they not only listened to each other but they were also listening to each other and they had this uh growth experience which i'm afraid they assumed would go on forever you know before very long another six months had passed and i was saying you know he or she takes me for granted and i happen to think that taking each other for granted is one of the good things about these lasting relationships because you don't have to be constantly checking everything out it may be less exciting less mind expanding but it is how you build a share of assumptions together when one or other of you dies quite suddenly you feel as if you lost every good thing that came with that person the truth is you haven't but for a while that's not the way it feels that awful feeling of people use the word through it was like my world's been turned upside down nothing makes sense anymore my life has lost its meaning habits of thought and behavior that have gone on for years suddenly come to an end what happens when i get up in the morning what happens when i get home from work in the evening 101 things that you've in a sense based your life on suddenly don't make sense and this sense of chaos this sense of of uh the familial world suddenly becoming unfamiliar um in a sense the assumptive world is now being undermined and this experience of disillusionment is not confined to bereavement it occurs whenever there's a major change in one's assumptions even something as good as winning the pools quite suddenly your life's been turned upside down having your first baby or losing a job 101 different things on the whole the ones we don't want to happen actually more difficult to cope with the ones we do want to happen as you might expect most people when they win the pool pretty pleased about it and that gets them through the difficulty of learning how much change there is in your life we don't look forward to the things we don't look forward to when you think about it most women marry men older than themselves and most uh men die before their wives as a result most women most married women are going to be one ago one day going to be widows i hardly even like to say this for most of our major changes in life we have all sorts of ways of preparing ourselves we go to school we we we when we we're taking educational programs like the one we're in today um and yet there are no schools for widows why not well if you start thinking that that i think part of the problem is that a plan you know if my husband's dies then i can do such and such it's so close to being a wish and death wishes are dangerous if you wish someone dead and they then die you're left with an enormous feeling of guilt that somehow your wish has come true and there therefore you're not allowed to benefit from it one can see why there wouldn't really be a very effective way of of um starting schools for widows it wouldn't take very many many people having said that i do think that being aware of this fact is something which does actually affect the way people behave to some extent for instance i hesitate to say this for in front of my wife but she's i know she spends a lot more time with her her peer group her lady friends and she used to at one time and i think part of that is perhaps an awareness that she might need them before long i i don't know that's just guesswork and i i think i better shut up about this um where am i going yes just a few examples i did some work on with amputees people who lost an arm or leg and a lot of them said the same thing they would say it's a kind of grief and there were 12 of them who'd actually suffered a major very loss of a person before their amputation and they all said oh it was just like when my husband died and yet you don't actually grieve for your left leg in quite the same way that you grieve for your husband uh it's not that you're in love with your leg there is a sense in which the big difference is that that it's the um restoration orientation bit of it that is what you're faced with learning to a new way of viewing the world new ways of walking new ways of uh i remember one man people hate these changes they'll try their very hardest to pretend that things are going to be just nothing has to change i remember one man he'd he was a roof tyler after he had his leg amputated he left he was one of those heroes of the ward you know while he was in hospital he was cantering around the ward on on his temporary prosthesis and everyone was saying how well he was getting on a month after leaving hospital he fell off a roof and broke the other leg and was back in the ward i'm laughing but it wasn't funny for him but this is it took it took that to persuade him that it wasn't really very sensible to go back to tiling roofs um and there are many examples i could give i don't want to spend more time on this than i have to but it's just a way in which it brings home the fact that we all have these assumptio assumptive worlds they're difficult to change because they're all we've got you know you have somehow to rethink something maybe the person who has died is the person you would normally have turned to for help and you're almost instinctively turning for help for someone who's not there if you follow me habits of thought and behavior again and again um okay i think i'm i'm catching up with myself now problems arise as you might guess when we're unprepared oh yes let's go through the rest of this i talked about amputations attachment to god and god's representatives very important for many people we personalize god and any threat to god or anything perceived as a threat to god is very very dangerous it feels very very dangerous um homes territories all of these things which we take for granted you lose your home it's incredibly difficult to to move from one territory one place where perhaps you've been for many many years you've got to know everybody etc your network of not just people but places which you take for granted anything you take for granted it has to be relearned and it's not easy to move from one place to another or from one country to another if you have to change languages and things like that it's enormously difficult takes a long time and particularly if it's something that was forced upon you and was not adequately prepared for um it's not surprising that it's a source of grief people um are often surprised how disabled they feel it's not just the people with physical mutilations but uh i remember one um bereaved one widow said you know i was in the bank the other day and there was this girl she'd lost a limb and i suddenly realized that she was going through the same sort of process of learning that i have i am now that my husband's dead this need to move into a new world um makes you feel weak and helpless traumatic losses sudden unexpected deaths are the ones that are most likely to cause these problems or disasters where you're losing not just one thing but a whole host of things all at once are particularly difficult to cope with so um major changes sudden unexpected for which were unprepared shutter many assumption my world's turned upside down life has lost its meaning and a feeling of disorientation after a traumatic bereavement we feel as if we've lost every good thing that came with the lost person goodness and value gone from the world but in truth we have not there is a continuing bond to the lost person who in a sense when people say he or she lives on in my memory that's actually true in many many of the reminded places that remind us of a lost person are something that we can actually treasure and once you're beginning to get your head rather i just it was exempt exemplified in one lady rather clearly she said well you know when my when my husband died that was his favorite chair and i can't find my eyes going back to that chair i'd be talking to one of my friends i keep glancing towards the chair hoping to involve him in the conversation and realizing each time i did it another pang of grief she'd be watching television i kept going back to the chair said but i solved all that i said yes how do you do that i went to sat in the chair myself and she said when i'm sitting in the chair i get that feeling that he's inside me and this was i think if you like i guess doubt um a a a a sort of almost a dramatization of a change in attitude an awareness that finally searching for that person out there is frustrating and a waste of time you're not going to get it once you recognize the extent to which you never quite lost them within here then you're on course to a much more realistic kind of if you like relationship with the dead there is a sense in which when people said he lives on in my memory i remember one lady saying well i i when i'm faced with the problem i think well what would my husband uh have done about this and quote it's as if he was inside my head telling me what to do the truth is we are all inside the heads of the people we love and and that's actually quite a reassuring thing i think a lot of bereavement counselling is about helping people to talk through and think through this kind of thing so that they as they begin to realize the extent to which they have a continuing opportunity to not to forget the dead that's not what it's about it's a matter of finding what assumptions continue to enrich and make sense of life and what you've got to let go of and and in a way it's a kind of teasing out these different things um freud spoke of this as in he used the language of internalizing the lost object i don't quite like that language uh i would say it's more a matter of rediscovering what we never lost in the first place you wouldn't be able to rediscover it if it wasn't already there if you follow me uh one of bobby's how am i doing for time sam can i give me half well plenty of time carry on good i i have a tendency to rabbit on too long and i need to check out with my bosses just find me beginning to help live my welcome one of bobby's trainees was a young canadian psychologist called mary ainsworth who developed a scientific way of measuring and studying child mother and mother child attachments during after brief periods of separation now she just oh there's there's the empty chair ah sorry i'd forgotten this i wanted i put this in at the last minute and didn't write it in my notes i i wanted to pause at this moment and just say a little bit about the problems that we meet that i meet as a psychiatrist i have been meeting as a psychiatrist over the years following bereavements because of my special interest in bereavement a lot of people were referred to me following bereavements and i found a lot of them had well problems which may have been around in some degree for many many years but had been aggravated or triggered by the bereavement people who'd always been a bit anxious became much more anxious people with an inclination to panic would tend to panic people with a tendency to would towards depression would become depression was actually quite a serious problem in about a third of of people following a major loss and people with a tendency to drink too much would go on bender and begin to get serious problems with alcoholism and other you know what i'm saying here is that any particular i hesitate to use the word weakness but it it in a sense it embodies the idea that we're all vulnerable in one way or another and vulnerabilities tend to become worse following anything as traumatic as a major bereavement nothing very surprising about this more perhaps different more specific to to bereavements are post-traumatic stress disorders which are peculiar to the very traumatic types of loss that leave horrific memories having a child killed in a car smash witnessing a horrible death these kinds of things will trigger off post-traumatic stress i'll say a bit more about that in a minute not necessarily bereavements uh they are people may actually survive the accidents but the fact you witnessed them seems to be particularly for people who are vulnerable to ptsd this this kind of problem adjustment disorders we're all vulnerable again to particular stresses but following bereavements they often take the the form of prolonged grief and the term prolonged grief disorder has been used by a psychiatrist to describe a particular type of prolonged grief i'm going to say a bit more about that in a minute but i'd like to go back for a moment to mary ainsworth studies because they throw a lot of light on these different problems what she did was to expose a small child this is usually about the end of the second year of life mother and child would be asked to come into a strange room strange situation few toys a place for the mum to sit and another was asked to stay with the child for five minutes then to leave the room for four minutes and come back for a further five so the whole experiment lasted 14 minutes during the course of that time crafty psychologists were making observations through a one-way vision screen of uh the way in which the child and mother were behaving what ainsworth described uh as a consequence of these was that the largest she described four patterns of of behavior there were the secure kids who or secure relationships where uh mother and child would come into the strange room when the mother left the room the child would probably stop what it was doing for a minute might whimper a bit but by the end of the next two or three minutes we'll be back back playing with the toys when mother came back into the room the child immediately stopped whatever it was doing went up to mum mum picked the baby up at this point the child sometimes cried but fairly briefly by the end of the second five minute period they they were wriggling to get down and that was what they she termed the secure attachment these on the whole they studied the the mother's way of parenting the way they were relating to the child throughout their lives they they were the ones who would protect the child when necessary but also encourage play encourage the child if you like to adventure uh within a safe boundary and both of these things are important part of our any good parenting is not just protecting it's also encouraging and and enabling the child little by little to learn the things that will eventually enable the child to become more independent um that was the secure pattern she just also described three insecure patterns there were the anxious ambivalent group uh right from the start these babies did not like this strange situation when mother left the room they cried right from the outset when mum came back into the room they went up to her and sometimes hit her with their fists uh they cry got louder at the end of that second five-minute period they were still crying and she told those the anxious ambivalent group they seemed to be very anxious it was interesting these tended to have rather anxious mothers if you like it the message seemed to be if you don't stay close to mom you won't survive they tended to be perhaps over controlling not encouraging play that might be dangerous and what they got was a much more clinging type of relationship you like mutual clinging on both sides the avoidant group were just the opposite of this first when they've when she first made the observation she was thinking they weren't really very attached because these kids didn't seem to take much notice when mum left the room when she came back into the room some of them actually turned their back and moved away from her others just carried on playing they didn't actually look all that disturbed and she thought they were detached they were not really very strongly attached what subsequently happened was that they they joined the chur that they they were found uh ways of measuring the physiological changes that were going on this child heart rates sweating all the indications of anxiety and depression the physiological level and when mother left the room all of these measures went way up in fact the hearts were racing away just as fast as the heart rates of the anxious ambivalent group what was going on here when they looked more closely at how these mothers were reacting these were mothers who couldn't stand being clung to these were mothers who were somehow teaching that child from an early age not to cry not to cling not to do all the what bobby called the attachment behavior these children were learning to inhibit their attachment behavior staying a safe distance not getting too close when they went to nursery school for instance they you might think that being a boy they'd sit at the back of the class they didn't they sat in the middle out of reach of the teacher but not so far back they felt even more insecure i emphasize this because it is important to recognize that these avoidance although avoidance tends to go on and is that inevitable these kids learn to stand on their own two feet from an early age that's what they're being taught to do they appear to be uncaring they're not and it's very important to recognize that fact i found well i'm going to come back to this in a moment and we'll talk about some of the consequences of these things um and then the third group she called disorganized or disoriented um you could say if you like well no i just could these were kids who uh when mother left the room sometimes they whimpered when she came back in some of them turned their back on her some just rocked backwards and forwards others ran towards her and then turned around and ran away again it was very confusing she said well disorganized you're in a lot of psychological experiments you find a few oddballs who don't fit your neatly discovered patterns and so she put them in this atypical category and forgot about them it was only when they followed them up over several years right up into adult life now these studies will be going on they discovered that this was the group that was greatest at greatest risk of a lot of problems i have my own take on this i'll say it a bit more now so we talked about the parenting the cure group encouraged play within safe limits they actually is ambivalent anxious clinging and controlling parenting the avoidant group entire their parents intolerant of closeness the disorganized group um either frankly abusive not wanting that child and making it very clear that the child was unwanted or they were people who suffered a major loss at around the time of the death of the birth of that child and had been unable for their own psychological reasons to provide the child with consistent parenting sometimes they would worry ab maybe become overprotective for a while and then they'd be struck with another pang of grief and they'd be off and quite unable to respond to the child's needs whereas you could say that the anxious ambivalent group had developed a strategy by staying close to mother the avoidance had learned to cope with this mother by keeping a distance the disorganized group because these mothers behavior had really nothing to do with them there was no way they could control it it was a kind of learned helplessness which itself is one of the recognized causes of depression i'm not going to say it's the only course of depression but there's a lot of evidence a chap called seligman wrote a book on helplessness making it very clear that both in humans and non-humans the more helpless people feel the more prone they are to depression uh so my take on this is to recognize that the two two of the most important things we need to learn from our parents a reasonable degree of trust in our ourselves and a reasonable degree of trust in others so you could say if you like that the secure group had a reasonable degree of self-trust and other trust the anxious ambivalent had very little trust in themselves they would needed the feeling of someone around who would be someone they could turn to um they're avoiding almost the opposite they learn to stand on two feet from an early age but keeping their distance uh from but a low level of trust of others and so far as they made relationships they were often rather controlling type of relationships they were not um comfortable mutually rewarding and then finally the unpredictable group had these low self-trust and low trust in others the double whammy if you like it's not surprising that screw this group were at the greatest risk particularly for depression after bereavement so you might be not surprised to learn that the insecure anxious ambivalent were prone to prolonged grief disorders this is i think a major major cause of prolonged grief it's not the only cause but it's the it's probably the greatest and most important one um i'll give you just one brief example this is not the patient again i'm not going to show patients pictures of patients except in one instance which might surprise you later um this uh i i quite like this picture because it shows not just not only the tendency to cling but also the reaction of the young man he's saying oh my god he's not he's not clinging back he's you can see him all my almost trying to back off and one of the problems of a tendency to cling is that for many people it leads to to a lot of um insecurity in the relationship a lot of people don't can't stand being clung to i know very well as young as a doctor when i meet one of these people before very long they try and cling to me and i want to run a mile there's that sort of awareness that there's something very unhealthy about this clinging doctors tend to respond by becoming very tough with the pain oh you mustn't cling they say as if the person had any choice you know clinging isn't not something they do on purpose if you tick them off about it they just feel all the more insecure and more and more tempted to cling so um what do you do about it well to understand it doesn't mean to say you're colluding with it but at least you're yeah one of the problems is when you give me people with a tendency to cling they behave like helpless child a helpless child am i running off yes okay hurry on uh as a as they um sorry i've i've lost my drift uh yeah they behave like a helpless child and the temptation is to treat them like one you know we all learned about empathy for empathic you see the world through the patient's eyes or the client's eyes when you as soon as you do that you're bound to respond in ways that would actually make problem worse rather than better the most important thing we have to offer to these people is not our pity for their weakness but our recognition of their true value and worth you have to see them as being worthwhile human beings with their own special qualities and if you have faith in that then you can help little by little to pass that message on to them so be careful about the empathic bit the empathy is important it's an important way of finding out what people feel about you but you have to be rather careful not to immediately assume that that's the way you have to feel about them if you follow me um and this lady uh when i first saw her uh she was a youngest child in a big family and was behaving like a small child i remember saying to her well what did you enjoy doing before you met your wonderful husband because that was the way she was seeing him oh she said well when i was at school i quite liked painting i said right go and start painting again oh i can't do that you know i've forgotten how to do it i know it doesn't matter go and get some painting and she can i think next time she came back um i said well how are you getting on and of course because i'm a doctor she thought i was interested in her symptoms so she started telling me about her sleep and i said well hang on i'm not sure i want to know about that yet you can talk about that in a minute what i want to know is how are you getting on with your painting oh she said funny you should say that i'm painting five hours a day and i said oh show me a painting oh she says it's not good enough i said don't matter show me a painting well she said i can't but there are storms at sea storms there's a little bit of art therapy going on here you know this was obviously something coming out in her paintings and i'll show you the picture i think we've got it here no i haven't sorry um the last pain when she finally said goodbye to me her gift to me was one of her paintings it was a lovely picture of a river meandering across the meadow it's a warm sunny day it's in she's in the autumn of her life her autumn leaves on the trees but it's a very peaceful sort of autumn painting and i think it shows something about the way she's now feels about life in other words she's managed to discover a way of living with things the way they are maybe not ideal but good enough and this is what we perhaps and i came across another one of her sons the other day well about a couple of years ago um who said oh you treated my mother and and uh i i remembered her very well i think he was quite surprised how well i remembered her but i didn't tell her i've been lecturing about her but he but uh she'd gone blind in later life but she was still doing very well and relatively independent of her children so far as that was possible so the it was a good example hastily moving on delayed inhibited grief um again here people what people seem to need is permission to grieve to have feelings recognizing i think that shows it all i have time to to and to find the learned helplessness and the depression you'll just have to take the pictures to illustrate the problems that we're up against these are perhaps the most difficult people to help we talked about gender differences no time to talk about them anymore but you begin to get the idea from that um boys young men particularly need to prove how strong and independent they are and this tends to aggravate any tendency to avoid distancing and avoidance controlling feelings not crying not breaking down and perhaps being a bit aggressive i don't have time to talk about death and bereavement across cultures i'm now with now this is the second edition of my book on this incidentally at the back of the room you'll see um a a giveaway there's a details about all of my books and you can get any of them for a 20 discount if you pick up a leaflet so do pick up a leaflet when you when you leave it's my only bit of salesmanship now we talked about the problem of the military and men not showing feelings but in rwanda rwanda has been at war with itself for years and um men and women have learned not to show their feelings it's a it's a civil war and it's the message seems to be you're not going to make me cry very unafrican most africans are very much in touch with their feelings but in rwanda it's certainly not the case i'm told it's the same in burundi um the maoris again you can see the maritangi is an amazing uh bereavement ceremony if you like when a maori dies his body is taken to the meeting house and for three days and two nights the immediate family and closest friends remain with the body friends from miles around come in to share in the tangy in which people cry wail shout even they're even allowed to say bad things about the dead if you've been a better husband your wife wouldn't have suffered as she has and there's a whole load of things sort of things that people get off their chests that have been hanging around for years and at the end of the third day maori gp said to me you know you after three days you've had enough it's a short circuit for the grieving process apparently and he said he'd never seen a pathological grief reaction well that's interesting i mentioned this because i think a lot of the cultural differences teach us a lot about how each culture has its ways of coping with bereavement and loss but i don't have time to go into that in detail in conclusion i want to just show you a few more slides about um one of the biggest conflicts today is between people who believe that emotion focused therapy getting it all letting it all hang out talking through your grief showing your rage of sadness etc etc will heal the problem versus cognitive behavior therapy which is sort of problem focused therapy where instead of talking about feelings you actually begin to look at the problems you're now facing in life it's much make the changes than the assumptive world that you need to make and he hence got assigned bereaved people to two groups and compared them with a waiting list control group and when he followed up all three groups a year after the bereavement he found that on the whole the therapy groups were doing rather better than the waiting list controls but there were big differences according to the gender of the people in this slide the the columns on the left show the intensity of uh ghq score is a score of overall emotional distress as reflected in what you might call sort of things that people take to their doctors sleeping difficulties and eating difficulties a whole range of things and he found that in the men it was the emotion focus group who benefited which is interesting because i suspect if the men had been given a free choice they would have chosen to join the problem focus group because that's what men are good at the truth is of course what we need is the things that we're not good at vice versa with the women it was the problem focus group who needed the help rather than the emotion focus group the emotional focus group did show an improvement but then so did the controls and i think that what this study shows in that case i'm not saying this was carried out in holland i don't know if it applies elsewhere but certainly um it does seem to emphasize that people who have difficulty in expressing grief may need some help in doing just that and conversely those and usually women who are able to express grief but nevertheless may have been having difficulty in reorganizing rethinking their lives will benefit more from the um cognitive type of approach so let's quickly i'm practically finished uh insecurity and fear underlying many problems after bereavement our job is to create a secure base a place a person placing the person where people feel safe enough to talk through and feel through uh whatever it is that's making them feel very unsafe see the world through a client's eyes but don't let this blind you to their misperception of the world be aware of your own attachment needs we all have an attachment history so we all need a supervisor and some people are difficult to help be patient but recognize your own limitations may not be your fault either some people who wouldn't be seen dead talking to me because i'm a psychiatrist or because i'm a man or because i'm wearing a tie all sorts of prejudices that people have which may not be anything to do with us but which nevertheless means that somebody else is better may be able to help better than than we do so refer on if you're stuck the final word in my latest book price of love selected works by me this is the final words of the of the book which i quote here love and loss can contribute to some of the darkest saddest and most painful aspects of life the cost of commitment can be very high any simplistic and sentimental ideas that we may have had love solves all problems must be set aside and yet our commitment to care which is another aspect of love may also hold the key to solving those problems and discovering that the price of love can be a price worth paying thank you you

Channel: Humane Philosophy

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Published: Sat Mar 12 2016