Facing a Loss in a Family. New Perspectives of Intervention

Summary

Loss embraces various sectors ranging from being far from a place, a person or a certain object, to any kind of important changement in one's inner world, which determines a situation of disease.

The work of mourning, or coping with a loss in general, may be, definitely, one of the aspects that most strongly contribute to the objective of family's well-being. Basically the human being has the ability to accept and overcome a changement experienced as a great loss up to the death of a loved one. Mourning could become pathological if one doesn't accept its inevitability. This article offers brief overviews on the modality of intervention.

Keywords

Loss, Mourning, Family, Group

As psychotherapists of couples, and families in general, we are often asked to define which problem could be considered of the greatest impact on the health and well-being of the components of a family.

We could answer that changements, in general, especially if unexpected and unwanted, could determine psychological problems so debilitating that may affect the entire life of those who are involved. We refer, for example, to illness, moving, separation, a loss: this kind of changement could cause a sense of sadness, anxiety or neglect [1,2]. In order to be able to properly take care of the psychological and social well-being of individuals and families, it might be useful to consider how to deal with these changes, even taking into consideration the peculiarities of the different situations as belonging to the same category of "loss".

Definition of Loss

A "loss", which is sometimes bereavement, is compared to a previous situation which is considered to be better than the present one. According to some authors like Galimberti U [3], bereavement embraces a more extensive category of the simple loss of a loved one. The bereavement can be defined as: "a psychological state consequent to the loss of a significant object, which has been integral part of the life of an individual. The loss can be referred to an external object, such as the death of a person, a geographical separation, the abandonment of a place, or to an internal one, such as the closing of a perspective, the loss of one's social image, a personal failure and similar" [3].

According to this definition, therefore, the concept of loss embraces various sectors ranging from being far from a place, a person or a certain object, to any kind of important changement in one's inner world, which determines a situation of disease. The work of mourning or the reaction to the loss in general, may be, definitely, one of the aspects that most strongly contribute to the objective of family well-being.

The Work of Mourning, Psychotherapy in Case of Mourning

Basically the human being has the ability to accept and overcome a changement experienced as a great loss up to the death of a loved one. When we face a death, we are normally able to enter into a state of acceptance within about 18 months [4]. With "state of acceptance" we mean a return to a situation comparable to the pre-mourning phase with an improvement in mood and a reduction of psychosocial issues [4].

Mourning could become pathological if one doesn't accept its inevitability. Depending on the type of attachment it is possible to take over a different level of vulnerability to symptoms [5], emphasized that a person with insecure attachment has a sort of predisposition to pathological mourning, due to a difficulty in managing painful emotions expected by the loss [6-8] also verified that the quality of the relationship which is interrupted by death affects the processing path (conflictual mourning). Is it possible, then, to treat psychotherapeutically a patient who has experienced an event that causes so many physical and psychological health disorders?

For [9] a loss could compromise or threaten personal purposes; the threatened or compromised purposes can affect both the loss itself than the related domaines. Therefore, as the loss has taken place, in order to lead the patient to the acceptance phase, the objective will necessary have to be oriented towards the divestiture and the abandonment of the purposes that have been compromised, and to the development of new behaviors directed to the attainment of purposes which are still achievable. To give up a purpose, one has to change the beliefs that motivate investment in it. So, what are the reasons that complicate the changing of these beliefs?

Severity of loss

If the loss hits the central purposes (thus it goes to adversely affect behaviors, emotions and the thoughts) it will be more complicated for the individual receding from the scope.

Lack of social support

If there aren't people to lean on and who can at least partially compensate for the purpose, one will have a more marked difficulties in the mourning process [10].

Behavior of inhibition or of suppression of suffering

If the exposure to the emotions related to the loss is denied, the revaluation of the event is inhibited and the acceptance process is delayed [11].

Stereotypes related to the right reaction

They go to structure secondary issues such as guilt, anger or shame, not favoring a functional recovery.

The non-security of loss

The person who has to go through the grief, unable to effectively understand the reality of the loss (an uncertain prognosis), not being able to know if the loss occurred or not (disappearance, kidnapping) or not being able to define one or a number of causes of loss (sudden death without explanation) is much harder to get into a status of acceptance. The normal reaction to these situations is the implementation of ruminative thinking styles oriented to understand the reason or find a solution, but have the effect of reinforcing a goal dysfunctional: the avoidance of loss [12].

So, how to deal with these cognitive obstacles that prevent the acceptance process? It will be necessary to give attention to the history of development and to the style of attachment. At the same time it will be of primary importance the construction of a good therapeutic relationship with a focus on its modulation. This relationship will be more successful if it will by taken into consideration that everyone can be considered as a unique universe because, the alchemy produced by the combination of genetic heritage and circumstances of life, such as social and working opportunities, creates a myriad of possible outcomes and different possibilities of the development of potential. It is therefore up to the preparation of the therapist, being able to capture and interpret languages and messages, even if they are silent and unconscious, but always full of meaning. This is a complex, precious and personal universe that it is not possible to live aside when one want to pursue the objective of therapeutic improvement [13].

"Each person is a unique universe and the body is the place where mind and body meet in a unique and unrepeatable alchemy" [13]. So it is also in the body, as well as in the mind, namely the entire functional unit of the individual, which is well hidden the secret of its possibilities for development and transformation.

A psychotherapist who takes into consideration the delicacy and complexity of the situation can be compared to chess player [14]. Who considers all aspects before making his move. But in the game chess the participants continue until one of the two wins. In the strategic therapy there is an alliance between the two players, the patient and the therapist, and both of them win or lose together.

The death of a loved one can be heartbreaking for those left behind, and indeed, bereavement is associated not only with adverse health effects but also a higher risk of dying oneself. Not surprisingly, its consequences have been the subject of much psychological enquiry, with a major interest in shedding light on how one adapts, who is most at risk, and why [15].

Even if the research on the bereavement has increased, only few studies have been focused on emerging approaches. We can mention, for example, the research conducted by Catherine Newsom, Henk Schut, Margaret Stroebeand John, Birrell & Stewart Wilson [16], "Telephone versus in-person intake assessment for bereavement intervention: Does efficiency come at a cost?". The research has taken into consideration standardized, evidence-based risk assessment as an important component in providing effective bereavement care. E-health intake assessments have been offered alongside or instead of in-person assessments, although evidence concerning the equivalence of assessment results is lacking. There are differences between a semi structured intake assessment for grief intervention conducted over the telephone (n = 330) and in-person (n = 115). Although composite assessment scores were lower in the telephone condition, further examination revealed this occurred in the semi structured assessment of risk of complications, not the structured grief symptom assessment.

Stroebe and Shut [15] affirm that often the focus is on the bereaved individual, yet people do not typically grieve in isolation; most do so with family members who have likewise experienced the loss. Family dynamics affect personal grief and vice versa. What is more, family concerns, such as reduced finances, legal consequences, and changed family relationships, have to be dealt with. While the latter stressful aspects have been investigated, there is still a huge gap between the individual and family approaches [15].

A Group Intervention

A group intervention, represents a great resource and possibility of support.

Being a part of a group allows one to share problems, make one feel accepted and supported and therefore feel reflected in it, and it can be a great support to cross the crucial moments of life (as can be to face a death). The most important thing that one experiences in a therapeutic group is the feeling of "not being alone anymore". The emotions that we consider negative (anger, sadness, fear) are common to all, and in an environment like this one can talk about them without feeling judged. Also for therapies conducted within groups it is particularly important, however, to assess the necessary internal arrangements to emotional management group, although this appears to be more incisive in structured and pre-existing groups, as demonstrated by a study of Collison, Gramling & Lord [17]. The authors has conducted a research on the role of religious affiliation in Christian an unaffiliated bereaved emerging adults' use of religious coping. The authors administered the RCOPE to a sample of bereaved college students (analyzed sample N = 748) and explored the relationship between self-reported religious affiliation and religious coping strategies used and endorsed as "most helpful". Results highlight the rich topography of bereavement previously unexamined in understudied populations (i.e., emerging adults, religiously unaffiliated).

The group often becomes a safe place where one can accept and face the anguish and the most painful thoughts, instead of having to spend enormous resources to fight those feelings. In addition, it becomes the place where one can begin to consider new strategies, new thoughts and new points of view, facilitating access to change.

Conclusion

The subject of bereavement and loss is probably something that everyone has to face during a lifetime. At present the researches and works on the elaboration of loss and mourning, if we want to draw a conclusion, starting from the most known and credited up to the more recent ones, which, in the opinion of the writer, are sometimes too much 'originals', cannot be considered exhaustive.

Though the current situation of research remains rather difficult to draw definite conclusions, the attachment theory of Bowlby [5,18] still seems to remain one of the basic frameworks, because it highlights the reasons why individuals approach (or relate to, or behave) differently than the separation and loss, and it provides the psychotherapist who works in this area a general model to help those who are suffering from a loss to deal with and manage his pain.

This does not, however, preclude the need to continue investigating the issue in innovative ways devoting oneself to new researches and applications, always careful to provide an assessment, a comparison and a demonstration of the validity and reliability of the conclusions adopted, not forgetting even for a moment, over all, that each one of us will have to try, before or later, the intense and profound pain of a loss.

"Today neuroscience is finally able to show the great power of the word, so great that a word can be considered as a drug with chemical a real emotional alchemy" [19]. The most recent researches can make evident the great capacity of the word and, therefore, of the strategic training and psychotherapy, to function as a true process of learning and remodeling of brain synapses [19].

According to Ruggiero and Icone [19] we can say that when the word becomes gesture, vibration, sound, resonance, favoring the contact with the deepest part of yourself', it becomes CARE, namely curiosity, eagerness, soul attitude. Care healing consists not only in attenuating or eliminating pain, but also in trying to tell it and share. Then it happens that "All the pains and losses become bearable if they are part of a story, if someone tells a story on them" [20]. The passions aroused by well-chosen words, thus, would be the best way to achieve an inner tuning, that kind of human ability to play together all the parts of which humans are made of [21]. Of course, this inner harmony goes through an attunement with a "resonant" therapist who thinks, listens, takes care of the relationship with the other [19], and that, just as with a refreshing music, conveys his beneficial action through strategically chosen words to heal [22,23].

As researchers and psychotherapists we are called to take care of the suffering and pain of our patients in the fullness of the meaning of the English word "I care", never forgetting the difficulties and sensitivity of the matter and always maintaining a professional attitude but at the same open time and creative, because diligence, ethics and creativity have no limits or boundaries.

References

1. KüblerRoss E (1990) La morte e il morire. Cittadella Editore, Padova.
2. KüblerRoss E (2002) La morte e la vita dopo la morte. Edizioni Mediterranee, Roma.
3. Galimberti U (1999) Psicologia. Torino, Garzanti.
4. Bonanno GA, Wortman CB, Lehman DR, et al. (2002) Resilience to loss and chronic grief: a prospective study from pre-loss to 18 months post-loss. J Pers Soc Psychol 83: 1150-1164.
5. Bowlby J (1973) Attachment and Loss. 2: Separation, Basic Books, New York.
6. Parkes CM (1980) Il lutto. Studi sul cordoglio negli adulti. Feltrinelli, Milano.
7. Parkes CM (2001) Bereavement: studies of grief in adult life. (3^rd edn), Taylor e Francis, Philadelphia, USA.
8. Parkes CM, E Weiss R (1983) Recovery from bereavement. Basic Books, New York.
9. Perdighe C, Mancini F (2010) Il lutto. Dai miti agli interventi di facilitazione dell'accettazione. Psicobiettivo 30: 127-147.
10. Stroebe W, Stroebe M, Abakoumkin G, et al. (1996) The role of loneliness and social support in adjustment to loss: a test of attachment versus stress theory. J Pers Soc Psychol 70: 1241-1249.
11. Spurio MG (2015) Il suono della guarigione. Roma.
12. Onofri A, La Rosa C (2015) Il lutto. Psicoterapia cognitivo - evoluzionista e EMDR. Giovanni Fioriti Editore, Roma.
13. Spurio MG (2011) "Milton Erickson e la Pettherapy", Quale Psicologia.
14. Haley J (1985) La terapia del problem solving. Nuova Italia Scientifica, Roma.
15. Margaret Stroebe, Henk Schut (2015) Family matters in bereavement; toward and integrative intra-interpersonal coping model. Psychological Science 10: 873-879.
16. Newsom C, Schut H, Stroebe M, et al. (2016) In: Death Studies. 40: 71-79.
17. Elizabeth A Collison, Sandra E Gramling, Benjamin D Lord (2015) The role of religious affiliation in Christian and unaffiliated bereaved emerging adults' use of religious coping. Death Stud 40: 102-112.
18. Bowlby J (1982) Costruzione e rottura dei legami affettivi. Raffaello Cortina, Milano.
19. Ruggiero G, Icone S (2014) "Il camice invisibile". Le emozioni nella relazione di cura. Idee in Psicoterapia-n.
20. Cavarero A (2001) Tu che mi guardi, tu che mi racconti. Filosofia della narrazione, Feltrinelli, Milano.
21. Siegel D (2008) Mindfulness e Cervello, Cortina, Milano.
22. Spurio MG (2015) Words that Heal. Psychiatr Danub 27: S21-S27.
23. Maria Grazia Spurio (2016) Saying Goodbye to the Silence. Commun Disord Deaf Stud Hearing Aids 4: 156.