A year ago, Russia launched a full-scale war in Ukraine. From the first day of the war, Ukrainians have been losing their compatriots, relatives, friends and acquaintances, beloved pets and homes. For an Ukrainian psychologist, it is important to help oneself and others to cope with grief, while traumatic events still continue. Grief is complicated and long-lasting. It is a very difficult task to “cope with grief” when the war is still ongoing. The train of death runs around the clock.
Some people are able to cope with loss and go through the grieving process on their own. Sometimes, kind words, family support, and time are the best treatment. However, when people are unable to cope with loss on their own, their lives become worse, more difficult, and they are unable to work, sleep, or find joy in life. The research cited in the article leads to the following conclusions (Stroebe et al., 2007, p. 5):
Reactions related to loss
Affective:
• Depression, despair, depressed state, suffering
• Anxiety, fears, horror
• Guilt, reproach, self-blame
• Anger, hostility, irritability
• Anhedonia – loss of pleasure
• Feeling lonely
• Sadness, lack of desire to live, exhaustion
Cognitive:
• Constant ruminations about the past, intrusive thoughts
• Feeling the presence of the one who has left
• Prohibition, denial
• Low self-esteem
• Remorse
• Helplessness, despair
• Suicidal thoughts
• Feeling of unreality
• Problems with memory and concentration
Behavioral:
• Excitement, anxiety, restlessness
• Fatigue
• Hyperactivity
• Ongoing searching
• Crying, sobbing, screaming
• Social isolation
Physiological-somatic:
• Loss of appetite
• Sleep disturbances
• Loss of energy, exhaustion
Somatic complaints:
• Physical complaints similar to those experienced by the person who left.
• Immunological and endocrine changes
• Prone to illness, ailments, suicide
These symptoms may appear in different combinations in different people.
A clinical problem occurs when a person has the following symptoms, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (Stroebe et al., 2007, p. 6).
The following criteria are proposed for defining complex grief:
Criterion A
Chronic and destructive grief, exhaustion, desire to be with the one who is gone (sadness and thirst to be with the one who is gone).
Criterion B
The person must have four of the other symptoms below at least several times a day or they must be so intense that they become distressing and disruptive to the person:
1. Problems with accepting death.
2. Distrust of others.
3. Excessive bitterness or anger related to death.
4. Concerns about continuing life.
5. Loss or alienation.
6. Feeling that life is empty or meaningless without the person who is gone.
7. A bleak future.
8. Agitation.
Criterion C
The above symptoms cause marked and persistent dysfunction in social, occupational, or other important areas.
Criterion D
The above symptoms of the disorders must last for at least 6 months.
**To diagnose complicated grief, all criteria A, B, C, and D must be present. Reprinted with permission.
To understand why it is important to work through grief and sadness with the help of a professional who provides bereavement support, let's consider the significance of this process.
We experience grief when we are faced with a loss. Servaty-Seib and Stantom (2021, p. 581) explain that loss is the death of a loved one. Death is an inevitable event. In fact, loss is any event or series of events that lead to a feeling of loss of meaning in life, loss of ordinary life. Such losses affect a person’s life experience, their attitude towards themselves, others and the world. Consequently, losses can lead to the disappearance of basic trust in the world and a sense of security. Some losses, especially those not related to death, can be underestimated by loved ones or other people, and the person will be left face to face with their grief, or, worse, ignore it, and this can lead to psychosomatic illnesses, depression and anxiety disorders. Especially when there are many losses at the same time: loss of home, loss of job, loss of identity, loss of a favorite toy, loss of a favorite thing, loss of normal life and rituals, loss of normal home environment, loss of certain habits.
The war, as a traumatic event, brought enormous losses and death, dividing life into two parts: before and after. Those who did not personally lose loved ones also experienced many losses not related to death. Every Ukrainian lives in grief, because he joins the common grief. Therefore, it is important to work with a professional, since Ukrainians experience grief over the death of their compatriots, one could say, this is a stream of deaths, as well as many losses related to the usual way of life, the idea of themselves, others and the world.
When a client comes for a consultation, I explain to him or her the meaning of loss, how our brain works during traumatic events, and the importance of working through grief and sadness, the meaning of grief, working with grief and sadness.
First, I teach the client, whether adult or child, to stabilize their emotional state through breathing and grounding techniques. For the adult client, it is important to explain the definitions and differences between the terms “trauma,” “loss,” “grief,” and “sadness.”
Thus, Servaty-Seib and Stantom (2021, p. 236) define these terms as follows:
Trauma is directly related to loss, trauma is a threat to life, fear of losing life or a loved one, loss of safety. Loss refers to the fact of loss, while grief is the subjective reaction to that loss. Loss is the fact of death, and grief is how a person experiences that loss. The intensity of grief depends on many factors, including previous experiences of loss, cultural traditions, and the internal permission to experience emotions without avoiding them.
So, it is very important to explain to the client that loss can cause trauma, and trauma can change our thinking, cognitive, emotional, somatic state of our health and our daily life. To improve our functioning and quality of life, we need to complete the work of grieving.
Effective models of dealing with grief
Let's look at two models that I find effective for customer support.
Model 1
Model 1 was developed by Theresa Rando (1984, 1993), who created the Six “R” model. (Servaty-Seib & Stantom, 2021, p. 274). This helps you work through grief based on what needs to be done in the grieving process.
i. Recognizing the loss. Acknowledging what you have lost is the first step to acceptance.
ii. Reacting to pain means expressing emotions of grief.
iii. Recollect and re-experience the deceased and the relationship. Letting go of those who have gone means remembering and grieving.
iv. Relinquish old attachments to the deceased and the old assumptive world. Letting go of attachment means changing your attitude and way of thinking about yourself, others, and the world. Accepting life in a world without your loved one.
v. Readjusting to a new world while remembering and appreciating the past.
vi. Reinvestment in new activities and new relationships involves adaptation to new conditions. Orientation to the future and prospects.
For this model, it is good to use the technique of therapeutic writing and drawing, as well as imagination (especially useful for children). It is important to express emotions and restore hope that life continues not in vain, but for something important. It is necessary to find a new meaning or appreciation of life in new circumstances.
Later, we will analyze with the client what he learned in these conditions, after going through this path. It is important that the client feels the great value of life. Grief gives new meanings to relationships and their quality. The client begins to see new opportunities, his mission in life, to appreciate his strength and work on spiritual changes in the personality, spiritual growth. But this will happen later, because every human tragedy is the beginning of the Hero's journey.
Model 2
Emmanuelle Zech and his Dual Process Model in grief therapy. Using this model is very important because a person needs to do housework, cook food, and of course we need to work and earn money. At the same time, we need to express our feelings because it affects our mental, physical and emotional health.
(Neimeyer, 2016 and Stroebe, Schut, 1999) in their dual process model in grief therapy, which I am referring to, describe a dual process model: loss orientation and recovery orientation (restoration or activity). On the one hand, it is important to grieve, to mourn the loss of love, a loved one. On the other hand, it is important to adapt to new conditions, to perform the functions that were performed by those who left, for example, managing a budget or cooking.
Figure 1. Model of the dual process of coping with loss.
Thus, constantly mourning the loss of a loved one when one cannot do anything is as bad as being in a hyperactive state of agitation. Therefore, it is important to learn how to switch from grief to activity and the fulfillment of urgent tasks. This technique will help us with this.
“Lost Box” Technique
The Loss Box technique, developed by Lara Kravchuk (Neimeyer, 2016, pp. 170-172), is suitable for both the dual model and the six “R” model. This technique can be applied to both adults and children. The client can identify important losses and give them unique meaning. Create a loss box. Each box also has a metaphorical container, that is, a special place where the box will be stored. Clients can consider all their losses in the box at a specially designated time in a safe and supportive space with the therapist and enjoy their life in the most difficult circumstances. At the same time, it is possible to go back and look at the losses again, talk about them and grieve. The Loss Box helps to temporarily step away from them and share their feelings with another person in due time.
Understanding and respecting loss and grief are integrated into personal experience, which creates more inner space for re-alignment to joy, hope, and prosperity, and also provides energy for adapting to a new life and allowing one to live fully, despite loss and prolonged traumatic events.
Denys Starkov, in his theory “Model of Psychological Rehabilitation of Post-Traumatic Disorders with an Emphasis on Mentalization,” emphasizes that a client in crisis suffers from the pressure of the crisis itself (he feels like a victim in the Child Ego mode) and suffers from a sense of helplessness when dealing with the crisis (he feels like a helpless Hero in the Adult Ego mode).
Therefore, it is important for the therapist to remember that showing compassion and support to the Child part of the client would be a mistake when the client is in an acute state of grief. The feeling of being a victim may be intensified.
Instead, the author suggests focusing on the Hero part and supporting that part by providing it with resources.
Therefore, when discussing the loss of a client, it is important to focus on the client's strengths, what they did well in the crisis, their ability to think and make complex decisions in difficult situations, and their resources.
Denys Starkov calls this technique affirmation. By affirmation, the author means a reflection of the client's Adult Ego, his ability to think, make the right decisions and act, his resources and abilities.
It is also important to close the emergency hatches together with the client during this work and confront their powerlessness.
In conclusion:
– Working through grief is of great importance for mental health.
– If we do not do this work, then first of all, we, as adults, will not be able to support our children and properly care for their needs.
– Secondly, we will not be able to work to meet our basic needs and lead a full life.
– Thirdly, it leads to an increased risk of cardiovascular disease, heart attack, increases the risk of cancer, and, most dangerously, a person can end their life by suicide.
In the article (Zisook, Shear, 2009) there are specific studies that show the following:
– In the Clayton studies described above, 42% met symptomatic criteria for major depression at one month and 16% met criteria at one year.
– 47% experienced major depression at some point during the year, compared to 8% in the control group and 11% throughout the year.
– 25% of patients were chronically depressed. In all of these studies, the best predictor of major depression at 13 months was depression at one or two months.
– According to the Zisook and Shear studies, a history of major depression also predicted major depression at one year.
Furthermore, bereaved individuals are not only at high risk of developing major depression, but also at risk of developing long-term subsyndromal symptoms of depression. Such symptoms, even in the absence of full-blown depressive disorders, can be associated with prolonged personal distress, role dysfunction, and an inability to cope with everyday tasks.
The article (Barlow et al., page 923) presents the results of a study that shows how useful different types of support are in dealing with loss. All types of support: individual, family, group, peer support, etc., were found to be extremely beneficial in the healing process in people who have lost loved ones and in overcoming the traumatic event.
Thus, the main task of working with grief is integration into society, the beginning of new activities and continuation of work, growth and personal development, a full life. Each specialist must understand that the grief process is individual for each person, and act not only according to general rules. A specialist in supporting victims must rely on theory, and take into account individual circumstances and individual personality traits. The most important thing is to remember that you can heal from grief only by experiencing the process of mourning and grief.