Why We Get Complicated Grief Wrong

I recently switched positions in my company to help manage our bereavement services. Don’t worry – I’m still in the field as a chaplain as well (with a very limited caseload – something I asked for)! I had a great deal of experience working in bereavement in my prior company so this has been a good fit so far.

However this move has brought up something that has always bothered me. That is even though that the staff I work with on a daily basis has years of experience in hospice care we still struggle with measuring and even recognizing complicated grief and bereavement.

Complicated grief is brought on by loss and differs from simple or “normal” grief in that it is chronic, debilitating, and associated with other illnesses such as clinical anxiety and depression. In hospice, we try very hard to support our families both before and after the patient dies. Part of this involves identifying risk factors in family members that may lead to complicated grief. In an overview of research provided by Burke and Neimeyer, clinically these factors include

  • history of prior clinical depression or anxiety
  • multiple stressers (concurrent losses, interpersonal difficulties, financial problems etc.)
  • anxious, avoidant, dependent or insecure relationships
  • history of substance abuse
  • timeliness of death (death of a child or young adult)
  • type of death (violent, suicide)
  • lack of family cohesion and/or poor support network
  • gender, income, culture, and education

However when I discuss deaths with others to see if someone may be prone to complicated grief, the reasons why are rarely associated with these clinical factors. Instead the feeling is more based on their current grieving, situational factors and good old “gut instinct”. It’s not uncommon at all for a staff member to tell me that a family member is “high risk” because they were very emotional, even irrationally so, at the time of death, without considering that this show of emotion is to be expected and in some cultures even required.

One difficulty I’ve found is that identifying risk factors prior to death is often very difficult. We may only have a few contacts with a family member before a death, and in some cases only one before the patient dies. It’s difficult to identify risk factors in that period of time, even with a good psychosocial assessment.

However the greatest hurdle we have is education. We simply do not know enough about what complicated grief is, how it progresses, and what signs to look for. Part of that is we don’t all agree what “grieving well” is. Naturally our own version of what “normal” is tends to overshadow how we view other people’s reactions, but our “normal” and theirs can be quite different. I find even most people who are grieving don’t know what “normal” is. I recently had a conversation with a woman whose mother died on hospice who was concerned that she felt guilty about being free from the burden of caring for her mother and wondered when those feelings would go away – 2 days after she died! I assured her that what she was experiencing was quite normal and that, to be honest, she still had a long way to go in her grief. She felt relieved in knowing that she was much more normal than she thought she was.

This is true for hospice staff as well. All staff who work with patients and families need to know what normal and abnormal grief looks like. The statement “they’re in denial!” should not be tossed around like an accusation toward a “noncompliant” patient or family member (more on that later) but as a recognition that denial is part of the grieving process and therefore is not a problem. Protracted, ongoing denial that is “stuck” can be a sign of difficulty coping. The prescription here though is not to get the other to see things your way but to to understand what they are going through. That requires patience and insight into the complicated dynamics of loss, relationships, and meaning that sometimes gets lost when you’re just trying to get someone to agree to have an oxygen tank in the home.

Chaplains can take the lead in this area in our teams, as we can often be the people who are needed to slow things down and address things that may be lost otherwise. We need to educate and reinforce to our staff what is and is not normal grief, and to be able to provide resources and support when we see someone at risk of complicated grief.

Research in complicated grief is frankly pretty scarce but it is growing. There are plenty of popular books about grief, but fewer scholarly papers. If you are interested in an overview of the research thus far the aforementioned article by Laurie Burke and Robert Neimeyer is a great overview. A quick search on Google Scholar will yield other articles, some of which are free to access.

Getting Your Foot in the Door: 8 Ways to reduce “declines” for chaplains

the chaplain makes his rounds

One issue that I see frequently coming across chaplain discussion boards is that many have increasing numbers of those declining chaplain support. One poster, a hospice chaplain in Georgia, said her declines went from 10% five years ago to about 35% now.

Many believe that the refusal of spiritual support is due to a decline in religiosity overall in our country and culture. That may be true, but I don’t think it accounts for the majority of declines. Even though the Pew Research Center found a nearly 8 point percentage drop in those professing Christianity between 2007 and 2014, about 70% of Americans still identify as a member of some Christian church or faith group. From my own experience I can say as that I have had many accepting of chaplain support who were atheist or agnostic, or believed in God but did not consider themselves religious.  And no these were not millennials, these were your typical elderly hospice patient. Continue reading

Spiritual Communication Boards for the Critically Ill: Wall Street Journal

This came across the line from the APC and thought it was such a brilliant and simple idea. The text is included below but please access the full article here.

When William Campion was in the intensive-care unit this month after a double lung transplant, he felt nervous and scared and could breathe only with the help of a machine.

Joel Nightingale Berning, a chaplain at Mr. Campion’s hospital, New York-Presbyterian/Columbia University Medical Center, stopped by. He saw that Mr. Campion had a tube in his neck and windpipe, which prevented him from speaking. The chaplain held up a communication board—not the kind used to check a patient’s physical pain and needs, but a “spiritual board” that asks if he or she would like a blessing, a prayer or another religious ministry. The board also lets patients rate their level of spiritual pain on a scale of 0 through 10, from none to “extreme.” Continue reading

When All is Said and Done: Death and “Magic Words”

Your average hospice chaplain. Probably had 3 units of Level II CPE.

Recently I had a family whose mother was on hospice with us. When Isabel* had a sudden decline and became active her family gathered around the bedside and all started to say the things that families and caregivers – including hospice staff – feel that they need to say in order for the dying person to “let go”. They all said that they loved her and that they would be OK. They had out of town family come in and say good-bye in person and on the phone. They told her over and over again that it was OK for her to go. The priest gave last rites. This went on for well over a week.

Needless to say it was rough. The family came and went, said what they needed to say, and still Isabel seemed to hang on. There were a lot of thoughts and questions: “What haven’t we said? Is there someone that hasn’t said goodbye yet? Is she waiting to hear from someone? What are we missing? Why is she still here?

My best response was, “I don’t know.”

Continue reading

The Unproductive Chaplain

welcome to the machine

welcome to the machine

I wrote previously how chaplains need to be productive, and how to do that. I now want to unravel all that. Productivity may be how we prove our worth to our employers, however it can also run counter to how we do that, and even to our ability to do that. Continue reading

The Productive Chaplain

here we see a Chaplain being productive…

If you’re a professional chaplain you have probably heard this phrase: “Let’s talk about your productivity.” For anyone the “productivity” talk is uncomfortable. For chaplains this talk is often more uncomfortable because what we “do” and “produce” can be very hard to grasp. Continue reading

Effective Swearing for Chaplains (and Other Clergy Too!)

***trigger alert: as this is a post about colorful language, be aware that there is colorful language abounding after the jump***

Clergy, sometimes it’s OK to use swear words. That’s the summary. For the full text click below, but language aboundeth herein

Continue reading

Amy Kumm-Hanson: The incarnational nature of Chaplaincy

photo: A.Kumm-Hanson, Iceland 2016

From Amy Kumm-Hanson; I thought her words spoke a great deal about the difference between the nature of Chaplaincy and its place in ministry.

Chaplaincy is not a cerebral ministry of long hours spent in a pastor’s study in preparation for preaching. It is holding hands through bed rails and wearing isolation gowns and being willing to literally stand in suffering with God’s beloveds. It is not about translating Hebrew or Greek from ancient texts, but about translating scripture into something now that matters to the mother who is delivering her stillborn child or the son losing his father to cancer.

The theology of the cross is particularly apparent to me in my hospital work. This theology holds that God’s love for all of creation is most clearly seen in the act of dying on the cross.  That God did the most human thing of all, which is to die. The theological conviction that shapes my ministry as a chaplain is that God knows what it is to suffer and to die, and there is no place that God is unwilling to go, even death. This is good news for all of us who feel immersed in suffering, our own or that of others.

Read her whole post here.

Is CPE broken? Reconsidering the “CPE horror story”

anyone having flashbacks to their CPE supervisor’s office?

If you Google “CPE” chances are pretty good that it will start autofilling “horror stories” in the search box. It seems like there are much more stories about bad experiences in CPE than good. Perhaps this is just bias toward the negative, but it certainly does seem to be that CPE is not a good experience for many.

If you follow that search you’ll see why. I read stories about supervisors that destroyed boundaries and exercises designed to tear people down in front of their peers. One person even wrote that “Clinical Pastoral Education is nothing more than a systematic ‘weeding out’ of orthodox seminarians through a process of enforced radical leftist indoctrination.” It’s criticized as being unnecessary, unhelpful, “navel-gazing”, pseudo-psychoanalysis. So why is it still required for those entering ministry? Is there something wrong with the program? Are supervisors adequately trained and supervised themselves? Or are seminarians missing the point of CPE entirely? Continue reading

Chaplain Certification: APC vs CPSP vs … SCA??

perhaps we need to drag the shirt out again

So I’ve written several times on the topic of board certification for Chaplains, especially regarding APC/BCCI and CPSP. Those weren’t the only players on the certification game, though. There are certification programs through the National Association of Catholic Chaplains and Association of Jewish Chaplains for example, as well as a smattering of other groups and agencies. Some have been around for a while and are well recognized, while others you will probably never hear of unless you look for them. The newest group to organize and enter the board certification mix has caused controversy though. Continue reading