The Complex Grief and Family Dynamics of Donna

BACKGROUND

Donna is single, never partnered or married, and has no children. Donna’s mother passed away six months ago after fainting and striking her head, where she sustained a brain injury that caused her death. Donna insisted that her mother go out for daily exercise to buy the newspaper, even after her mothers GP advised Donna that her mother was becoming unstable on her feet.

Donna displays feelings of anger and guilt surrounding her mother’s death. Donna’s father died six years ago after a long illness. Her parents were married for twenty years and had divorced when Donna was seventeen years old. Her father remarried soon after. Donna had minimal contact with him and missed having her father in her life. Donna’s mother, Brenda, insisted that she had perused divorce in the best interest of Donna, their only child.

Due to Donna’s childhood/ adolescent experience, there seems to be an insecure attachment style. Donna works fulltime at a university bookshop and until her mother’s death, attended a monthly book group. Donna has only a few friends and having no other relationships, keeps somewhat distance from her peers, in particular after her mother’s death. Donna returned to work two months after her mother’s death but is finding it difficult to concentrate and to add to this, the current pandemic has meant Donna is working from home.

With Brenda’s passing away, Donna has preferred to remain in their home and rejected both social invites in person or online.

Donna’s has not been sleeping well, with regular night-time awakenings of which she has been prescribed sleeping pills by her GP.

Presenting problem

Donna was referred to counselling by her GP after the death of her mother six months ago. Donna presents with feelings of abandonment, sadness and feeling helpless (Stroebe et al. 1996). Since the death of her mother, Donna feels angry and stated to her GP that, life “feels empty”.

The referral was due to her insomnia, which has lead to feelings of fatigue with frequent night-time awakenings. Since Brenda’s death, Donna’s has withdrawn socially, with an increase in isolation due to the current pandemic, this has perpetuated her sense of isolation and is likely contributing to her “feeling empty” (Stroebe et al. 2001). Donna was not with her mother when she passed away. Her absence at her mother passing precipitates feelings of guilt and anger.

Applying Worden’s task of grieving (Worden 2018), possible factors underlying Donna’s grief presentation may include anger, guilt and responsibility of her mother’s death. The death was unexpected; therefore, Donna may be coming to terms with the reality of her mother death, Task 1, to accept the reality of the loss (Worden 2018). Within this task of grieving mediator 3, how the person died, seems to be impacting the grief, as Donna may believe that it was preventable. Police told Donna of her mother’s death at her work, and her mother died in an ambulance before Donna arrived, which may be contributing to her feelings of guilt and responsibility.

Predisposing factors that appear to be influencing Donna’s response to her mother’s death are her insecure attachment style and history with her mother as the primary caregiver (Stroebe et al. 1996). Donna presents with an avoidant/fearful attachment style, lacking in self-confidence and a tentative attachment style due to the fear that these attachments may break. Furthermore, broken stressful early relationships, which Donna experienced with the divorce of her parents, together with weak social skills, highlights her attachment style. (Kominsky & Jordan, 2016)

Mediator 2, attachment to the deceases, takes into consideration the nature of the attachment one has with the deceased. Within mediator 2 there are two areas to be considered, the ambivalence in the relationship, how was her relationship with her mother, particularly after her parents divorced. The death also leads to enormous amounts of guilt as well as the anger of being left alone, as Donna is now essentially orphaned (Prigerson & Jacobs, 2001). Secondly, the dependent nature of the relationship can influence Donna’s adjustment to the loss, especially the challenges in task III.

A precipitating factor that may be influencing Donna presenting issues is that Donna does not have many friends, and she may have been dependent on her mother for her only relationship.

There are possible unresolved issues following the death of her mother that may be related to unresolved grief of her father’s death and the loss of her family unit with secondary grief issues related to social changes in her adolescence.

Mediator 4, Historical antecedents also needs to be considered in Donna’s grieving process, to understand if and how she processed her past losses sufficiently or does she carry a lack of resolve from her previous loss to this current loss.

According to Worden’s model, Donna seems to be moving between task II and task III as she is processing the pain of grief and needing to adjust to a world without her mother. Before Brenda’s death, Donna found her work enjoyable; with some connections in her book group and in addition to taking the steps in seeking help demonstrates some protective factors that will support Donna in improving her presenting condition.

Goals and Interventions

Treatment goals

Applying Wordens’s counselling principles and procedures, the treatment goal for Donna would be to help her actualize the loss of her mother. With the use of evocative language, one can stimulate some painful feelings for the client that needs to be felt. How did your mother die? How were you informed of the death? What did you do after you heard the news? How was the funeral?

I would apply the use of symbols and ask Donna to bring a photo of her mother so I can have a clearer sense of who Brenda was, and provide a concrete focus on actualizing her mother’s death.

The following goal, principle 2, will support task II of mourning, process the pain of grief to help Donna identify and experience her feelings surrounding her mother’s death and her loss. Encouraging Donna to identify and process feelings of sadness, guilt, abandonment, anger and emptiness. During this stage of the treatment, Donna’s insecure attachment style will be an essential mediator for the grieving process as it can make an adaption to the tasks challenging and add to the unfolding of complicated grief. Donna’s avoidant/fearful attachment style makes her vulnerable to depression when a loss is experienced, with social avoidance behaviour typical of which Donna may use as a coping style. I would introduce The Hamilton Scale of depression (HAM-D) to identify any concerns or referrals for possible depression (Hamilton, 1960).

The use of Role-play or empty chair will give Donna an opportunity to express her guilt surrounding Brenda’s death and provide practical work that will be useful to establish task III of mourning, assist living without the deceased, by facilitating cognitive awareness and possible new behaviours.

Furthermore, addressing Donna’s coping style, with the use of a mood diary, will help identify if there is rumination or repetitive negative thoughts. This cognitive coping style can prolong the mourning process, which not only leads to a depressed mood but can also affect the handling of task II.

The last goal will be task III, Donna adjusting to the world without her mother.

According to Worden’s model task III, there are areas of adjustment that need to be addressed after the loss of a loved one to death, the external adjustments, the internal adjustments and the spiritual adjustments (Stroebe et al. 1996).

Addressing what Donna’s external adjustments are after her the loss of her mother, the role her mother played and how Donna can adjust to her new environment. To explore what beliefs have been challenged after the death of her mother, what is her core life purpose, can she find new meaning in the face of her loss and focusing on goals that Donna can achieve to develop social relationships. Including a grief-counselling group, to highlight that she is not alone and to develop new relationships. Also explore Donna’s return to her book group, albeit on-line during this pandemic, as it will give her something to anticipate.

Donna will now need to internally adjust to her sense of self, her self-definition, and self-esteem. Who am I? Who am I without my mother? With the use of restoration of the dual-process model, (Stroebe &Schut, 2001), the focus will be on setting out new personal goals. Asking Donna what she would want from herself if the grief, sadness, emptiness was finally gone, once these goals are articulated, working with Donna towards them at a comfortable pace.

Within task III of mourning, there is the spiritual adjustment, one’s sense of the world, how Donna can reconstruct her world and its meaning after her loss. Prigerson & Davies (2002).

Potential treatment challenges

The potential treatment challenges for Donna will be her attending counselling sessions. Donna has cancelled the first two sessions and together with her social isolation may indicate that Donna is either not fully committed to improving her current condition or that Donna finds it challenging to confront her pain (Worden, 2018). As a counsellor, I will aim to provide a safe space for Donna to be heard with no judgment and to build a rapport. Donna may want a quick fix, as with the medication that the GP subscribed, which could impede her fully participating in the counselling process.

As Donna has few friends, the work on rebuilding and building relationships through existing friendships or counselling groups may be uncomfortable for Donna. The challenge will be to use Role-playing and cognitive restructuring to assist Donna through the pain of the loss and adjust to the world without her mother.

My coping style, active emotional coping, may be at odds with Donna’s coping style, avoidant emotional style, this could hinder on setting a task for Donna as what I may think is achievable may not be the same for Donna.

As I have experienced my personal losses, I believe that this can bring more empathy into our sessions as well as the potential to bring up my own unresolved grief issues. I will need to be aware of transference in the counselling session and seek supervision if any personal grief arises.

Progress Notes

Subjective

Donna presents to counselling with a referral from her GP.

Donna is experiencing feelings of “abandonment, sadness and helpless” and life “feels empty” since the death of her mother, six months ago.

Donna’s sleep is poor, with frequent night-time awakenings, of which she has been prescribed sleeping tablets by the referring GP (Prigerson & Jacobs, 2001). Donna cancelled two sessions before presenting to her first counselling session, which was delivered online.

Objective

Donna presented to counselling well dressed and smartly groomed. During the session, Donna appeared visibly fatigued and was tearful at times. Donna’s facial expression was sombre with little eye contact and signs of fidgeting. The Hamilton Scale of depression prepared to identify a possible state of depression (Hamilton, 1960). Treatment model chosen for intervention is Worden’s task of grieving. Treatment includes actualizing the loss of her mother, followed by identifying and experiencing her feelings surrounding her mother’s death and her loss. Encouraging Donna to identify and process feelings of sadness, guilt, abandonment, anger and emptiness. Role-play or empty chair to give Donna an opportunity to express her guilt surrounding Brenda’s death. Provide practical work that will be useful to establish task III of mourning, assist living without her mother by facilitating cognitive awareness and possible new behaviours.

Assessment

Donna presented with a state of depression associated with the loss of her mother, which may be contributing to her insomnia and “feeling empty”. Donna is adjusting to the loss of her mother and has not been able to process her grief and guilt associated with the death. Donna has attended the counselling session after cancelling twice, which demonstrates that the grief is challenging but is willing to improve her current presenting condition. Work required is processing her grief, guilt and anger surrounding her mother’s death and adjusting to life without her mother, including an understanding of her coping style, attachment style and building a support network through rebuilding connections with friends and possible group grief work.

Plan

The treatment plan is to go from task I to III of mourning, by processing Donna’s grief and loss through role-play and empty chair where Donna will be able to experience her grief, guilt and sadness.

The outcome is to reduce Donna’s symptoms of grief, sadness, and “feeling empty” which will improve her sleep, allowing Donna to move into task III and adjust to a world without her mother.

Self-assessment

Reflection on my work and of the knowledge that I have gained through this case study was to begin integrating the grief model, Worden’s task of mourning, into a counselling session. I believe that as challenging as it was for me, it allowed me to formulate the steps when working within a model. My self- assessment is critical of my academic communication skills and language.

I would give my self a 75% mark for this case study, as I believe I demonstrated a good understanding of the model but I was not succinct enough in my delivery of the case formulation and treatment goals.

References:

• Hamilton, M. (1960). The Hamilton Depression Scale—accelerator or break on antidepressant drug discovery. Psychiatry, 23, 56-62.
• Kosminsky, P. S., & Jordan, J. R. (2016). Attachment-informed grief therapy: The clinician’s guide to foundations and applications. Routledge.
• Prigerson, H. O., & Jacobs, S. C. (2001). Traumatic grief as a distinct disorder: a rationale, consensus criteria, and a preliminary empirical test.
• Stroebe, M.S., Hansson, R.O., Stroebe, W.E. & Schut, H.E., (2001). Handbook of bereavement research: Consequences, coping, and care (xv-814). American Psychological Association.
• Stroebe, W., Stroebe, M. S., Abakoumkin, G., & Schut, H. (1996). The role of loneliness and social support in adjustment to loss: A test of attachment versus stress theory. Journal of Personality & Social Psychology, 70, 1241– 1249.
• Worden, J. W. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner. springer publishing Company.

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