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Lecture 10

PSY333H1 Lecture 10

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Lisa Lipschitz

PSY333H1F L10 Nov 21, 2013  Although K-R admits that these stages can occur in different orders, most people regard her stages as “the way to die” and  Final exam next class: this is misleading o 2 hrs  People don’t necessarily go thru stages; may go back and o Non-cumulative forth o Worth 25%  Does not fully acknowledge the importance of anxiety o Shorter than the last test due to less content o Not everyone copes the same way  Leaves out totality of person’s life Psychological & Social Issues  Dying is a complex & individual process, subject to no rules  Changes in Self-Concept & few regularities o Difficulties w biological & social fn’ing o Changes in appearance (due to illness or treatment) Task Work Approach to Dying  Ex. loss of hair, eyebrows, skin discoloration Charles Corr’s task-based approach (1992) from cancer  Focus on 4 distinct types of tasks (not the order) by patients  Act as constant reminder of the illness diagnosed w terminal illnesses: o Mental regression or decrease cognitive fn’ing 1. Physical Tasks:  Hard for family members to adapt to these o managing their pain & physical symptoms changes o satisfying body’s needs  Social Interaction Issues 2. Psychological Tasks: o Withdrawal caused by grief, depression, fear of o maintaining independence depressing others and becoming an emotional burden o feeling secure  Don’t go out as much  isolation  depression o rewards  Communication Issues o feel in control o Family members, hospital staff, and patient may have 3. Social Tasks: difficulties talking about death o enhancing relationships o The belief that others do not want to talk about it o interpersonal 4. Spiritual Tasks: o thinking through issues of meaningfulness and hope Stages of Adjustment to Dying o connectedness Elizabeth Kübler-Ross’s Five-Stage Theory of Dying: o contributions they have made 1. Denial: initial reaction (“It can’t be me”) o mindfulness o Numbness  Continuity o defense mechanism o No order o avoid the implications o protection in the short-term from shock Dying Role o Becomes more maladaptive when taken for too  Emanuel, Bennett, & Richardson, 2007 long & don’t treat self  Dying role includes certain privileges and responsibilities: 2. Anger: “Why me?”  3 key elements: o hard for family and friends (often directed at them) 1. Practical elements: o angry at fate, rage, envy, resentment o tasks that people need to arrange at the end of their 3. Bargaining: trading good bhvr for good health, pact w G-d, do lives (e.g., finances) good in exchange for health, charitable activity, delay 2. Relational elements: 4. Depression: “anticipatory grief” o reconciling the dying w other roles o coming to terms w lack of control o must integrate these roles o mourn their death, withdrawal o (e.g., caregiver, spouse) o symptoms worse o Saying goodbye, final words o prepare for future 3. Personal elements: 5. Acceptance: “quiet expectations” o “finishing one’s life story” o too weak to be angry o reexamine life o not depressed anymore o derive new meaning from their life o tired o peaceful, pleasant calm Concerns in the Psychological Management o saying goodbye, cut off contacts w ppl Things to consider: o making necessary changes & preparations  Restrictions may prevent a patient from dying in comfort or presence of support Advantages: o Death may be long, dehumanizing, painful, lonely  Does describe a range of reactions to death  Focusing on treatment, pain  Points out counseling needs o Significance of hospital staff for the terminally ill  Broken down barriers & taboos  Palliative care: make patient feel comfortable  not curative care: designed to cure the Criticisms: disease/illness  Terminal care – for staff a lot of unpleasant  Bereavement: emotions attendant upon the loss of someone custodial work (feeding, changing),  Grief: deep sorrow, usually is response to bereavement emotionally draining o Involving a feeling of hollowness and marked by  A lot of research on this preoccupation w the dead person, expressions of hostility toward others, and guilt over death Achieving an Appropriate Death o May involve restlessness, inability to concentrate,  A set of goals for medical staff in their work w the dying and other adverse psychological and physical patient symptoms 1. Informed consent: patients should be told  Can be mistakenly diagnosed as depression, but 2. Safe conduct: helpful guides is actually bereavement o Psychological safety, pain management  So when psychologists assess for 3. Significant survival: use remaining time depression, they ask if there was a recent o Focusing on patient’s significance of the end loss o Trying to find significance in their live (what they’ve o Can last from days to years already accomplished) 4. Anticipatory grief: work thru loss & depression Stages of Mourning 5. Timely & appropriate death: allowed to achieve death w 1. Reaction stage: dignity o numb, shock o coping mechanism (plan) Counselling o may need assistance  Therapy is short term & timing of the session dependent o make sense of death on the patient o anger (could have done anything differently?) o Thanatologist: those who research death and dying 2. Yearning & Searching: o Clinical Thanatology: therapy for those who are dying o desire to return things to how they once were  Individual Therapy o not acknowledging the finality o Patients talk w someone about how they feel about 3. Disorganization & reorganization : themselves, their lives, their families, and death o disappointed that the loss cannot be undone, despair, o Need to regain perceived control over their life depression o Symbolic immortality: a sense of leaving behind a o difficulty enjoying & making plans legacy o struggle w forming a new identity  Family Therapy o make go thru depression & despair o When a family member is dying, all are affected. 4. Reorientation & recovery stage: o Sometimes, it is necessary to bring in outside help to o take part in new activities deal with a wide variety of issues o “rejoin” the world  Socialize more Alternatives to Hospital Care: Palliative Care  Some people may have unresolved grief: never return to a Hospice Care normal pattern of living  Designed to provide warm, personal comfort  Can be residential (have doctors available) or home-based The Adult Survivor and Grief  Pain is managed and invasive treatments are Psychological problems  Depression, sadness, anger, anxiety discontinued (do not prolong lives) o psychological comfort is a key concern and increasing  Most people display resiliency social support, personal care Physical problems Home Care  increased rates of illness, dying, impairs immune system  Favored choice of terminally ill patients – personal o ex. increase mortality rate of a widower whose wife just control & available social support passed away  Can be problematic for family members – daily routines; constant contact can be beneficial & stressful Social problems  Easier w services (health care workers, nurses)  Difficult for outsiders to appreciate the degree of a survivor’s grief Issues Survivors Face o Often ppl feel that because the death was a long time  Even when the death is anticipated (funeral preparations ago, the person should be done grieving o Talking about “getting over it” & “finding someone made, etc…) and on some level even wished for, it can be very hard for survivors to cope. new” often starts within a few weeks of the death  Rumination (thinking about the stressor over & over)  The Adult Survivor  The survivor’s routine has often disrupted by the course of o increased experiences more stressors the terminal illness & adjustment after death can be o less social support o feeling less optimistic difficult  The survivor is often left to do things that they have not  Men ruminate more been responsible for in the past (general housekeeping,  Is it more adaptive to grieve or to avoid prolonged grief in response to death? minor fix-it jobs) o It may be more adaptive to avoid ruminating  Big portion is cancers, heart disease thoughts and engage in (+)ve assessments of the situation & social support resources Heart Disease o Those who engage in “grief work” experience better Coronary Heart Disease (CHD) psychological & physical well-being  CHD is a general term referring to illnesses caused by o Avoiding thoughts about loss, suppressing feelings, and Atherosclerosis distracting oneself leads to maladjustment 2 years late Build up of plaque on the artery walls   narrowing of the coronary arteries (vessels that supply the  Social support heart with blood)  harder to pump blood o A study of ppl who had lost a spouse to an accident or  w/o adequate oxygen & nutrients the heart doesn’t work suicide found that those who talked to friends about properly  chest pain (angina pectoris) the death had a smaller increase in number of  When more than one artery is completely blocked  heart illnesses following the death attack (myocardial infarction) o Those who continued to ruminate about the death had more illnesses (ulcers, headaches, pneumonia)  CHD is a major chronic disease  Also less social support  Cardiovascular disease is #2 killer in Canada, accounting for o The bereaved who take some type of action benefit 20% of deaths  Ex. planting a tree, starting a scholarship fund, CHD accounts for 20% of deaths in Canadian men and 22% of creating a scrapbook  So they’ve done something for their loved one deaths in Canadian women A number of factors appear to contribute to CHD: The Child Survivor  Explaining the death of a parent or sibling to a child can be Family history o Genetics difficult o similar Envts to one’s family o Child’s understanding of death is incomplete  diet, lifestyle  depending on age  Hostility and prolonged exposure to stress  May not understand that the person is not  Low levels of physical activity coming back  Cigarette smoking  Role changes  They don’t understand why  Socio-economic status  Inflammatory processes (c-reactive protein – a sign of  More psychological problems inflammation in the body) – contributes to the buildup of  submissive, dependent, introverted, irritability, depression, rebellion atherosclerotic plaque  Metabolic syndrome involves 3 or more of the following: o When the death is a sibling, the child may feel that o obesity around the waist, high bp, low HDL, problems they are at fault – may illicit feelings of guilt or shame  Loss of identity metabolizing sugar, high triglycerides, high reactivity  A disease of modernization & industrialization  Instead of waiting for the death to occur, it is in the child’s (occupational stress, demand of daily life, social instability) best interest to be prepared for the death, if possible  Might lash out as a sign of bad coping o Constantly under stress o Demanding lifestyles o Not sleeping a lot Death Education o Many responsibilities How do we make coping w death easier?  Educate o Less time to exercise o Difficulty eat a balanced diet  Helps ppl develop realistic expectations about what modern medicine can achieve  Determine kind of care the dying person wants or needs Women & CHD  CHD is leading killer of women in Canada (and most other  Dispels myths ppl may have about death developed countries)  Explaining the normal reactions of survivors, ways of coping o Important to say that there is no set defined way of  Occurs later for women (protective factors), however, it is more dangerous when it does occur coping o Fewer women are checked & check for symptoms, fewer sent for consultations, fewer sent to Ch. 11, 12: cardiologists Chronic Illnesses: Heart Disease, Hypertension, Diabetes, o Women are less likely to recover from a cardiac event Cancer o Fewer women are referred to see a cardiologist  We will only be asked about these 4 on the exam o More women die after being admitted to the hospital for heart problems  Chart of worldwide causes of death, made by the Gates family o More likely to experienced reduced quality of life o 1.7 million ppl die every year compared to men o Infectious Disease & birth problems (acute illnesses that can be prevented)  Less is known about women’s heart disease  In less developed countries  Why? o Preventable injuries o Used to be seen as a man’s disease o Non-communicable diseases o Women are less informed  Lack of education  Ex. Men give pain in left arm while women get Depression & CHD back pain  Depression a major independent risk factor in the onset o Less likely to receive preventative treatments (ex. of coronary disease medications, information, counseling)  Depression symptoms & metabolic syndrome o Lack of research  Depression & likelihood of a heart attack  Less is known about the pattern of heart disease Btwn hopelessness & heart attacks in women  Depression has been tied to inflammatory processes  Protected at young ages – HDLs, higher levels of estrogen – (elevated c-reactive protein, a marker of low-grade higher risk after menopause (weight gain, increased bp & inflammation) & its symptoms to metabolic syndrome cholesterol)  Treatment of depression may improve long-term  Estrogen diminishes sympathetic nervous system arousal recovery from heart attack  Lifestyle (men’s higher rates of unhealthy lifestyle factors during younger years) Other Risk Factors o Less healthy diet than females  Vigilant Coping: chronically searching the envt for potential threats Expressing vs. Harbouring Hostility  Anxiety  Anger: unpleasant adaptive emotion accompanied by o Trait anxiety results in poorer quality of life for physiological arousal when we are treated unfairly cardiac patients o Maladaptive when not expressed properly or not  Helplessness, pessimism, and ruminating over problems expressed at all o Depressive symptoms  Hostility: (-)ve attitude toward others  Social Dominance: dominate social interactions thru verbal o Expression of hostility and anger is related to competition enhanced cardiovascular system reactivity (not just o Constantly feeling you have to one-up other ppl the state of being hostile or angry)  Vital Exhaustion: a mental state marked by extreme fatigue, o It’s hostility that leads to the heart problems feeling defeated, enhanced irritability  Cardiovascular reactivity: increase in bp and heart rate due to frustration, harassment, or stress Frasure-Smith & colleagues at McGill University o The suppression of hostility or anger has been  Investigate the relationship btwn cardiovascular disease & associated with higher cardiovascular activity depression  Rumination  Followed 896 participants for 5 years after they had a o Less social support – less ppl gravitate toward them myocardial infarction  Assessed depression, anxiety, anger, perceived social Cardiovascular Reactivity and Hostility
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