Adapted from the Accommodation to Violent Dying
A Guide to Restorative Retelling and Support
Violent Death Bereavement Society
(July, 2008)

Each session begins with a brief individual “check in” for each participant. Emphasis will be placed on the Self-care Checklist. Beginning each group with this brief “check in” maintains a specific focus and allows facilitators to see how each participant is progressing concerning self-care over the course of the six weeks.

Each session ends with a 10-15 minute calming period. This will be comprised of soothing music and/or other relaxation techniques suggested by participants. In addition to teaching and encouraging practice with self-soothing techniques, ending sessions in this way gives participants a chance to quiet themselves before leaving the group.

 

Current Sources of Support

Family, friends, community, work, faith or spiritual beliefs.

It’s important to feel supported, that you have someone or something to fall back on. All of us need this, the sense of some person being there. Have you become isolated? Do you ever feel you are surrounded by people, you don’t belong and, you’re not supported? Perhaps here in the group you will begin to feel connection, a matrix of belonging.

• Who has been supportive to you? How so?
• Have your supports changed since the loss?
• Do you think you have “worn out” all your sources of support?
• What support could be available now?
• Do you protect those closest to you, hiding how you really feel or pretending to feel one way when you feel another?
• Who/what does not feel good/safe for you to be around?
• Do you ever feel that “nobody can ever understand?”

Spiritual: What about your spiritual community, beliefs or practices? Do they sustain you? What concept of death does each of you have? Do you have a concept of there being an afterlife? Do you sense a promise of reunion with the person you lost? Do you ever consider death to be a release for that person? Has this changed? Question of meaning: Why?

How Have You Changed?

(See handout on last page).

• How have you changed since the loss? (Consider physical, emotional, spiritual changes.)
• Possible changes include health, work, creativity, finances, nutrition, exercise, routines, sleep, friends, future, family relationships, sense of pleasure.
• How have you been dealing with these changes? Who has been most affected by these changes in you?
• How have you been dealing with these changes with others?
• What about self-care? Do you do things for yourself?
• What is “co-morbidity”? Prevalence of disease or illness or ill health that often goes along with “bereavement”. This may include accidents, illness and disease.Feelings of revenge for the loss (particularly related to homicide), self-blame for what happened (if only I’d…) and, most commonly re-enactment what you imagine the person heard, saw, felt (pain, suffering, terror) and what happened during the last moments are often co-morbid with loss due to unnatural causes.
• What is PTSD? (Panic attacks, flashbacks, re-enactment, active avoidance of reminders, terror, nightmares, intrusive thoughts).
• Depression (lack of concentration or focus, inability to make decisions, feelings of worthlessness, hopelessness, loss of identity, social isolation, weight loss or gain, psychomotor agitation or retardation, suicidal ideation or attempt, restricted range of emotions, sleep problems, no pleasure, no meaning).
• Substance abuse
• Panic attacks
• Change in or disappearance of sexual feelings, perhaps the disappearance of this in an ongoing significant relationship. “I look in the mirror and all I see is a middle-aged woman,” one group member said, “my husband moved upstairs last week”.

Of significance also is the feeling of being frozen since the loss. Everything has been on hold, often for years. Perhaps people in the group can identify what they feel they need to do, specifically and/or generally (e.g., sell a house; divide family treasures among family members; end a relationship), but they have been unable to take steps towards doing it. They don’t know where they’re going, and don’t even see a bridge.
This is also related to feelings of guilt, which lead to feeling unworthy. If someone feels as unworthy as group members do oftentimes, they feel they don’t deserve to feel better, to move on, to walk into any future, to create a home, to start something new, to laugh, to love and be loved, to hope.

Commemorative presentations

Note: These presentations vary widely in the degree to which each participant has organized their time. For example, a participant may bring a manila envelope, long unopened, containing news clippings related to the loss, which the participant then reads in no particular order and passes around the group.

In contrast, presentations may center around printed collections of writings and sketches produced by the deceased with copies for each group participant. We have eaten favorite foods, viewed videotapes, listened to musical recordings, shared accounts by an artist whose professional art pieces were based on memories of the deceased and of the nature of the loss. What is important is giving the group a feeling for the unique and special qualities of the deceased and of the nature of the group participant’s relationship with that person.

Preparing for these presentations has helped participants repair their sense of perspective. Sometimes members say they haven’t thought about or looked at special things which belonged to the deceased because of the pain it caused them to feel. Or participants may realize how they’ve lost a sense of time or the order of events surrounding the loss. Preparing for the group helps them identify these “blurs” and sort through them.

Relaxation Techniques

The facilitators guide the group towards “connected awareness”. Know that your voice is an important connection for participants who are new to working in this way and/or new to working with you as a guide.

Give them time to focus on their breathing, and relax on their own during this period of stillness, with you as their guide. They will become confident in you, in themselves, in the group. Your voice is a connector.

Speak at a comfortable volume but be sure all can hear you. It produces anxiety in someone who is straining to hear what you’re saying. Ground yourself in your practice so you can guide others.

Share with the group that in learning progressive relaxation, they may find themselves going to sleep.

Sometimes this is an important and sought after outcome; but when using relaxation for self-soothing or centering, they will need to focus on one thing – their own breath. Gently maintain awareness.

Benefits from practicing relaxation techniques:

• Relax: your mind (intrusive thoughts, images); your body (rapid heartbeat, stomach-digestive problems, dizziness, panic, headaches, blood pressure, infections, e.g. sinus, colds, flu)
• Positive physiological effects
• Calming
• Way to ground yourself after upset/difficult time or when you feel anxiety or disconnection

Reinforce and practice anchoring, soft belly, focus on the breathing, grounding your feet on the floor, the Earth.
Whether any of this is old or new for people, it is always good to practice.

• Hands over your belly can comfort you when you feel anxious or vulnerable.
• Hands over your heart can warm you to feel compassion.
• Anchor–thumb and forefinger; rest hands in lap
• Sit comfortably; nothing crossed; feel where you’re tight blocked
• Close eyes if you’re comfortable doing so
• If people, thoughts, pressures, negative voices–acknowledge: “later”
• Focus on breathing

Facilitator Roles

As in any group, the facilitators act as role models who set boundaries (time, space, order), put words to actions, thoughts and feelings, models nurturing and caring behaviors, and encourage connections and interactions among group participants. Group participants often view the facilitators not only as an authority, but as professionals with obligations to perform in certain ways in the group. They count on this. But this has its limitations and, in fact, as the group coheres and becomes more active, the role of the facilitators changes and becomes more of being present, holding, “getting out of the way” of the group.

The facilitators model acceptance, not judging participants, not giving advice. The facilitators value feelings which are honestly expressed. Distress or anger, sadness or confusion are made safe within the group as the facilitator maintains the healing setting and the relationships “under fire”. Active listening, restating, soliciting input from the group are all important behaviors which aid individuals and the group in developing trust and resilience.

Questions and interpretations remain open-ended and tentative, since each participant will discover their own distinctive pathway toward accommodation. The facilitators are not authorities with unitary solutions, but guides who help in establishing coordinates and boundaries. By maintaining group morale while inculcating resilient capacities as a counterbalancing referent to separation and trauma distress, the facilitators re-establish movement and direction beyond the unnatural death.

Since treatment is time limited, a strong and confident assumption comes from the facilitators that the group member can make this transition. Treatment goals are limited to beginning adjustment to unnatural death and to creating a solid basis for future accommodation. This emphasis on accommodation as a lifelong challenge rather than a short-term cure is important to emphasize. In doing so, facilitators clarify their role as collaborative and catalytic instead of primary and sustained.

Facilitator Characteristics

The facilitator will have had enough group support experience to demonstrate competence in initiating, reinforcing, and restoring group cohesion. Also, the facilitator will have a solid knowledge base and experience in support with participants with traumatic distress and separation distress. Facilitators will also require enough diagnostic insight to carry out an accurate pre-support assessment including the recognition of co-morbid disorders. The facilitator will have competence in managing the format and goals of short term support which dictates a high level of organizational skills. They will also have familiarity and skill with techniques of stress management and graduated exposure.

This combination of clinical capacities can be found in any level of clinician (psychiatrist, psychologist, social worker or counselor). Clinicians with extensive experience with participants unable to accommodate to unnatural death will presumably be more comfortable with this target population.

Expertise in the following areas is requisite for a facilitator:

• An active, energetic style of engagement
• Knowing how to intervene in an altruistic way
• Ability to teach group members how to become effective listeners and supporters because of the facilitator’s own respectful and sensitive communication style.

Facilitator Attitudes

A tolerance for ambiguity (i.e., accommodation to unnatural dying cannot be “completed”). Since accommodation will never end, it seems wise to approach these sessions as a beginning or a piece of the healing journey rather than insisting on it being a definitive end and goal. Acceptance of ambiguity will allow participants the freedom and flexibility to develop their own tolerance for ambiguity instead of maintaining the rigid and repetitive imagery and behaviors of separation/trauma distress.

Self-maintenance of calmness, hopefulness, genuineness and humor. Facilitators see their role as collaborators in helping participants retell their traumatic death narratives in a way that provides modification and change in meaning. A facilitator who insists on maintaining authority cannot “author” someone else’s narrative.

The Healing Setting: Safety

Late Arrivals

Lateness is disruptive to group cohesion and coherence. While these interruptions cannot be avoided, we emphasize the importance of participants’ making every effort to contact the facilitator so that absences can be explained. Consider “bringing it to the group”. Ask them how they feel when these things happen. Have them state this during the group session. Have them convey this directly to the group member the next time the participant attends. Hold your boundaries; start and end the group on time.

No Shows

Will you call a participant who doesn’t attend and doesn’t call? Yes. A brief call the following day is important. Check in briefly, let them know the group missed them and ask if they’ll be there next time. Reiterate the importance of their calling you if they’re not coming. Continue to give members your phone number and encourage them to call if they’re not coming. We also point out that there are no “make-up” sessions so absences are irrecoverable.

Participants who are Intoxicated

What will you do if a participant comes to a session while intoxicated? Would you ignore the obvious? No, and neither will the group. Kindly, ask the participant if this is what is going on, acknowledge it in the group’s presence and let the individual know you appreciate how important the group must be to him/her. However, you need to also let the participant know that it is not appropriate for anyone who is intoxicated to come to the group.

Drop-outs

What about a group member who drops out before the end of the six sessions? Of course you want to talk with that person individually. Find out what makes it necessary for them to stop attending. Invite them to call you in the future if they are interested in being in the group. Let your group know you’ll call that participant, then inform the group of the individual’s decision. You might want to invite the group to sign a card to send to that individual. This is an opportunity for your group to say “good-bye” in a “safe way” for them.

A Participant Becomes Overwhelmed

What if a group participant begins to dissociate or get caught up in trauma and lose track of relating to the group? We suggest that it is your role as facilitator to interrupt in an empathic way, acknowledging your feeling that something is going on with that participant, that you want to hear what he/she is saying, but it feels like that person is becoming isolated from the group. Ask the group if anyone else is having the same feeling. Let the group participant know you’re going to begin interrupting when the dissociating occurs. Reiterate that you want to hear, and the group wants to hear, about what is going on but when you feel that group participant is getting isolated, you’ll let the participant know you recognize it and will try to help him/her stay in touch with the group. You may find you are met initially with an angry response from that participant, but if you remember what your role is, this will resolve within the group. That person knows on some level that he/she “loses it” when he/she talks about certain things, and the group feels anxiety escalate when this occurs. You as facilitator are not alone in feeling a loss of contact with the individual. Have the group work with this. Ultimately, this will be a group building experience, something you do together.

How Have You Changed? Handout

As you look through the following list, consider how you’ve changed since the person you loved died. Are there others you might add?

1. Physically
   • Significant weight gain/loss
   • Decreased/no energy
   • Headaches
   • Frequent accidents
   • Frequent illness
   • Cancer
   • Stomach problems
   • Digestive problems
   • Heart problems
   • High blood pressure
   • Not enough sleep
   • Sleep a lot
   • No exercise
   • Poor nutrition
   • Eat irregularly
   • Abusing substance(s)
   • Ache all the time
2. Spiritually
   • No sense of direction
   • Meaningless
   • No joy or pleasure
   • No connection
   • Sense that nothing matters
   • No ritual
   • Feel alone
3. Emotionality
   • Depressed mood
   • No interests
   • Despondent
   • Hopeless
   • No interest in friends
   • No interest in activities
   • No routines
   • No future
   • No dreams
   • Not creative
   • Not interested in family
   • Easily frustrated
   • Can’t concentrate
   • Forgetful
   • Rages/increased anger
   • Mood swings
   • Irritable
   • No tolerance
   • Just drag through the days
4. Productivity/Work
   • Became unemployed since the loss
   • Co-workers of no interest
   • No ideas
   • Just hanging in there
   • No interest in work
   • Feel trapped
5. Financial
   • Don’t spend any money
   • Have spent way too much
   • Behind in paying bills
   • Have incurred late payment charges
   • Things are out of control
   • Don’t care

Are there any other things you would add? How have you been dealing with these changes?