From Loss to Rebuilding

FALL 2015 - Vol. 6, N0 1 FROM LOSS TO REBUILDING:

Seniors and the Grieving Process JOURNAL OF THE CENTRE DE RECHERCHE ET D’EXPERTISE EN GÉRONTOLOGIE SOCIALE JOURNAL OF THE CENTRE DE RECHERCHE ET D’EXPERTISE EDITORIAL BOARD DESIGN AND PRODUCTION Virginie Tuboeuf Valérie Bourgeois-Guérin, Ph. D. Psychologist Professor, Department of Psychology ISSUE COORDINATION Université du Québec à Montréal Geneviève Lamy Coordination of knowledge transfert Isabelle Van Pevenage, Ph. D. Institutional researcher, CREGÉS Integrated Health and Social Services University Network CONTACT for West-Central-Montreal CREGÉS Annette Leibing, Ph. D. 5800, Cavendish Blvd, 6th floor Professor, medical anthropology Côte St-Luc, Québec H4W 2T5 Université de Montréal phone : 514 484-7878, ext. 1463 Faculté des sciences infirmières e-mail : [email protected]

REVISION AND TRANSLATION Vanessa Nicolai and Marie-Chantal Plante

Pluralages is published by the Centre de recherche et d’expertise en gérontologie sociale (CREGÉS) of the Integrated Health and Social Services University Network for West-Central-Montreal. This magazine is designed to inform the public and raise awareness of social issues surrounding aging by, among other things, presenting the research initiatives and expertise being developed by members of the CREGÉS. Pluralages also aims to promote and foster ties between the research, education, practice and citizen action - for and by seniors - communities. Issues related to aging are presented through the lens of social gerontology, touching on such themes as diversity in aging, social and citizen recognition of the elderly, experiences with social exclusions and solidarities, political concerns, State directives and public policy targeting the aging population and its needs. Pluralages is published in French and English, in print and electronic versions. Please feel free to contact us for a paper copy in your preferred language. Articles published by external collaborators are the sole responsibility or their authors, and the CIUSSS board of directors and management are in no way liable for their contents. The contents may be reproduced with identification of the source.

ISSN 1920 - 7166 © CREGÉS - Centre de recherche et d’expertise en gérontologie sociale FALL 2015 - Vol. 6, N0 1

EDITORIAL

Valérie Bourgeois-Guérin, Isabelle Van Pevenage and Annette Leibing...... 5

GROUNDED PRACTICES

Alzheimer’s Disease and Ambiguous Loss...... 8 April Hayward, Jessica Seidman and Gisèle Poirier

The threat of being less than we are when encountering loss...... 12 Christopher J. MacKinnon and Deborah Ummel

How to support practitioners in their care of the caregivers: mapping factors that affect the grieving process...... 19 Isabelle Van Pevenage, Pam Orzeck, Zelda Freitas, Claire Van Pevenage and Patrick Durivage

APPLIED RESEARCH

Cultural Reflections on “Aging, Death and... Change”...... 25 Luce Des Aulniers

Ways to understand the grief and losses experienced by seniors...... 34 Valérie Bourgeois-Guérin

STUDENT’S FORUM

Harp accompaniment in palliative care: A preliminary exploration of an emerging practice...... 39 Mehdi Azri, Florence Vinit and Annabelle Renzo

Aging out of place into homelessness: The role of grief and loss...... 44 Victoria Burns

Collage: an art therapy intervention facilitating an experience of loss among hearing-impaired seniors...... 49 Marie-Soleil Blanchet

CITIZEN’S FORUM

Being gay in a heteronormative society...... 53 Jean Lalonde 4 Pluralages – FALL 2015 – Vol. 6, N0 1 ©freemagebank.com editorial

What do we know about the losses and grief of seniors?

Aging is often accompanied by loss and grieving. Yet, despite frequency of these experiences, we tend not to know much about them.

In May 2015, the Centre for Research and Expertise in Social Gerontology (CREGÉS) held the conference "From Loss to Rebuilding: Seniors and the Grieving Process". Several hundred individuals attended a variety of inspiring presentations and works- hops. This issue of Pluralages aims to share many of the thoughts and ideas presented at the conference with a wider audience. The short articles offer a variety of theoretical, clinical and more personal perspectives, painting a broad and diverse portrait of the losses experienced in late life.

The articles show the different faces of loss and grief, as well as their more universal aspects. They encourage us to avoid reductive thinking, which too often leads to a pathologization and medicali- zation of grief, advocating instead a more nuanced approach, which examines both the pain and solace in these experiences. Loss and grief necessarily involve letting go. Whether they are directly or indirectly related to death, they are clearly part of life. To preserve what is vital in these experiences, we need to recognize them and remain attentive to those who are living them.

These reflections help to better identify the needs of grieving seniors and their loved ones. They also aim to reveal forms of grief that are less well known or recognized in our society: the grief of homosexual seniors, the ambiguous loss experienced by families of patients with Alzheimer’s, the grief of homeless seniors.

©freemagebank.com In a context where death is often taboo or denied, a source of fascination or great discomfort, the grief of seniors is often passed over Loss and grief in silence, both at the social level and in terms of research. Several necessarily involve articles in this issue offer a careful, nuanced analysis of how this silence affects experiences of grief. letting go. Whether they are directly or What can we do to support seniors who are coping with loss and indirectly related to grief? Many people feel ill-equipped to confront loss or to support grieving loved ones. The articles in this issue look at different ways death, they are clearly to support bereaved seniors and end-of-life patients and those part of life. close to them. >

FALL 2015 – Vol. 6, N0 1 – Pluralages 5 The articles are also related to the research pillars of the Centre for Research and Expertise in Social Gerontology (CREGÉS). In describing the many faces of grief in late life and in noting that seniors are also “survivors” who can continue to change (by reviewing their priorities, for example), Valérie Bourgeois-Guérin encourages us to see older people as “social actors” (Research Pillar 1). Luce Des Aulniers similarly notes that seniors, with all their life experience, are just as confronted by “the new” as younger generations. Perhaps even more so, since they are “out of sync” with the modern cultural imperative to be “brief, intense and compact.” The article by April Hayward, Gisèle Poirier and Jessica Seidman on the grief experienced by family members of Alzheimer’s patients invites readers to discover the “heterogeneity of aging” (Research Pillar 2) and to reflect on the various aspects of grieving in this context. The moving personal account by Jean Lalonde is also clearly aligned with this research pillar, which reminds us of the importance of viewing aging from multiple perspectives. Christopher MacKinnon and Deborah Ummel invite us to pay attention to the grief of practitioners. In a similar vein, the article by Isabelle Van Pevenage, Pam Orzeck, Zelda Freitas, Claire Van Pevenage and Patrick Durivage proposes a tool to identify loved ones who likely need additional support following the death of a family member. The practice of harp playing in palliative care settings, described by Mehdi Azri and Florence Vinit, also opens up interesting avenues for future interventions. These articles are aligned with our third research pillar, “service delivery to seniors and their loved ones.” The study conducted by Victoria Burns, which explores the various forms of loss (family, work, health ) that can contribute to late-life homelessness, is related to our fourth research pillar, “living environments,” and how they affect the experience of seniors. Finally, in line with our fifth research pillar (“public policy”), several articles in this issue note the importance of developing interventions that meet the needs of grieving seniors and their loved ones.

These articles invite us to reflect openly on the grief and losses that come with aging. What if these painful experiences could also help us to forge ties and rebuild, in a different way, that which has been lost? Perhaps, in the final analysis, our efforts to understand and support bereaved seniors should be guided by this question: how, without denying the painful aspects of these experiences, can we help to turn the person’s loss and grief into something that is also . . . fertile?

Valérie Bourgeois-Guérin,

Isabelle Van Pevenage

Annette Leibing

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FALL 2015 – Vol. 6, N0 1 – Pluralages 7 Alzheimer’s Disease and Ambiguous Loss

April Hayward, Gisèle Poirier BSW Director of Programs and Services Volunteer spokesperson Alzheimer Society of Montreal* Alzheimer Society of Montreal [email protected]

Jessica Seidman, MSW Coordinator of the Counselling-Network Alzheimer Society of Montreal [email protected]

This past May, it was an honour to present “Alzheimer’s Disease and Ambiguous Loss” at the conference "From Loss to rebuilding: Seniors and the Grieving Process". With an audience composed primarily of health care professionals, our goal was to define and explain ambiguous loss; to describe the impact of this loss on a person living with dementia, as well as family members, caregivers and health care workers; and to propose concrete strategies to support people experiencing this form of grief. Above all, we hoped to provide some insight into the experiences of people facing ambiguous loss and grief.

To help us achieve this goal, we in their relationship; giving up linking with support services were fortunate to be joined by many of their dreams and plans (counselling and groups), and Gisèle Poirier, former caregi- for retirement; his move to long- learning more about dementia. ver for her husband, who cou- term care, which she described Although each person’s story rageously shared with workshop as “tearing them apart”; and, fi- and experience of grief will be attendees the ways in which her nally, adjusting to his passing distinct,1 Mrs. Poirier’s account journey as a caregiver had been away and finding herself no lon- captivated the audience, and interlaced with ambiguous loss ger a caregiver. Despite the de- brought a human face and voice and grief. Mrs. Poirier described vastating disease process, she to the theory being presented. specific moments such as reco- described how the loving bond gnizing the first signs of demen- between the couple remained Grieving is a universal, natu- tia and her husband’s diagnosis; strong, leaving her with beauti- ral, personal, necessary and of- the loss of verbal communica- ful memories. Mrs. Poirier found ten complex response to many tion between her and her hus- strength by connecting with her types of life events. Still, we live band, and the resulting changes network of family and friends, in a culture where the process >

*The Alzheimer Society of Montreal is a leading non-profit health organization working to improve the quality of life of people affected by Alzheimer’s disease and other dementias, and to advance the search for causes and cures. The Society provides direct services to people affected by dementia, including counselling, education, support groups, respite-stimulation programs and education. Currently, more than 33,000 Montrealers are living with Alzheimer’s disease or a related form of dementia.

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of grief is primarily associated spouse may feel she is no lon- Of course, in addition to the with death and dying. Kenneth ger married, since her husband grieving process, there are very J. Doka2 describes grief as “a does not know who she is. She real stressors associated with ca- companion to Alzheimer’s di- may feel she is living in a state of regiving. Traditionally, health sease at all phases of the disease uncertainty, which she does not care providers working with ca- and following death” (p. 144). know how to resolve. In addition, regivers focus on the stress and Alzheimer’s and other demen- caregivers may not recognize burden of caregiving, paying less tias involve multiple losses for their experiences and feelings as attention to the emotional im- the person living with the di- stemming from loss and grief5. pact of the losses experienced by sease and their family mem- the patient and their caregiver(s). bers. The person experiences Alzheimer’s disease is progres- Over the past 30 years, research losses in their functioning, role sive and irreversible, meaning has shown that grief and sorrow and autonomy, as well as their losses will continue to occur, of- significantly contribute to ca- sense of identity. Family mem- ten for many years. Caregivers regiver stress, and that it is not bers and friends lose elements of must continually adjust to only the tasks and responsibili- the person and their relationship, changes that occur as the di- ties that become overwhelming along with hopes and dreams for sease progresses. It can be and make it difficult for the per- the future. They may face other helpful to assist caregivers in ac- son to carry on4. Unidentified losses, including friends and so- knowledging these changes as and unattended grief may be cial networks. Their grief often losses. Common events include: expressed through a variety of begins well before the person initial symptoms and the diagno- emotions and symptoms: sad- dies3. This type of grief is com- sis; loss of a driver’s license; loss ness, anger, denial, fatigue, an- plex and ambiguous. It differs of autonomy (when the person xiety, loss of appetite and guilt,

Western culture is focused on fixing, curing and solving. Living with loss is often discouraged; instead, we seek closure. from the grief that typically ac- can no longer be left alone); loss among others5, 6. Unfortunately, companies death, because it is of friendships; the need for res- the symptoms associated with unclear, indeterminate and irre- pite care; incontinence; a move ambiguous loss are often not well solvable. Closure is not possible, to a long-term care facility; ag- understood or recognized by ca- because the person is physically gressive or embarrassing beha- regivers themselves or by health present but may be psychologi- viours; failure to recognize family care workers, and may overlap cally absent4. In other words, the members; palliative care and with signs of caregiver burden. person is still there, but not the death; bereavement and mour- “Grieving takes energy and ca- same way as before. Caregivers ning; and, for the grieving per- regiving takes energy” (p. 12)5. may not know whether or how to son, loss of the caregiving role.5, 6. Therefore, the emotional load grieve these losses as they arise. Helping people to identify, name may be doubled for a person ca- They may have trouble connec- and acknowledge these losses ring for someone living with de- ting with the person who re- can assist them in processing mentia. Allowing the individual mains. Ambiguous loss brings their grief. to explore, understand and re- complexity and confusion into cognize their grieving process, relationships—for example, a all the while addressing and >

FALL 2015 – Vol. 6, N0 1 – Pluralages 9 attending to practical means of and grieve losses along the ►► Consider addressing issues support, may ensure that nei- way4, 5. of grief and loss in support ther component is neglected, al- groups, which may help ca- lowing the person’s stress to be ►► Help the person work regivers to normalize and alleviated1, 5. towards "paradoxical share their experience with thinking"—that is, to others. Western culture is focused acknowledge the paradoxi- on fixing, curing and solving. cal situation they are expe- ►► Help caregivers find new Living with loss is often discou- riencing (the person is there, ways of connecting with the raged; instead, we seek closure. and yet isn’t), and to gra- person, despite their grief. However, if we wish to support dually become more comfor- Even at the more advanced people facing complex losses, we table with these seemingly stages of dementia, the per- must normalize grief. Following contradictory ideas1, 5. son can be reached and may are some suggestions of ways to enjoy the presence of others support those experiencing am- ►► Encourage caregivers to stay through music, touch, hu- biguous loss and grief associated connected with others, such mour, etc. This may relieve with dementia. as family and friends. distress4, 5.

►► Identify, name, validate and ►► For caregivers who appear ►► Provide information about normalize this experience. more isolated, try having dementia. Help the person This can help people cope, them identify their “psy- recognize and anticipate the move forward and gradually chological family”—those changes that may accom- make sense of what they people in their lives who may pany the disease. Be espe- are facing. Healing happens not be their biological family cially aware and sensitive in as people allow themselves but who are present, reliable moments that are known to to process their emotions and able to offer support1, 5. trigger a grief response, >

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such as moving a family The Alzheimer Society of Canada member to a long-term care has developed three practical re- facility5. sources to help health care professionals better understand the ►► Encourage caregivers to at- loss and grief associated with de- tend to their own well-being mentia. These can be accessed by taking time out for their free of charge8. own needs, eating well, being physically active and Special thanks to Mary Schulz, nurturing their spirituality. Director of Information, Support Services and Education, at the ►► Provide assistance with the Alzheimer Society of Canada, for more practical aspects of ca- her assistance in preparing this regiving (respite, home care, workshop. domestic tasks, etc.).

►► Be aware that each person

grieves differently and ad- 1. Boss, P. (2006). Loss, Trauma, and Resilience: just your approach accor- Therapeutic Work with Ambiguous Loss. NY: W.W. Norton & Company. ding to the person’s style 2. Doka, K. J. (2004). Grief and Dementia. In Doka, 3 and needs . K. J. (Ed.), Living with Grief: Alzheimer’s Disease. Washington, D.C.: Hospice Foundation of America. ►► Recognize that there is no 3. Doka, K.J. (2010). Grief, multiple loss and de- solution for ambiguous mentia, Bereavement Care, Vol. 29 (3) 2010, 15-20. grief; this does not, howe- 4. Boss, P. (2011). Loving Someone Who Has ver, mean your efforts have Dementia: How to Find Hope While Coping failed4. with Stress and Grief. CA: Jossey-Bass. 5. Alzheimer Society of Canada. (2013). Ambiguous loss and grief: A resource for Finally, it is important for pro- health-care providers. Accessed at: http://www. fessionals who apply these alzheimer.ca/~/media/Files/national/For-HCP/ for_hcp_ambiguous_loss_e.pdf principles in their work to ac- 6. Alzheimer Society of Canada. (2013). knowledge and allow space for Ambiguous loss and grief in dementia: A re- their own grieving. As human source for individuals and families. Accessed at: http://www.alzheimer.ca/~/media/Files/na- beings we connect with others tional/Core-lit-brochures/ambiguous_loss_ family_e.pdf and feel their loss, sometimes 7. Alzheimer Society of Canada. (2014). Dementia very deeply. Professionals can and staff grief : A resource for healthcare provi- equally benefit from normali- ders. Accessed at: http://www.alzheimer.ca/~/ media/Files/national/For-HCP/staff_grief_e. zing, validating and expressing pdf these feelings, engaging in ri- 8. www.alzheimer.ca/healthcareprofessio- tuals or symbolic gestures that nals, French version: www.alzheimer.ca/ professionnelsdelasante. help them remember the person and achieve closure, and obtai- ning formal support from super- visors and the administration7.

FALL 2015 – Vol. 6, N0 1 – Pluralages 11 The threat of being less than we are when encountering loss

Christopher J. MacKinnon, 1 Ph. D. Department of Oncology, McGill University Balfour M. Mount Palliative Care Unit McGill University Health Center [email protected]

Deborah Ummel, Ph. D. candidate Balfour M. Mount Palliative Care Unit, McGill University Health Center Department of Psychology, Université de Montréal

Professionals who have chosen to work in the field of aging are often confronted with the complexities of loss and bereavement. Some perils of working with loss include the risk of stressful circumstances that can evoke feelings of hopelessness, powerlessness, and meaninglessness. It is incumbent on us to attend to these perils lest we risk job dissatisfaction, heightened absenteeism, and burnout. This article explores some of the personal and professional challenges for those working in the domain of aging, identifying responses that may foster resilience, as well as renew meaning and fulfilment at work.

The most painful state of being is remembering the future, particularly the one you’ll never have. Søren Kierkegaard2, 1954, p. 54

If you work with elders, you may inherent vulnerability; we are at soul, some of us may ask several be faced with the dual hardship the mercy of a universe that can difficult questions: of witnessing not only the losses visit loss upon us at a time of its of others, but confronting your choosing. Lurking somewhere in ►► “What does it say about me own losses as well. In this cumu- our consciousness is the realiza- that I work with aging and lative encounter with loss we are tion that one day we will lose it loss?” > reminded that our lives are fi- all at the moment of our death. nite. We sometimes sense our During our dark nights of the

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►► “How do I marshal ways to work. Furthermore, we might ourselves and compel us to chart sustain myself in this compli- probe those deep parts of our a new course for our life story. cated enterprise?” humanity which are stirred when confronted with loss to discern The death of someone impor- ►► “How do I respond what message our psyche is tant is often a watershed mo- constructively when my re- trying to relay to us. ment, bringing about a moment serves erode in the face of of great transition. A primary suffering?” character of our life story exits LOSS: A COMPULSORY the scene and we can find our ►► “What can continue to PASSAGE very meaning and purpose in give my work (and my life) life derailed. The ways in which meaning?” People cope with the death of we react can be unprecedented; those they love with remarkable we panic, we get depressed, we Wrestling with these questions, and sometimes inspiring resi- criticize ourselves for not dea- which some would say is com- lience—except when they don’t, ling with things better7. We dis- pulsory if we are not to slip into in which case they risk becoming cover how much we tend to burnout3, is not for the faint of immobilized in a world seemingly make plans for the future, at the heart. To honour these misgi- devoid of that one, compellin- same time lamenting the fact vings, it is necessary to dig down gly essential attachment figure, that these plans will not be rea- deep and find courage. Working unable to assimilate the appa- lized. The world becomes less with loss demands nothing less rent impossibility of the death safe and predictable than it once than periodically revisiting ques- into a life story now bleached of was. Difficult questions arise, tions like these, all expressions of meaning by bereavement. which evade all our attempts to our profound need for purpose, Robert Neimeyer4, 2010, p. 88 answer8. direction, and meaning in both the personal and professional As a starting point, we will ground When encountering loss, be it spheres of our life. what follows within the narrative- a loss of our own or the loss of constructivist tradition of psy- those for whom we work, there Perhaps part of a reply to these chology and psychotherapy, and is a significant risk that we can be queries lies in rediscovering more specifically within the mea- diminished by our own response. what drew us to this discipline ning-reconstruction paradigm5. We are diminished when we that some might call a vocation. This theoretical framework pre- disengage from our lives, des- Oftentimes we can trace our mo- supposes that humans tend to cend into bitterness, ruminate tivations to experiences from organize their lives around the about past decisions, lament early life that set in place a defi- stories they tell6. All good stories over regrets, or even stagnate9. ning social script we continue to have turning points, be they mo- When the metaphorical clock of follow into adulthood. After all, ments of triumph or unexpected our lives stops ticking, we are being a caregiver of others is a reversals. Over time, changes in held captive by our tendency common role many of us assu- both the personal or professio- towards lethargy, putting off med as children and adolescents, nal domains are guaranteed, and the inner work that a construc- for better or for worse. We might thus the story changes. Changes tive response to loss necessi- also try to better understand what can be of our own choosing, but tates. Lethargy can take the form gives, or gave, us some sense of more often the painful ones are of avoiding certain situations or fulfilment and satisfaction in our imposed by forces greater than responsibility, as well as more >

FALL 2015 – Vol. 6, N0 1 – Pluralages 13 problematic behaviours like per- If you work in the sometimes har- Warren’s despair was palpable nicious substance abuse or other rowing field of aging, no doubt and powerful. His story stirred addictive activities. you are often faced with the in the psychologist his own an- complexities of people who are xiety. The depth of Warren’s pain We are proposing here the exis- confronting loss. Let us never was almost overwhelming, evo- tence of a paradoxical response forget that our elders are vete- king a sense of powerlessness in to loss, namely that said loss can rans of loss. The steady march the clinician. It also brought up be a summons for us to partici- of time brings with it a myriad of his own longstanding fears of in- pate in a deeper engagement losses that encompass not me- competence, his concern that he with our lives9, 10. It is an oppor- rely the loss of relationships, but is unable to make any real diffe- tunity, albeit a painful one, to also the more subtle and perva- rence in the lives of those he ac- cultivate a more profound matu- sive losses of identity, autonomy, companies. He asked himself, rity. Now, while all of this sounds control, respect and confidence “Are there any words of comfort great, when we are most ho- in life. that would assuage even slightly the torrent of despair Warren is The steady march of time brings with it a sharing?” Moreover, the story myriad of losses that encompass not merely the reminded the psychologist of his own losses, recent reversals loss of relationships, but also the more subtle in his marriage, and turns of for- and pervasive losses of identity, autonomy, tune in his career. “How can I be control, respect and confidence in life. a good helper to Warren when I too am overwhelmed by shatte- nest, nobody really wants to res- To illustrate some of the com- ring loss?” pond to this summons from life. plexities of this subject, here is Growing up is often excrucia- a real-life story with the fine de- In these moments of witnessing ting work, and there are protec- tails masked to preserve anony- the suffering of the other, we can tive forces inside each of us that mity and confidentiality. Warren, be deeply touched by the reso- will always choose the path of a gentleman in his mid-sixties, nance of our own loss history. A security (and lower anxiety) over came to consult with one of our metaphorical chasm opens be- the path of expansion. The risk psychologists several months fol- fore us and the road seems im- is that our response to bereave- lowing the death of his spouse passable. We are reminded, in a ment can reduce us, halting the in our palliative care unit. He humbling way, of our own limita- discovery of a possibly richer and was suffering greatly, and one tions. We stumble, hesitate, and fuller life. day he arrived at a session with desperately look for guidance. tears streaming down his face. THE CHALLENGE OF “I miss her so much. My life is In this case, the psychologist ENCOUNTERING LOSS over without her. I have no va- unwittingly fell back on his well- lue. Nothing matters anymore.” honed strategies of avoidance. Meaninglessness inhibits fullness He arches his head back towards He changed the subject, gave of life and is therefore equiva- the ceiling. “I am so tired,” he advice, minimized the distress, lent to illness. Meaning makes a says with a whimper. “I just want and essentially neglected to great many things endurable— to sleep and never wake up. I meet Warren where he was at. perhaps everything. don’t want to kill myself, but I am It was only later, in consulting Carl Jung11, 1963, p. 340 through with life.” with his own therapist, that >

14 Pluralages – FALL 2015 – Vol. 6, N0 1 groundedpractices ©Istock some of the deeper truths about aftermath of death can look like. what transpired between himself However, there are also strong Neglecting loss across the lifes- and Warren came into conscious and implicit anxieties at work in pan reinforces the idea that avoi- awareness. the background that advance ding these difficult realities of this agenda of minimization. life, even unavoidable realities Imagine the reaction of parents like death, is preferable. THE RISKS OF or teachers to the introduction NEGLECTING LOSS of a death education class in Moreover, there is always a schools! Despite the monumen- tendency to minimize the im- Sometimes the minimization of tal pushback we could realisti- pact of loss in our lives, often loss as a valid subject harkens cally expect from such a radical because loss carries with it an ex- back to messages from our his- idea, the neglect of loss as a va- cess of heavy-hitting emotions. torical authorities (i.e., parents lid and important topic for all For many of us in the aging busi- or guardians) who neglected to ages carries with it important ra- ness we call gerontology, there is mention, or shielded us from, mifications. Many bereft indivi- often the understandable desire the fact that death is an integral duals who have consulted with to stay afloat; after all, we need part of being human. Perhaps us in psychotherapy have often to come back to work in the mor- this oversight comes from the expressed feeling betrayed that ning to keep plowing our parti- understandably strong desire of no one took the time to warn cular field. > parents to protect their children them that people in fact do die, from some of the tragedy of life. or to inform them of what the

FALL 2015 – Vol. 6, N0 1 – Pluralages 15 The fallback position for many neglect to acknowledge the im- is a poor measure of life, but li- of us is found in the professio- pact of working with loss on our ving meaningfully is a good one, nal boundaries literature, further personhood, we may risk being for then we are living a develop- enshrined in the ethics codes less than we are, or diminished mental rather than a regressive of the various licensing bodies. in some ways and not fully living agenda. Professional boundaries are the the life we can. James Hollis10, 2006, p. 232-233 various forms of symbolic insula- tion that keeps us buffered from The ways in which we James Hollis is perhaps one of those we serve. Yet, while boun- acknowledge loss will vary as our most thoughtful psycho- daries and ethics are certainly im- each person follows the dictates logists when it comes to ad- portant, a part of us senses that of their conscience. We might dressing the profoundly human the failure to attend to the cumu- consider whether we lean to- dilemmas that keep us from fully lative effect of loss on our per- wards more instrumental or in- showing up to our own life. In his sonhood demands of us a more trinsic approaches to coping latest book9 argues that we are considered response than sim- with loss13. Individuals following usually defined by either the sto- ply falling back on those codified an instrumental grief style tend ries that have shaped us, or a partitions. We cannot forget that to engage in problem-solving path in opposition to these sto- a rigid adherence to boundaries as a means to cope and im- ries. For example, if we have often leads to other problems, merse themselves in activities been visited by a series of trage- such as a further de-humnized such as work, all the while ex- dies in life, we can perpetually health care system12. pressing fewer emotions. An in- fall back on a narrative of a doo- tuitive grief style is characterized med future that no amount of If you have read this far, you may by more expression of feeling, effort on our part will change: be working up the nerve to chal- sometimes with more depth and “Nothing ever goes my way.” If lenge your internal tendencies intensity. Correspondingly, intui- we are defined in opposition to to minimize the impact of expo- tive grievers may benefit from these tragedies, we might seek sure to loss. When this happens, talking more about their loss and to not take any risks so as not to a more anxiety-provoking ques- may seek out formal or infor- be caught off guard by tragedy tion surfaces: what are the risks mal support. On what end of the again: “I will never put myself in of failing to grieve our personal continuum do you find yourself? a place where an event like that and professional losses? will occur again.”

You may have already discer- REKINDLING WHAT Regrettably, neither of these two ned that the risk is disengage- MATTERS MOST: paths is a genuine expression of ment, not only from our work CHOOSING A who we are. Hollis quite compel- but from our lives. Because work CONSTRUCTIVE lingly places the responsibility is such a critical part of who we RESPONSE for our life path squarely on our are, when we disengage from shoulders. The implication for work we risk disconnecting with The central paradox of our cur- those working with loss is clear: ourselves. Part of the answer to rent feel-good culture is that we between the two paths descri- the question of risk is that when grow progressively more and bed above, you have a choice of we fail to grieve our losses, we more uncertain and less and less how you are going to respond risk not fully showing up to our persuaded that our lives really when encountering loss14. A lives. Put another way, if we mean something. Feeling good constructive response usually >

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demands creativity on our part To encourage a more personal and loss will bring about? in order to break away from the treatment of these topics, we of- two polarizing narratives. If we fer a series of prompts you may ►► What is my vision for my or- fail to respond to this summons use as a rough scaffolding to ganization and how do I wish from our psyche, we risk dimi- help you map a constructive and the future to look? nishment, disengagement, and meaningful response to the pre- living life more on the surface10. sence of loss in your life. Your CONCLUSION answers to these prompts will, of Often the constructive response course, be highly personal, with There has been a recent up- is the meaningful response. We certain questions being more or surge in scientific research on are, after all, meaning-seeking less useful, depending on your loss and bereavement. Perhaps creatures that need our lives particular sensibilities, develop- it is an indication that bereave- to make sense, to be purpose- mental phase in life, and current ment is playing a more funda- ful and, ultimately, to be wor- circumstances. mental role in scientific inquiry, thwhile15. Below we consider the commensurate with the role it implications of such a creative or ►► What initially drew me to has always played in human life9. meaning-based response16. work in the field of aging and Bereavement challenges us to loss?17 live again, resist diminishment, and learn ways to salvage some A MEANINGFUL ►► What do I most want for happiness from heartbreak20. APPROACH TO LOSS the patients and families I AND BEREAVEMENT serve?17

I would say that our patients ne- ►► When have I recently made Chris MacKinnon is the senior ver really despair because of any a difference in the life of palliative care psychologist at the suffering in itself. Instead, their someone I am working New Royal Victoria Hospital loca- despair stems in each instance with?17 ted at the Glen site of the McGill from a doubt as to whether suffe- University Health Centre. He ring is meaningful. Man is ready ►► What is fear making me, or holds an academic appointment and willing to shoulder any suf- keeping me, from doing in the Department of Oncology fering as soon and as long as he in my work with aging and at McGill Univeristy. He also can see a meaning in it. loss?17 maintains a private psycho- Viktor Frankl14, 1961, p. 5 logy practice at the Monkland ►► What was one of the more Professional and Medical Center It is in our response, sometimes meaningful moments I had in Notre-Dame-de-Grâce. as challenging as learning a new in working with aging and language, that we create for our- loss?9 Deborah Ummel is a palliative selves the possibility of discove- care psychology resident at the ring new, authentic, and more ►► What is the most valuable New Royal Victoria Hospital loca- meaningful expressions of our- thing I have learned in wor- ted at the Glen site of the McGill selves. This deeper engagement king with aging and loss?18 University Health Centre. She is a can help us get in touch with PhD candidate in clinical psycho- what matters most for each of us ►► What changes do I hope my logy at Université de Montréal. > in life10. research in the areas of aging

FALL 2015 – Vol. 6, N0 1 – Pluralages 17 14. Frankl, V.E. (1961). Logotherapy and the chal- Unité de soins palliatifs Balfour M. Mount, 1. lenge of suffering. Review of Existential Centre universitaire de santé McGill, 1001, Psychology and Psychiatry, 1, 3-7. boul. Décarie, D.09.3022, Montréal (Québec), Canada, H4A 3J1. christopher.mackinnon@mc- 15. Neimeyer, R. A. (2009). Constructivist psycho- gill.ca. therapy: Distinctive features. New York, NY: Routledge. 2. Kierkegaard, S. (1954) Fear and trembling and the sickness unto death. Garden City, N.Y., 16. MacKinnon, C. J., Milman, E., Smith, N. G., Doubleday. Henry, M., Berish, M., Copeland, L. S., ... Cohen, S. R. (2013). Means to meaning in cancer-re- Leiter, M. (2014). Évaluer et traiter l’épuisement 3. lated bereavement: Identifying clinical im- professionnel. Accredited continuing educa- plications for counseling psychologists. The tion workshop at the annual meeting of the Counseling Psychologist, 41(2), 216-239. Ordre des psychologues du Québec, Montreal, Quebec. 17. Lawlor, K., & Vachon, M. (2014). Cultivating resilience in a specialized palliative care multidis- Neimeyer, R. (2010b). Reconstructing the 4. ciplinary team. McGill University Heath Centre, continuing bond: A constructivist approach Montreal, Quebec. to grief therapy. In J. D. Raskin, S. K. Bridges & R. Neimeyer (Eds.), Studies in meaning: 18. Breitbart, W., Poppito, S., Rosenfeld, B., Vickers, Constructivist perspectives on theory, practice, A. J., Li, Y., Abbey, J., …Olden, M. (2012). Pilot and social justice. (pp. 65-92). New York, NY: randomized controlled trial of individual mea- Pace University Press. ning-centered psychotherapy for patients with advanced cancer. Journal of Clinical Oncology, Neimeyer, R. A., & Sands, D. C. (2011). Meaning 5. 30(12), 1304-1309. reconstruction in bereavement: From principles to practice. In R. A. Neimeyer, D. L. Harris, H. R. 19. Neimeyer, R. A. (2006). Lessons of loss: A guide Winokuer & G. F. Thornton (Eds.), Grief and be- to coping. Memphis, TN: Center for the Study reavement in contemporary society: Bridging of Loss and Transition. research and practice (pp. 9-22). New York, NY: Routledge. 20. Simmons, P. (2000). Learning to fall: The bles- sings of an imperfect life. New York, NY: 6. Neimeyer, R. A., & Bridges, S. K. (2003). Bantam Books. Postmodern approaches to psychotherapy. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies: Theory and Practice (2nd ed., pp. 272-316). New York, NY: The Guilford Press.

7. Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R. A., Duan, N.,… Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28(2), 103-117.

8. Katz, R. S. (2006). When our personal selves influence our professional work: An introduction to emotions and countertransference in end-of-life care. In R. S. Katz & T. G. Johnson (Eds.), When professionals weep: Emotional and countertransference responses in end-of- life care (pp. 3-9). New York, NY: Routledge.

9. Hollis, J. (2013). Hauntings: Dispelling the ghosts who run our lives. Asheville, NC: Chiron

10. Hollis, J. (2006). Finding meaning in the second half of life: How to finally, really grow up. New York, NY: Gotham.

11. Jung, C. (1963). Memories, dreams, reflections. (R. Winston & C. Winston, Trans.). New York, NY: Vintage Books.

12. Kopacz, D. R. (2014). Re-humanizing medicine: A holistic framework for transforming yourself, your practice, and the culture of medicine. Alresford, UK: Ayni Books.

13.Doka, K. J., & Martin, T. L. (2010). Grieving beyond gender: Understanding the ways men and women mourn. New York, NY: Routledge.

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How to support practitioners in their care of the caregivers: mapping factors that affect the grieving process1

Isabelle Van Pevenage, Pam Orzeck, Ph. D. SW, M.Sc. Institutional researcher, CREGÉS Coordinator of the Leading Practice in Caregiver Support, Integrated Health and Social Services University Network CREGÉS for West-Central-Montreal Integrated Health and Social Services University Network [email protected] for West-Central-Montreal [email protected]

Zelda Freitas, Claire Van Pevenage, SW Ph. D. Clinical Activities Specialist Clinical psychologist Integrated Health and Social Services University Network Hôpital Universitaire des Enfants Reine Fabiola (Brussels, for West-Central-Montreal Belgium) [email protected] [email protected]

Patrick Durivage, Avec la collaboration de SW, M.Sc. Coordinator of the Leading Practice in Community Chloé Dauphinais, B. Sc. Palliative Care for Seniors, CREGÉS and Eleonora Bogdanova Integrated Health and Social Services University Network for west-Central-Montreal [email protected]

BACKGROUND A number of studies have shown that families and friends are the primary source of care for seniors. Contrary to what today’s individualistic trends might suggest, it is still a widely held belief that families should be primarily responsible for the care of their aging family members. >

FALL 2015 – Vol. 6, N0 1 – Pluralages 19 This responsibility is reinfor- describing in details the distinc- process. This decision is based ced by policy guidelines on tion between a normal, compli- on the practitioner’s knowledge, providing care to vulnerable in- cated or pathological grieving experience and their professio- dividuals. Since the shift to am- process, it is worth noting that nal judgement. Although this bulatory care, these guidelines some individuals require more practice is common, it is not have encouraged families to active supportive intervention systematic, which may result in maintain older family members and follow-up, while others will some family members who may at home or in the community.2, 3, 4 work through this difficult time require additional bereavement In 2007, in Quebec, 728,000 ca- without requiring a professional support might fall through the regivers aged 45 and over pro- intervention. cracks. vided care to individuals aged 65 and over who were suffering How do healthcare practitioners It is due to this shortcoming that from a long-term health problem currently identify caregivers who a multidisciplinary team adapted or a physical limitation. Given require professional interven- a mapping tool, initially deve- the increased life expectancy, fa- tion ? In Quebec, the home care loped in the context of pedia- milies provide care to an elderly program (SAPA: soutien à l’au- tric palliative care. This tool was family member parent over a lon- tonomie des personnes âgées a relevant starting point, since it ger period of time. ie. support for the autonomy was designed to help practitio- of seniors) have propensity to ners identify and monitor more Caregiving experiences are di- view caregivers as a resource in vulnerable caregivers, assess the verse and influenced by several the client’s care evaluation form resources and obstacles in their individual, family cultural and so- and in the intervention plan. lives, and determine the on- cietal factors. A number of stu- Caregivers’ are can therefore going support they may require. dies have explored the various be viewed (not seen) as having ways in which this caregiving role any needs of their own and are METHODOLOGY can affect loved ones’ physical therefore not systematically eva- or psychological health, family luated. Furthermore, At the time A number of studies have looked dynamics and professional life. of death, the client’s file is closed at factors affecting the grieving Regardless of the family mem- and, unless their needs are not process from a number of dif- ber’s caregiving experience and systematically screened or as- ferent perspectives such as psy- the location where the care is sessed. They simply disappear chology, sociology, social work provided (long-term care facility, unless they are receiving some and nursing. (Most are in the hospital or at home), the death professional support of their own, field of psychology, but some of- of a loved one represents the last identified as a client. (Caregiver fer perspectives from sociology, stage in the caregiver helping re- is already receiving some form of social work and nursing fields lationship. The caregiver’s ex- professional support, he or she (science).) Certain studies consi- perience with their grief and simply “disappears.”) der the specific circumstances of bereavement process will also the death, such as suicide, can- vary according to several fac- It is therefore left to the discre- cer, degenerative disease and tors. The grief literature supports tion of the practitioner to de- palliative care. While others, that most individuals go through cide whether or not to follow examine the specific characteris- a “normal” grieving process. For up or open a file for a caregiver tics of the bereaved, and others, some, however, this is a long who may be at risk of developing the context of the relationship and complex phase.5 Without complications in their grieving with the deceased (spouses, >

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young children, older adults, cultural environment; and pro- list all of the factors on a single etc.). fessional and financial situations. page. This provided a complete It is important to note that, with visual overview of the situation. The first version of the mapping the exception of complicated Furthermore, the factors could tool was developed as part of a grief factors, all of the factors are be colour-coded according to study aimed at determining whe- presented in an unbiased man- whether they were a resource or ther the parents of seriously ill ner—to be evaluated as either obstacle (this underlines the im- children had received adequate obstacles or resources, depen- portance of presenting the fac- support. Based on a literature re- ding on the situation or person. tors in a neutral manner). Once view and analyses of in-depth cli- For example, the health of a lo- the practitioner or team deter- nical interviews with parents, the ved one can be good or poor. mined the implication of va- researcher drew up a preliminary The practical availability of the rious factors, they would be able list of factors influencing their family can be considerable or to answer two questions. First, experience during palliative care nil. We describe below how this does this person currently have and following the death of their choice is made. more obstacles than resources child. In addition to the compli- in his or her life? If so, bereave- cated grief risk factors identified Once these factors were iden- ment follow-up could be consi- in the literature, some 50 fac- tified, we then had to consider dered necessary. In addition, if a tors were grouped under six to- how practitioners could apply person requires more intensive pics: the child; the parents; the these factors in their clinical prac- support, the practitioners have nuclear family; the relational and tice. First, the authors opted to already identified resources >

FALL 2015 – Vol. 6, N0 1 – Pluralages 21 that may be mobilized as part of ►► the relationship between the using a pink highlighter). When this intervention. patient and caregiver; in doubt, they do not highlight ►► the family network; the factor. Undoubtedly, the pediatric and ►► the social network; geriatric contexts are different. ►► the professional and financial Once the map has been colour- However, having participated in situation of the caregiver; coded (even partially), it provides the development of a mapping ►► the caregiver’s experience practitioners with an overview of tool in a pediatric context, we felt with the health care and so- the situation and allows them to that the procedure used to iden- cial services system. answer two main questions: tify at-risk individuals, potential obstacles and/or resources du- In addition to these, factors that ►► Based on the colour-coding, ring the grieving process, could are recognized in the literature does this person have more be adapted to a geriatric context as signs of complicated grief are resources than obstacles, or since grief and loss are univer- included. In addition, the map- vice versa? sal human experiences, and as ping tool includes a glossary of already mentioned, there is cur- factors identified. Each one is ►► If this person requires follow- rently no tool in place to syste- listed in the form of a question up, what resources should matically identify individuals at and accompanied by examples. be mobilized to provide the risk of developing complications necessary support? following the death of a loved USE OF THE MAPPING one. TOOL TESTING THE MAPPING TOOL The Leading Practices in It is important to bear in mind Caregiver Support and later joi- that this tool has two main Once the factors related to an ned by the Leading Practices objectives: adult context had been iden- in Community Palliative Care tified and grouped according for Seniors at the Centre for ►► to provide a procedure or to the various aspects of grie- Research and Expertise in Social process to systematically ving, we began testing the tool Gerontology (CREGÉS), with the observe families in order to by asking three social workers support of the researcher on the identify those that are more from the CLSC René-Cassin and initial project, therefore concur- vulnerable; Benny Farm sectors, in Montreal, red to adapting the above- men- to use it in a retrospective man- tioned tool to a geriatric context. ►► to identify resources that ner. They were given instruc- Based on an extensive second li- practitioners can help mo- tions on how to color-code the terature review, some 60 factors bilize to develop a bereave- map, and were asked to use a influencing the losses expe- ment support plan with the recent client from their palliative rienced by loved ones were iden- caregiver. care caseload in the community. tified. While we cannot review all In addition, they were asked to of these factors here, we have Alone or with their interdiscipli- comment on the tool and one grouped them into seven broa- nary teams, practitioners colour- meeting was held with them to der themes related to the loss code factors that are considered discuss the results. experience of older adults: to be resources (e.g., using a ►► the person with diagnosis; green highlighter) and those The conference on grief held by ►► the caregiver; considered to be obstacles (e.g., CREGÉS in May 2015 was an >

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opportunity for us to present the observed that the comprehen- Practitioners expressed an avid preliminary version of the tool to sive quality of the tool would en- interest in using the tool in an approximately fifty participants sure that practitioners do not interdisciplinary work setting. who had registered for the ses- overlook certain elements when Several noted that the tool al- sion on post-caregiving grief. evaluating a situation, and would lows information to be shared We asked these participants to force them to consider aspects among team members and hi- test the tool the same way as the that are often neglected, such as ghlights the often stressful situa- first three practitioners (i.e., re- the caregiver’s experience with tion of the caregivers and how it trospectively). They were then the health care and social ser- may affect their post-caregiving instructed to form small groups vices system. bereavement. They also noted to discuss the pros and cons of a number of problems, notably the tool, based on this expe- Regarding the application of the that since the caregiver is not rience. Seven copies were com- mapping tool, participants com- considered a client with a file pleted. We present here some mented that it was practical and of their own, the tool does not of these results related to the easy to understand, although have a legitimate place in cur- content of the mapping tool, its many would have liked to have rent practices in the health and application and the professional more descriptive information on social services system. In addi- context in which the tool could certain factors. Participants ap- tion in certain situations, it could be administered. preciated the visual aspect of be difficult to single out one ca- the tool and noted that the co- regiver when several persons are In terms of content, the partici- lour-coding scheme gave them involved in the care. It was also pants pointed to the extensive a rapid overview of the person’s noted that clinical judgement is nature of the factors. One parti- resources and obstacles. A num- an important element to consi- cipant expressed concern at the ber of participants stated that der when evaluating a multi-fa- number of factors and the length using the tool would help them ceted situation of this nature. of time it may take to complete. save time in evaluating the si- Finally, several participants as- This concern, after some discus- tuation of caregivers. However, ked about the most opportune sion, proved to be not substan- they also mentioned that the sta- moment to use the mapping tiated by the other participants. tic, rigid quality of the tool could tool. As one social worker poin- However, to code all of the fac- be problematic. The map leaves ted out, it should not be used tors relatively quickly, practitio- little room for nuance. It pro- immediately after the patient ners noted the importance of vides a snapshot, whereas situa- passes away, since caregivers being well acquainted with care- tions tend to be more fluid and usually have a lot of support at givers and their individual situa- evolve over time. Some partici- this time. tions. Although the tool seems pants expressed reluctance to to be all-inclusive, several parti- use the tool at this time, as it CONCLUSION cipants remarked that additio- has not been scientifically valida- nal factors (information) could be ted. In addition, the participants The participants’ response to the added to the various categories. in the conference workshop did mapping tool was generally po- Several said they liked the fact not have the glossary and the- sitive. However, their feedback that the tool included positive as- refore lacked information that illustrated a number of issues pects of the person or situation, may have clarified some of the must be resolved before the tool since these are often neglected factors. can be implemented and used in an intervention. Finally, they effectively. >

FALL 2015 – Vol. 6, N0 1 – Pluralages 23 6. Van Pevenage, C., Van Pevenage, I., Geuzaine, The first step is to begin the va- C., Schell, M., Lambotte, I. & V. Delvenne (2013). Les besoins des parents confrontés aux soins lidation process. This would not palliatifs et au décès de leur enfant – étude ex- only ensure the effectiveness and ploratoire. Neuropsychiatrie de l’enfance et de l’adolescence, 67(7-8): 433-440. relevance of the tool; it would also reassure some practitioners who might be reluctant to use it. Validation would also allow us to answer a number of questions raised about the use of the mapping tool. For example, what skills are required to use the tool? Who should be involved in the process? When is the optimal time for administrating the tool? To what extent should the caregiver be involved in the process? For example, should a self-administered tool be developed in addition to a clinician administered one?

1. Thank you to Luisa Zacchia and Bill Green, practitioners at CLSC René-Cassin, CIUSSS du Centre-Ouest-de-l’Île-de-Montréal, and to all participants in the workshop “Ce qui arrive aux proches aidants lorsque l’aide au proche se ter- mine” (What happens to caregivers when caregiving ends) during the conference From Loss to Rebuilding: Seniors and the Grieving Process, held by CREGÉS in May 2015.

2. Lavoie, J. P. & N. Guberman (2010). Les poli- tiques québécoises à l’égard des personnes âgées avec des incapacités. Combattre ou gérer l’exclusion ? In M. Charpentier, N. Guberman, V. Billette, J. P. Lavoie, A. Grenier and I. Olazabal (dir.), Vieillir au pluriel. Perspectives sociales. (pp. 413-430). Quebec City: Presses de l’Univer- sité du Québec.

3. Ministère de la Famille et des Aînés (2012). Vieillir et vivre ensemble. Chez soi, dans sa communauté, au Québec. Quebec City: Government of Quebec.

4. Ministère de la Santé et des Services sociaux (2003). Chez soi, le premier choix - La poli- tique de soutien à domicile. Quebec City: Government of Quebec.

5. Hanus, M. (2006). Les deuils dans la vie. Deuils et séparations chez l’adulte et chez l’enfant. 3rd Edition. Paris: Maloine.

24 Pluralages – FALL 2015 – Vol. 6, N0 1 appliedresearch Cultural Reflections on “Aging, Death and... Change”

Luce Des Aulniers, 1 with the collaboration of Marie Lefebvre Ph. D. (Doctorat d’état) in Anthropology, Emeritus Associate Professor Faculty of Communications Founder of UQAM’s first interdisciplinary graduate program on death (1980) Université du Québec à Montréal [email protected]

TO START: CAN WE LEARN HOW TO GRIEVE? As you well know, with grief comes the recognition that life does not always match our dreams. These dreams are filled with fantasies about love (“If I love Louis enough, he’ll survive”), thoughts (“Where there’s a will, there’s a way”), and techniques (“They’ve found a new gene therapy, combined with drug x”). All of these beliefs, legitimate as they may be, are more or less manifestations of our child-like fantasy of being all-powerful.

Naturally this fantasy comes way. We live not as braggarts so as to keep something alive. up against reality, and not only blinded by our pretensions; ra- Something civilized. the reality of death—the ulti- ther, we become lucid about our mate limit! The aging process capacity for invention, precisely As I lead you toward the topic foreshadows a truth we must all because we are confronted by that is the focus of this confe- recognize at a given point: the li- this challenge. We don’t get rid rence, it is to celebrate our ap- mitation of this fantasy of omni- of the challenge; we overcome it. titude for grief, which we show potence. Civilizations temper the We surpass ourselves. from a very young age. A small shock of this unwelcome realiza- child learns that his fantasy may tion through institutions, rituals, In other words, our capacity to be both lessened and channel- rules and taboos. And through think, connect and create stems led into a project that will make solidarity. Human beings be- from the act of renouncing this him grow. When death occurs, come powerful, because they are fantasy of omnipotence. Our hu- he learns to survive through the connected to others. This sup- manity is born of the very expe- support of a person with a clearly port also limits the potentially to- rience of grief. The dynamic of defined identity and through the talitarian nature of our individual grief is set in motion when we expression of complex emo- will. In a sense, it is reassuring to choose to examine, sort, let go tions in the face of what no lon- be guided and supported in this or prolong in a different way, ger is and will no longer be. >

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Gradually, the sense of absence world (if only partial). our attention. shifts from a cruel void to a source of inspiration. To put it bluntly, today’s seniors When we stop to consider to- are experiencing an unprece- day’s generations of seniors, we In approaching grief as a limit dented, massive and unique realize they are the first, in thou- to omnipotence, I have consi- phenomenon in the history of sands of years, to experience derably shortened our intended humanity: our world is beco- the evanescence, if not the di- presentation. An act of renounce- ming dematerialized, notably sappearance, of traces of death. ment, indeed. through communication techno- There are far fewer tombstones logies and the omnipresence of in cemeteries: more than half of I will therefore focus my talk on images. This social demateria- all corpses in the West are cre- what is changing for older ge- lization, which our seniors can- mated, and the ashes are less nerations. A 90-year-old woman not ignore, curiously coincides and less frequently stored in of- put it well: with the growing importance of ficial burial places. If they are, it a very personal form of materia- is usually in columbaria, which “I think they invented the Internet lity. What type of materiality is connote a neat, orderly storage at the same time as floating this? That of the body maintai- area. The flat, uniform rows do floors. I have both. Some days I ning physical and spiritual life—a not necessarily allow for personal have the impression there is wa- materiality that, with age, makes ornamental features that surpass ter under the floor and it’s mo- its presence increasingly felt with the hard, cold reality of death. ving. I’m not saying that because a growing list of “things falling Both literally and figuratively! I have a floating brain! That’s apart,” as some might jokingly another matter. To put it simply, remark. Without over-generali- Here the raw, empirical way in could it be that the ground I’m zing, we could say that today’s ol- which a past existence is reco- walking on is more slippery than der generations are experiencing gnized often takes precedence before?”2 a psycho-cultural clash between over the metaphor of our shared two worlds. On the one hand is human destiny. Throughout the QUESTION: HOW the empirical, everyday, personal world, burial places are a physi- DOES ONE QUALIFY, world of sensations—a world that cal reminder of this destiny. IN CULTURAL TERMS, can prove challenging. On the THE ENVIRONMENT other is a largely dematerialized How can we surpass our indivi- IN WHICH TODAY’S world, reflected in new forms of dual existence and how should SENIORS AGED 60 TO virtual expression and control of we store it? In other words, 100 ARE LIVING? OR: We daily operations. As they expe- how has civilization taught us to should recognize that older rience this clash, older people transcend? We learn from the generations (and our own!) may quite reasonably think that experiences of those who came are enveloped by an often the end of their own existence before us and those who will fol- imperceptible mist that af- will coincide with the “end of a low. We learn by becoming aware fects us as a collectivity. way of being in the world”, as my of our terrestrial existence wit- dear 90-year-old woman would hin an infinite cosmos. Finally, we First layer of mist: We are af- say. The end of an era. are able to transcend our indivi- fected by the materiality of the dual destiny by seeking comfort aging body and, at the same This more or less confused im- in the many variations of the time, a dematerialization of the pression of slipping deserves world of the spirit, both in this >

FALL 2015 – Vol. 6, N0 1 – Pluralages 27 life and the next. You are familiar Second layer of mist: I propose need to be recognized and pro- with the exultant thoughts, the we examine this dematerializa- cessed. They require a capacity mythologies, the many beliefs in tion in terms of our relationship for discernment... our daily lives and, of course, re- to time. ligions. We can all agree that it Our experts on change ob- is easier to be poetic and serene Our relationship to time is a col- serve how we can run after any- when we detach ourselves from lective phenomenon, as wit- thing, provided it is new... Run, our observations of concrete rea- nessed by the statements of yes, since the present is mobile lity by trying to give them some today’s seniors, even though we and constantly being reinvented. kind of meaning. are tempted to hear in them only Which leads us to our second specific accounts of suffering fo- characteristic: the imperative to Let us return to the idea of di- cused on what and whom they be brief, intense and compact. sappearance, which silently have lost, as we have seen at to- We have to keep things concise, shapes our collective and perso- day’s conference. make an impression, grab atten- nal relationship with death. This tion, get a reaction. is how we observe a correlation How does our relationship to between two opposite tenden- time invite us to disappear? In this sense, seniors are clearly cies: on the one hand, as I have swimming against the tide. We just noted, the gradual disap- We are all witnessing a swelling, all know how difficult it is for pearance of funeral practices a hypertrophy of the present. them to be brief, for a number and material traces of death; on Phrases such as “live for today” of reasons. For some, the reason the other, the rise of individual vi- or “everything, right here, right might be related to the extent sibility, the public showcasing of now” reflect how the present and variety of their knowledge. each person’s life and acts, parti- has become a religion, which we Since all knowledge belongs to cularly online. On the one hand, might call presentism. Each one an environment, which it seeks to a disappearing act; on the other, of us is ordered to worship time, symbolically control or in which it an ego-driven call for attention. understood as this cult of the seeks to find coherence, the very Our seniors are not unaware of present. What are the characte- expression of this knowledge this: in recent months, they have ristics of this presentism? takes on a unique significance: had to consider how they would the more the environment moves like to die. Adding to this confu- First characteristic: our era is fo- and shrinks in daily life, the more sion is an increased uncertainty cused on the new. Ironically, se- words, that basic symbolic form, about the beyond, and an inse- niors are continually faced with turn into long, detailed accounts curity about how their traces and new situations, as they notice with many twists and turns, with even their legacy will be treated. changes in their physical vita- arguments by turns chaotic, by lity or perhaps have to move to turns organized. Behind these Today’s seniors experience this a new living environment. Of accounts is a symbolic gesture slide into dematerialization with course they can rely on past ex- of survival. In essence, people all of their senses, even when perience to deal with these new aged 60 and over are experien- those senses have been altered. developments. But unlike the cing a cultural arrhythmia, given We need to examine this impres- new approaches readily em- the emphasis we place on reac- sion of slipping into demateriali- braced by today’s managers, tivity. However, this arrhythmia zation in further detail. the new situations faced by se- reveals strategies and ideas that niors are more subtle. They many younger generations >

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can appreciate, provided they processes require an effort of handed down to him by his pre- see beyond the idealized image sorting and weighing. Rather decessors, but rather to the form of an old person telling stories than embracing brevity, seniors, that he gradually creates through about the “good old days” . . . in the way they see the world his experience of cyberculture. and fight against the dissolving What is valued must come from These treasures of the imagina- quality of death, can learn and HIS world before he can turn to tion may be enjoyed by all when teach us about the time requi- OTHER worlds of meaning-ma- young people ask seniors about red to grieve a loss. Any loss. king and analysis. today’s world as well. This deeply energizing learning requires us to be present... and We are therefore experiencing In the length and slow pace of patient. the loss of a form of knowledge the older person’s account lies that even affects how knowledge perhaps an aptitude for discern- Let us return to the cult of is transmitted. For all of the ge- ment, which we hope is inter- the present. There we find a nerations before us, transmit- generational. It involves taking third characteristic: Apart from ting knowledge involved coming time or allowing people time to newness and brevity, the world to terms with the enigmas of settle, to “process”... A “flash” as a series of instants can give existence and finding ways for is not the equivalent of a strong rise to an urgency to see eve- human beings to use their mea- opinion and even less a thought. rything before moving on to the ning-making capacities as part of When we “settle,” we unfold next thing. (Rarely do we think a cultural group. People transmit what is happening, we open the about how this sense of urgency a culture that is created out of an petals of our “impressions,” we might result from a mess of unre- awareness of death and ways of analyze the ins and outs, and solved problems . . . ). This world confronting this reality. then we prioritize and organize of the now and the new is one what is worthy of our attention. of fragmentation; it is a world For today’s generations, trans- By “settling,” we decide what to that values provisional meanings mitting is more about commu- keep to guide us. which are only valid in the mo- nicating information from our ment in which they occur. In this self-referential world. This is har- The fact that seniors reflect, ta- regard as well, seniors are out of dly an exaggeration. In any case, king the time to discern, brings sync. Their aptitude for discern- we seem to have abandoned us back to the idea I mentioned ment, which I mentioned just the art of living and shaken off at the beginning of my talk: na- now, is part of a unified logic that our responsibilities in our quest mely that grief is an ability to re- allows them to feel they are par- to “live life to the fullest,” in the ceive reality as it is, to deal with ticipating in worlds, with all of present. the mixed emotions resulting their mysteries, and are able to from loss, and to choose what act in a coherent manner. This in- This world of presentism, to let go, and what to keep as tegrative logic of worlds stands through brevity as well as an ob- something essential to our vital in opposition to the current do- session with the now, is slowly spirit. What the cognitive pro- minant definition of knowledge. becoming a world of non-attach- cesses behind both grief and How does this dominant trend ment. I don’t think I’m mistaken aging teach us is very different work? By valuing the interpre- in saying that the fourth cha- from the constant stream of inter more than the knower, in racteristic of this world is ephe- formation that reaches us in an the sense that the interpreter merality, which undermines the undifferentiated mass. These does not give priority to what is very principle of attachment. >

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In today’s presentist climate, our simply a treadmill, without mys- societies are organized by the teries and hidden paths to be HOW TO IMAGINE AN ephemeral, through the com- discovered. ART OF GRIEVING? plex and capricious operations of economic and technologi- As a result, both the past and fu- The resolution of any crisis— cal globalization. This obsession ture are obliterated, since nei- seen as something that upsets with the ephemeral, with being ther meets the criteria for what is and separates—requires us to on the move, necessarily oblite- agreeable and pleasant. Sources take time. Anyone who has ex- rates everything else, although of embarrassment, they must be perienced the death of someone paradoxically, for all its conven- quietly done away with. close will tell us they need time tional discourses on memory, our out, a time to just be. It is a phy- era is particularly forgetful. The future is necessarily frighte- sical need. We need time to cry. ning for a person who is fo- Our tears do not translate the For older people, regardless of cused on the self or, worse yet, feeling of being abandoned, of whether they have cognitive im- has only “himself” as a refe- finding no meaning in life fol- pairment or not, the reality of the rence. The cohesive force of so- lowing the loss of a person we ephemeral is traced on the very cial ties will naturally come apart. held dear. Crying creates space, arc of their existence. Seniors A self-centred person consumes a moment out of time in the jag- feel on ever more slippery and destroys. He cannot interna- ged process of grief. ground, given these different lize the fact that he is just pas- types of ephemerality—that as- sing through and is connected to If I were to create a formula, I’d sociated with constant move- others. say that the art of grieving is one ment (giving the impression we of 3 Ss: silence, solitude and are living) and that of our own fi- Those who feel downgraded, solidarity. nite existence. “past their expiry date” or put away, might oscillate between It is in silence, solitude and so- If an older person decides to shying away from the future and lidarity that people can find “move with the times,” he or she politely withdrawing. solid ground. A ground more so- will seek solutions in the things lid than that which moved be- of this world—practical, short- Nonetheless, you know people neath the feet of our 90-year-old term strategies that are legiti- for whom the future is not just a woman. mate, in principle. However, this hopeless abyss. Some see it as person runs the risk of lamenting a sort of welcoming nest. It is as The art of grieving can also be his losses. He might allow himself if the fact of recognizing one’s seen as building a house. A pro- to be persuaded by those who mortality, with all of its joys and cess of building a house in the magnify these “unbearable” and sorrows, allows people to go sun, at a variable pace. A house painful losses in order to sell him beyond the notion of time. We that is never completely finished. forms of relief—soothing plati- call this acceptance, although I tudes or a premature end to his prefer to think of it as honouring After 40 years of dialogue with life. the law of all living creatures, in- people facing death, I would cluding at the time of our own like to share with you five points We are witnessing the banali- death. to consider slipping into the zation of the ephemeral nature conversation. > of our existence, as if life were

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1st point. Grief, like art, is not a li- in everyday events and anec- loss,” as if grief were something near, univocal process. It involves dotes. This rich ambivalence is that could be neatly packed away making room for a sort of chaos also present in our collective ac- after a certain time? How does . . . a creative chaos. That is why, knowledgement of death: fune- the person cope with the pain of like any relationship, grief is ex- ral rites.3 possible remorse or the melan- perienced as an intermingling of choly of regret? Does she coun- contradictory feelings or ambi- 2nd point. The work of grief, terbalance moments of solitude valence: among all the feelings like art, is not a solitary exer- and fragility with moments of brought on by death, there is a cise. The person we are accom- sharing? How does she balance tension between relief and de- panying has experienced grief her hopes and fears? And what vastation; between guilt at being and sorrow. She can talk about does she fear and hope for? relieved and confusion as to it. But how can she relate her ex- what may be learned. Even if we perience to what she has seen 3rd point. Grief, like art, is a are often asked to decide on one in her own society and in other call to reflection. Grief not only attitude or another, I believe we cultures? Through these different confronts people with the verti- need to accept this ambivalence. cultural palettes, are there ways ginous sense of facing the void, It is reassuring to work through of experiencing grief that the the absolute unknown that gives grief knowing that we are divi- person has admired and sought us a sense of what lies in store. ded. It allows us to lay the foun- to understand? An approach she At any age, grief is unsettling. It dations that will help us cope may have wanted for herself and undoes our usual, comfortable with these losses in our life with her loved ones? What does the ways of dealing with the un- more serenity. We need to iden- person think of the famous ex- known, especially when we cling tify and explore this ambivalence pression “coming to terms with to the known. The “elderly” >

FALL 2015 – Vol. 6, N0 1 – Pluralages 31 certainly don’t have a monopoly worrying about how old you look received. It involves transmit- on that. or the many miles you have tra- ting knowledge of what huma- velled. It means welcoming with nity achieved prior to our arrival Clinging to the known and, as a kindness and saying what you on Earth... Considering this heri- result, trying to recognize our- think. The secret to aging suc- tage allows us to gain perspec- selves as we were BEFORE, is cessfully, with or without a di- tive on what has been, what was self-deceptive. This misleading ploma, is that twinkle in the eye of its time and what cannot exist imperative is the source of inc- that shows the person’s open- outside of this time. In other reased suffering, which is often ness to difference. words, admitting as well that ignored in theories of grief. some things will disappear into

But we can also suffer more when we seek, at all costs, to seal the [...] grief is experienced as an intermingling of past and brutally turn the page. contradictory feelings or ambivalence: among

Grief changes us. It etches itself all the feelings brought on by death, there is on our consciousness. And if we a tension between relief and devastation; do not insist on returning to how things were before, or on “moving forward,” eventually, surpri- Solitude is their lot. I’ve been the void of necessary oblivion singly, grief makes us lighter. This told that the older we get, the and cannot be recovered. This is happens without warning when less we need to say everything. part of the grieving process. we are open to it. That is what Those who remain silent as we have to accept! they think about how to bet- Here we distinguish better what ter express themselves are dif- can remain present from the past 4th point. The work of grief, ferent from the silent ones who and how the present makes us like art, is a step into the un- feel they are marginalized and responsible for the future. known. Grief is made up of me- no longer themselves. It is im- mories that arise unexpectedly, portant to draw a distinction We think of last wills and testa- of smells, scraps of conversa- between reflective solitude and ments. We understand that so- tion, minor and major hurts, loneliness that screams in si- mething of us will be filtered fragments of dreams. It is an ad- lence. And to get people to talk down to those who come after venture in which one has the about their many apprehensions, us. However, if we are fixated on strange feeling of being stripped past and present. the fate of our precious selves, and discovering one’s strength: for example, indicating in detail “I never thought about that. I 5th point. The work of grief, what others should remember of never thought about things that like art, involves recognizing the us, we face a painful stumbling way . . . ” When you hear these trace of others, the trace that is block: the weight of culturally words, all you have to do is stay not only spectacular and ephe- unspoken anguish increases and quiet and wait. There is an ope- meral. Knowing that we will leave condenses in a manner that is ning. Being open does not mean or that we are in the process of devastating to us. The more wor- making a list of the many ways leaving, it is always possible to ried we are, or even obsessed one can lose control and become take stock. This involves recogni- with the traces we leave, the overwhelmed. It does not mean zing our debt or what we have more our impression of loss >

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will augment. A wise person once In accepting the very idea of told me that we do not know the lack, we are conceiving of grief content of everything we know. as the wellspring of a civilization What we have to leave to others that might have forgotten the is not necessarily what we know, extent to which death can also but much more the pleasure of be a source of inspiration. learning, and knowing we are sharing this pleasure. What do you think?

TO CONCLUDE... 1. In addition to performing as a mime artist, Of course, there is the pleasure Marie Lefebvre helped to prepare this article. of linking astonishing elements of 2. This excerpt was read by actor Marie Lefebvre. It reflects a certain unease felt by some seniors time, connecting past and future, who, at the same time, doubt the validity of debt and legacy. Which raises a their impressions. question, never fully answered, 3. In addition to my work on requests for eutha- nasia, I am currently conducting research on that helps us to remain open: contemporary death rites, to be published in 2016. how do the various forms of lack experienced by different generations help to build them, not to rebuild them? Supporting references:

Auger, M. (2003). Le temps en ruines. Paris: Galilée.

In inviting you to answer this Balandier, G. (2012). Carnaval des apparences. question, I suggest we step Paris: Fayard. back from a very contemporary Debray, R. (2014). Le bel âge. Paris: Flammarion. concern, which is to sometimes Delsol, C. (2008). Qu’est-ce que l’homme ? Cours psychopathologize grief, espe- familier d’anthropologie. Paris: Cerf. cially the grief of older people. de Montigny, J. (2010). Quand l’épreuve devient vie. Montréal: Médiaspaul.

Des Aulniers, L. (2009). La fascination, nouveau dé- In asking the question about sir d’éternité. Québec: Presses de l’Université the lack that builds us, we are du Québec. helping to limit the follies of om- Dupré, L. (2014). L’album multicolore. Montréal: Héliotrope. nipotence and, once again, we Hanus, M. (1994). Les deuils dans la vie. Paris: are creating strengths that are Maloine. targeted, fruitful and essenti- Massicotte, S. (2014). Avant d’éteindre. Montréal: ally alive—strengths that emerge L’Instant Même. from our encounter with others, Thomas, L.-V. (1991). Traces de mort. Mort des traces. Paris: L’Harmattan. whoever they are. Virot, L. (Director). (2012). Le sens de l’âge [do- cumentary film]. France: Coloured Plates Production, Ludovic Virot, Inca, Bernard Cochin.

FALL 2015 – Vol. 6, N0 1 – Pluralages 33 Ways to understand the grief and losses experienced by seniors

Valérie Bourgeois-Guérin, Ph.D. Psychologist Professor, Department of Psychology Université du Québec à Montréal [email protected]

“The night is never completely dark There is always . . . at the end of sorrow, an open window A light in the window There is always a watchful dream A desire to fulfil a hunger to satisfy A generous heart A hand held out an open hand Attentive eyes A life to share.”1

INTRODUCTION With aging inevitably comes the experience of grief, of small and major losses. Although aging is clearly not limited to these losses, it is important to recognize that they are part of the reality of getting older. As Bacqué2 has noted, seniors are well versed in grief, since losses multiply at this life stage.

Although seniors experience and recognize the different faces This short article draws on both grief more often than others, of grief experienced in late life, our clinical practice with grie- that does not make it any easier we will be better able to listen ving seniors, the literature on to bear2. Whether grief is expe- to and accompany the grieving grief among the elderly, and the rienced by an older or younger seniors in our lives. To invite re- partial results of a study we are person, the emotional pain and flection on the experience of currently conducting on grief upset are the same. However, grief among older adults, we of- among seniors in residences. To the grief experienced by se- fer here an overview of how this promote a more nuanced un- niors has certain specific charac- grief may look. derstanding of this phenome- teristics. If we better understand non, we have adopted an >

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interdisciplinary perspective, REFLECTIONS ON GRIEF FREQUENTLY rooted in a humanistic psycho- AND LOSS EXPERIENCED TYPES OF logical framework and comple- mented by views from other Although aging is a time of many LOSS disciplines such as social work, losses, not all of these losses re- The quantity and nature of losses anthropology and sociology. sult in a grief process. Grief has experienced by older adults been defined in a number of are not the same as those ex- SUCCESSFUL AGING ways over time4. These defini- perienced by younger people. AND THE GRIEF OF tions belong to different para- Many seniors experience grief SENIORS digms and reflect a certain way following the death of loved of relating to the world, life and ones—for example, brothers or For decades, in the field of ge- death. Some definitions of grief sisters, their spouse, their friends rontology, aging was perceived are broader, others narrower. To or their children2. Some of them in terms of degeneration and invite reflection on the various also face the loss of their home, loss3. In reaction to this perspec- losses that may lead to a grieving physical capabilities, autonomy, tive, the more recent “successful process among seniors, we will projects, status and so on. aging” trend has sought to pres- adopt an expanded definition of ent a far more optimistic view of grief that could be formulated as AN ACCUMULATION OF this life stage. Successful aging follows: “Grief is the process of LOSSES has been defined by some in detachment that may occur fol- terms of maintaining good health lowing an experience of signifi- In addition, a number of seniors (physical, cognitive, etc.) and re- cant loss.” This definition is not experience an accumulation of maining active and involved in limited to grief caused by death. losses5. Precisely because these the community. Obviously this losses are more frequent, they is an ideal for most, but one GRIEF FROM AN OLDER are sometimes less easily reco- that remains out of reach for PERSON’S PERSPECTIVE gnized or are under-estimated, many seniors, such as those suf- since they are considered more fering from health problems3. The grieving process is very dif- normal (statistically speaking) at Furthermore, some proponents ferent from one person to ano- this stage of life. Nonetheless, re- of successful aging have focused ther. Factors that influence this cognition of loss is a fundamen- so much on the positive aspects process include the personality tal aspect of working through that they have overlooked some and life experience of the per- grief.2, 5 of the more difficult realities ex- son; his or her attachment to the perienced by seniors. Although individual, state, situation or ob- In certain cases, without any de- aging is not exclusively about ject that has been lost; previous liberate effort on the part of the loss and grief, these are an in- experiences of grief and loss; re- older person, losses may remain herent part of this life stage. This cognition of the loss; and gende4. unknown or unspoken. Some article examines the experience That said, certain aspects of grief losses are simply not named of grief among seniors, reco- are more frequently experienced by those experiencing them. gnizing the pain, difficulties and by older people. Seniors have reported not telling challenges involved, as well as others about the loss of a close the consolation and opportuni- friend or person they cared for. > ties for learning.

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It has also been observed that EXPERIENCE OF SECONDARY LOSSES current losses frequently stir me- CERTAIN FEARS mories of previous losses. The A significant loss tends to bring accumulation of losses can af- Whatever their age, those who about secondary losses, which fect the grieving process of are grieving are confronted by can also be a source of emotional seniors and can revive former ex- archaic fears. The death of ano- upset. As people get older, these periences of grief, adding more ther person brings up existential secondary losses can be quite si- complexity, intensity and depth questions about the finiteness gnificant4. For example, in a rela- to the person’s suffering. This of one’s own life, and can give tionship where both partners rely explains why the experience of rise to a variety of fears. Some of on one another to remain inde- grief among seniors can be so these fears are more frequently pendent, the death of a spouse powerful.6 experienced by grieving se- can result in the surviving partner niors. Fear of abandonment and no longer being able to live at SOLITUDE death, and feelings of insecurity home. When a senior faces a ma- may be experienced following jor physical loss, he or she may In most cases, this accumulation a loss.7, 8 This is particularly true also lose certain important so- of losses gradually reduces se- in cases of grief following death. cial roles (e.g., helping to take niors’ social network2. In addi- The way the person was treated care of the grandchildren). These tion, some seniors are reluctant before his or her death and the losses can compound the per- to form new ties with people their rituals that were carried out (or son’s grief. age, since they are all too aware not) colour the fears of some se- of the fragility of life and these niors, particularly when the per- CONSERVING AND new relationships. Consequently, son’s death has gone unnoticed PASSING ON MEMORIES grieving seniors can become inc- or their end of life seemed diffi- reasingly lonely or even isolated cult or painful. For many seniors, it is very im- as their losses accumulate. portant to conserve memories and traces of what has been lost. They sometimes fear >

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that these memories will be lost tremendous emotional distress, It has also been shown that, when they too pass away, espe- which is why it is important to re- for many seniors, grief brings cially when they are the last ge- cognize their grief and provide about significant and meaningful neration.9 As a result, a number adequate support to those who changes and transformations. It of seniors have a strong desire to need it. can be an opportunity for people share and pass on their memo- to change, review their priorities ries, to keep the past alive. This RESILIENCE and adopt a more authentic way is a reminder of how important it AND LEARNING of being, which can make for a 6 is to listen to these precious sto- OPPORTUNITIES happier, more meaningful life. ries when they are offered. Experiences of grief and loss are As mentioned above, most se- not only negative; they can also POSSIBLE niors get through the grieving be opportunities for growth. COMPLICATIONS process without complications. Many show a strong resilience in CONCLUSION People sometimes experience the face of grief. If, as Bacqué2 complications in the grieving notes, seniors tend to expe- This article invites us to become process. Obviously, this is also rience loss often, they are also aware of how grief is experienced the case for grieving seniors al- survivors who have dealt with by older adults and provides in- though, in general, this age losses throughout their lives. formation that can guide those group copes better with berea- What helps seniors become re- who are accompanying people vement than other age groups.10 silient and cope with their grief? faced with the loss of a loved Nonetheless, some seniors find Rituals, religious beliefs and spi- one. At the same time, it is es- the grieving process very diffi- rituality help many to build resi- sential to recognize that each cult. They can experience an- lience and experience their grief grieving process is unique, just xiety, or increased or new forms in the community, which greatly like every relationship. Reflecting of cognitive loss, and can de- facilitates the process.12 Those on the grief of seniors can help velop a variety of psychologi- who have an optimistic out- us to be open to the many faces cal disorders.11 Bereaved seniors look and who remain active also and ways of grieving, to be em-

It can be an opportunity for people to change, review their priorities and adopt a more authentic way of being, which can make for a happier, more meaningful life.6 can also experience functio- seem better able to cope with pathetic towards individuals in nal losses and hospitalizations, their grief.12 Finally, as noted ear- their suffering and ambivalences, and will generally die more ra- lier, recognition of loss and so- and to gently accompany them pidly than non-bereaved elderly cial support are vital in helping in the gradual process of de- people.9 Finally, as with people people get through the grieving tachment. We hope, in this way, in other age groups, some grie- process.9 to help people find meaning as ving seniors might have suicidal they work through this difficult ideation or could even attempt process. > suicide.9 Seniors may experience

FALL 2015 – Vol. 6, N0 1 – Pluralages 37 1. Éluard, P. (1951), Le phénix. Paris: GLM, p. 55..

2. Bacqué, M.-F. (2004). Augmentation de la lon- gévité, multiplication des deuils. Les nou- veaux « vieux » sont aussi de grands endeuillés. Études sur la mort, 126(2), 149-158.

3. Grenier, A. (2012). Transitions and the Lifecourse: Challenging the Constructions of growing Old. Bristol : Policy Press.

4. Hooyman, N. R. et B. J. Kramer (2008). Living Through Loss: Interventions Across the Life Span. New York: Columbia University Press.

5. Chen, S.-l., Brown, J. W., Mefford, L. C., de La Roche, A., McLain, A. M., Haun, M. W. et D. J. Persell (2008). Elders’ Decisions To Enter Assisted Living Facilities: A Grounded Theory Study. Journal of Housing For the Elderly, 22(1- 2), 86-103.

6. Moon, P. J. (2011). Bereaved Elders: Transformative Learning in Late Life. Adult Education Quarterly, 61(1), 22-39.

7. De Broca, A. (2010). Deuils et endeuillés (4th édition). Paris: Elsevier Masson.

8. Hecquet, M. (2013). Accompagner le deuil chez la personne âgée. Le Journal des psychologues, 305(2), 33-36.

9. Azaiza, F., Ron, P., Shoham, M. et T. Tinsky-Roimi (2011). Death and dying anxiety among bereaved and nonbereaved elderly parents. Death studies, 35(7), 610-624.

10. d’Epinay, C. J. L., Cavalli, S. et L. A. Guillet (2009). Bereavement in very old age: impact on health and relationships of the loss of a spouse, a child, a sibling, or a close friend. OMEGA-Journal of Death and Dying, 60(4), 301-325.

11. Shah, S. N. et S. Meeks (2012). Late-life bereavement and complicated grief: A proposed comprehensive framework. Aging and Mental Health, 16(1), 39-56.

12. Damianakis, T. et E. Marziali (2012). Older adults’ response to the loss of a spouse: The function of spirituality in understanding the grieving process. Aging & Mental Health, 16(1), 57-66.

13. Sachet, A. (2004). Mourir âgé en institution. Études sur la mort, 126(2), 115-124.

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Harp accompaniment in palliative care: A preliminary exploration of an emerging practice

Mehdi Azri, Florence Vinit, Ph.D. Bachelor’s student in psychology Department of Psychology Department of Psychology Université du Québec à Montréal Université du Québec à Montréal [email protected] [email protected]

Annabelle Renzo,

Harpist and professional musician [email protected]

When all possibilities for medical treatment have been exhausted, a multidisciplinary, whole- person approach to care is particularly appropriate. So-called complementary approaches such as “bedside arts” are increasingly used in care settings, but these practices and their therapeutic effects have yet to be explicitly defined and documented. Since Antiquity, music has been described as beneficial for patients.1 Several literature reviews confirm that music can enhance patients’ well-being, reduce stress and pain, and can even have an effect on physiological measures.2, 3 This study aims to explore an emerging practice in palliative care settings, namely harp playing at the patient’s bedside. Part therapeutic, part artistic, this practice is tailored to each patient’s needs and seeks to promote a sense of well-being. We will look at the possible effects of harp playing on participants’ sense of their own mortality and on the grieving process of loved ones. >

FALL 2015 – Vol. 6, N0 1 – Pluralages 39 study included 28 participants aged 65 and over (on average) who were receiving palliative care. Among these participants, 72% were women. Only 9% were able to enjoy two or more harp- playing sessions, given the short period of their stay at either of the two care facilities.

The participants answered questions on their perception of pain (Visual Analog Scale for Pain) and stress (Likert scale) before and after the harp-playing session. During the session, the research assistant used an observation chart to note the various reactions of patients and their loved ones. Participants were then invited, during a short interview (maximum 30 minutes), to relate their experience of listening to the music and its effects on their imagination, emotions and physical sensations. In addition, some interviews were carried out with members of the health care imagination, and to observe team. OBJECTIVES AND the interactions (eye contact, METHODOLOGY reminiscences) between pa- THE HARP: HISTORY, tients, their loved ones and the CULTURE, IMAGINATION The main objective of this study musician. AND THERAPEUTIC was to explore the experience PRACTICES of hospitalized elderly palliative This qualitative research follows care patients while listening to the work of social scientists A. The harp has a particular symbo- harp music, played at their bed- Giorgi and R. Anderson (1997) lic resonance, frequently appea- side by a professional musician. on the exploration and transla- ring in myths and stories about Within this general framework, tion of lived experience into phe- care and healing. Apollo, God of we aimed to analyze the effects nomenological terms.4 Our two musicians, physicians as well as of the music on patients’ physi- patient recruitment sites were the sun, made the harp his instru- cal experience (including stress a mobile palliative care unit at ment of choice, while King David and pain), to understand the Hôtel-Dieu hospital (CHUM) and cured Saul with its harmonious ways in which it captured their the Source Bleue hospice. The melodies.5 The Celts called >

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the harp an instrument of joy, be- devoted to them (“she [the mu- (the health care setting, intru- cause of its ability to elicit laugh- sician] came to play for me”)— sive thoughts about health and ter and contentment, and to a welcome surprise in their daily mortality). The music was also induce sleep. Through his system routine. The unexpected visit associated with closeness—in of modes (or keys), Pythagorus was also perceived as a time- relation to the self (patients re- recognized the effects of sound out (“I don’t have to think about ported feeling connected to on people’s moods and emo- anything”). themselves through a memory tions (e.g., stimulating, calming, or pleasant thoughts inspired relaxing) and recommended Three participants were able to by the music, such as beautiful plucked-string instruments for enjoy several sessions, which al- landscapes or birdsong)—and in optimal results. Today musicians lowed the team to see how the relation to others (“I love that the practising harp therapy, an ap- interactions between patient music brings us together... we’re proach developed in the United and musician evolved. Over the being silent together, without States, play for patients in the course of the sessions, the pa- doing anything”). spirit of these ancient traditions.6 tients became more invested in IDEA OF TRAVEL: The harp sessions created a “unique atmosphere” GOING FAR AWAY for both participants and their loved ones. The While the non-verbal behaviours music brought people together, allowing them to of patients during the sessions share a special moment in the context (closed eyes, falling asleep, re- of loss and grief. laxing) reflected a body in sta- sis, their thoughts, as expressed the relationship, shared more of in the interviews, were very mo- PATIENTS’ their personal tastes (songs and bile. The plucking of harp strings RECEPTIVENESS AND styles), and adopted more direc- allowed them to travel in their RESPONSES tive behaviours. The harp session mind, to go “far away”: “We became increasingly tailored to don’t get to move around much The vast majority of participants the desires of each patient. here, but this is like a vibration in the study responded positi- that fills the room”; “you don’t vely to the harp-playing session MUSIC THAT IS GENTLE need words; you can immerse (smiles, gazing at the musician, AND SOOTHING yourself through music.” The comments on the beauty of the music also evoked personal me- music, curiosity and questions The words “gentle” and “soo- mories for some patients, which about the instrument). Two pa- thing” were frequently men- they shared with the musician or tients declined the harp-playing tioned during the sessions and loved ones who were present. session, because they were in too interviews: “it’s peaceful, not much pain or did not have a par- at all jarring”; “it’s like being HARP MUSIC AS A ticular affinity for that instrument. stroked with a feather”; “it’s a BRIDGE BETWEEN TWO balm for the heart.” Patients WORLDS During the first meetings, parti- echoed popular perceptions of cipants described the harp ses- harp music. They used words The “elsewhere” patients travel- sions as a “surprise” and “gift.” referring to inner peace and a led to in their mind often had a They saw it as a musical moment break from habitual concerns spiritual dimension. The harp >

FALL 2015 – Vol. 6, N0 1 – Pluralages 41 has long been associated with After playing the first notes, the world of the spirit. In the po- the musician always asked whe- LIMITATIONS AND pular imagination, the female ther the patient liked the piece, PRELIMINARY harpist plucking the strings of or whether he or she had a spe- RECOMMENDATIONS her (often) white instrument has cial request. The artist took part an angelic quality. The pallia- in a spontaneous musical game, One of the limitations of this tive care setting is like a transi- creating plenty of room for im- study was our inability to ana- tion point between two worlds: provisation according to the pa- lyze the effects of the harp music life as we know it and the myste- tient’s wishes, physical condition on patients who were experien- rious afterlife. In interviews, par- and openness. cing significant pain or stress. ticipants described being at the One might wonder why these threshold of their existence, fee- The bedside musician must have patients declined the invitation ling a tension between their mor- a broad repertoire and must be to take part in the harp sessions. tality, a letting-go of possibilities able to switch from gentle to Was their pain too overwhel- and an anticipation of their de- more lively melodies, depending ming for them to listen to mu- parture. The harp was associated on the patient’s mood and de- sic and interact with the harpist? with travel, with another world sires. The artist must also be able Another limitation of the study is where existence continues in a to look up from her sheet music related to the interviews, which different form. These thoughts in order to be present and main- had to be cut short, given partici- gave patients a sense of peace. tain visual and verbal communi- pants’ limited concentration. We They were happy to be transpor- cation with the patient. were therefore not able to dis- ted by the music—in spirit ra- cuss topics in greater detail. ther than in body, since in most The bedside musician not only cases, physical movement was adjusts her playing according FAMILY AND LOVED impossible. to the patient’s needs, but must ONES: POSSIBLE also adapt to different hospital AVENUES FOR FUTURE For most participants, the harp settings and palliative care units. RESEARCH ON GRIEF music was a pleasant, soothing Over the course of the study, the symbol of movement and depar- musician was welcomed by me- Although families were not the ture. However, one patient did dical teams. The harp was not main focus of this study, we gai- not want to take part in the ses- seen as intrusive, but rather as a ned insights into the experience sions, because for her the music means to create a pleasant mu- of grief when older family mem- symbolized the end of her life: sical environment without com- bers pass away. “it’s music for my death.” promising care (“the volume of the instrument did not drown Those accompanying the end-of- BEDSIDE MUSICIANS: out the machine beeps.”). The life patients in this study descri- ADAPTATION AND medical staff tended to adopt a bed the bedside harp sessions ADJUSTMENT participatory approach, which al- as: lowed them to step out of their Bedside arts require constant ad- usual professional roles. ►► a moment of sharing and justment to the patient’s needs. pleasure in a context of loss During each session, the patient and mortality. When family and musician interacted, crea- members were present, the ting a musical moment together. musical session became >

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a lot more festive, often ins- This notion of “aesthetic plea- understanding the experience of piring people to sing toge- sure” is helpful in considering grief, whether the person is grie- ther and choose songs from how caregivers experienced this ving the loss of a loved one or a variety of styles (jazz, pop, musical moment. They said they the loss of his or her own life. etc.); felt more confident and closer to their loved one. They were able ACKNOWLEDGEMENTS ►► a moment that brightened to act like they did before their up their days at the patient’s family member became ill. They We would like to thank the me- bedside; gave themselves permission to dical and administrative team in touch, to sing together and to the palliative care unit at Hôtel- ►► a moment of beauty that lower their defences in the face Dieu, in particular, Dr. Delisle and provided comfort to the of loss. Diane Therrien. dying patient and support to the bereaved family (many The fact that family members in- Many thanks as well to the me- wanted the musician to play vited the musician to play at the dical and administrative team at at the patient’s funeral); funeral, or asked for a group the Source Bleue, in particular, to photo during the harp-playing the hospice director, Suzanne Le ►► a moment creating happy sessions, can be seen as ele- Breux. memories, which could help ments facilitating the grieving with the grieving process. process. Conserving an image or Last but not least, we thank memory of a dying person is an Annabelle Renzo, professional The harp sessions created a act not of sadness or defeat, but harpist. “unique atmosphere” for both rather of vitality and shared joy. participants and their loved ones. The music brought people toge- CONCLUSION 1. Williams, S., (2015). The Mythic Harp. Macungie, ther, allowing them to share a PA: Planet Harp. special moment in the context of The bedside harp sessions in 2. Aragon, D., Farris, C. et Byers, J. F. (2002). The effects of harp music in vascular and thora- loss and grief. In the words of one this exploratory study were per- cic surgical patients, Alternative Therapies in family member, “I love that we’re ceived as a gift and a surprise, Health and Medicine, 8(5), 52-60. brought together by the music. helping participants to enjoy an 3. Macdonald, R.A.R. (2013). Music, health, and well-being: A review, International Journal of It’s rare. Usually, we’re busy fil- experience of calm and close- Qualitative Studies on Health and Well-being, 8, 1-13. ling the gaps, checking informa- ness, to take a break from the tion online, chatting. But here we medical routine, and to be trans- 4. Repéré à http://www.harptherapy.com. are in silence, doing nothing.” As ported in a spiritual way. The 5. Pépin, C. (2013). Quand la beauté nous sauve. Paris : Robert Laffont. the philosopher Charles Pépin musical moment did not inter- has noted, when we are tou- fere with the work of the medical ched by beauty, we “relearn how team and created a moment of to trust our instincts, to listen to sharing for loved ones who were ourselves... to open up... to face present. This approach requires what usually frightens us, the sensitivity and flexibility on the mystery of things, our own obs- part of the musician. This first curity. Beauty gives us the abi- musical contact allowed us to lity to love what is and to hope consider possible avenues for fu- for what could be” [Translation].7 ture research on caregiving and

FALL 2015 – Vol. 6, N0 1 – Pluralages 43 Aging out of place into homelessness: The role of grief and loss

Victoria Burns, Ph. D. Postdoctoral Fellow Institut national de la recherche scientifique-Centre urbanisation, culture et société [email protected]

Homelessness is on the rise among older adults in large Canadian urban centres, including Montreal, with many becoming homeless for the first time.1, 2 Despite some recognition that various forms of loss (i.e., family, work and health) contribute to late-life homelessness3,4, 5, there has been little research on the role of grief and loss in relation to the experiences of older homeless adults.6 Rather, the assumption that homelessness in later life results from personal liabilities, individual responsibility, deviancy and choice continues to prevail.2, 7

This article examines two case normative understanding of late- changed to protect their anony- studies of newly homeless older life homelessness. mity. The constant comparative adults (NHOAs) through the lens method (a systematic method of of grief and loss—a framework METHODOLOGY AND analysis that compares within and that examines normative reac- METHODS between cases9) was used to ana- tions to the loss of important lyze the data. Participants were elements in individuals’ psycho- Using semi-structured, face-to- given a $10 honorarium (in cash) logical, social or physical wor- face interviews, the larger study to compensate for their time. lds.8 The two case studies have from which these case studies been drawn from a larger ethics- are drawn explored the personal Participants were recruited from approved McGill University re- histories of 15 NHOAs (8 men, Montreal emergency shelters for search project that considered 7 women), their relationships to men and women. To be eligible 15 NHOAs’ encounters with first- everyday places, the meanings to participate, they had to be ex- time homelessness.2 Here, it is they attributed to home and ho- periencing homelessness for the argued that using a lens of grief melessness, and the events lea- first time at age 50 years and over, and loss to understand late-life ding up to their homelessness.2 and had to have been homeless homelessness is a promising fra- Each interview was recorded for no more than two years at the mework that shifts the focus from using a digital voice recorder time of the interview. The age an individual-blaming discourse and transcribed verbatim. All criterion was set at a minimum towards a less stigmatizing, more of the participants’ names were of 50 years, since the health >

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status of older homeless adults homelessness with little warning. not been able to overcome the tends to resemble that of people grief she experienced as a re- 10 to 20 years older, and this is The following two case studies sult of this loss. Even though she the age most widely used in the and associated quotes illustrate subsequently lived in the same aging and homelessness litera- the two different pathways into apartment for 13 years prior to ture.3 The two-year cut-off point homelessness characterized by becoming homeless, she explai- for homelessness was used in or- chronic and acute experiences of ned that, without her husband

However, family breakdowns seemed to have a greater financial impact on the women, which in turn put them at a greater risk of homelessness. der to be consistent with existing grief and loss. The participants’ and son, she “never felt at home research on what is considered names have been changed to again”: “newly” homeless10, and to en- protect their anonymity. sure that participants would be V: Is there a certain residence able to recall the events leading CASE STUDY 1 you consider to be home more up to their homelessness. than others? Charlotte, age 64: Unresolved MAIN FINDINGS losses over her life course C: The home that was my home contributed to a gradual de- that the babysitter had rights to. In the larger study, two dif- cline into homelessness ferent pathways into homeless- V: That the babysitter had rights ness were identified. About half Charlotte, age 64, was born in to? of the participants had gradual the United States and came to pathways, experiencing social, Montreal with her Quebec-born C: Yes, the one who replaced me health and occupational losses husband. University-educated, [crying]. That was my home! That over an extended period. Their she worked a series of odd was my home! [crying loudly]. grief was chronic, in the sense jobs until the birth of her son The difference between my that they seemed to have never in her late 20s. During her 20- apartment and my home is that fully recovered, and commonly year marriage, she had no fi- my home was our home, it was experienced feelings of fear, re- nancial troubles and lived in a a shared environment, whereas jection and insecurity over the large, 13-room suburban home. my apartment, I don’t call it my course of their lives. The remai- When she was in her early for- home, it was my apartment. To ning participants had rapid de- ties, her husband unexpectedly me there’s a difference. Home clines into homelessness. This filed for a divorce, leaving her to me includes other people, group had more stable personal, for their 18-year-old babysitter. because that’s what makes any housing and employment histo- When Charlotte was forced to place a home, because you have ries, and experienced a series of leave the residence she had sha- people with you. > multiple, acute losses (i.e., social, red with her husband, she felt health and occupational) in la- that her home was literally being ter life that propelled them into stolen from under her. She has

FALL 2015 – Vol. 6, N0 1 – Pluralages 45 five months. These consecutive where he had resided for 27 deaths led him to relapse into al- years with his wife and had run a cohol abuse, after more than 30 successful home-based business, years of sobriety: to becoming widowed, jobless, and living on the street: Everything happened at the same time. Two and a half years DISCUSSION ago, there were three consecutive deaths. My mother died first, Temporality of social losses then my daughter, my oldest, affects pathways into who died second, and then my homelessness wife was third. All of that in the span of five months. Let’s just say While the loss of a spouse affec- Grief by Cynthia Angeles, n.d. that it took about a month be- ted trajectories into homeles- fore it all started. I already had sness for both the men and Charlotte’s housing instability a problem with alcohol, which I women in this study, some gen- increased over the years. With had under control for the past der-based differences were re- age, her mental health issues 30 years. It was foolish of me vealed. David, in his late sixties, (hoarding) worsened, and she to retire. I don’t feel very good, became increasingly disorga- continued to struggle financially because there are lots of oppor- nized in his home following his (she was receiving $740/month tunities that are out of reach for retirement and the death of his from basic social assistance and me because of my age. It’s like wife, and was propelled into ho- a small Quebec pension, and there are barriers, in terms of melessness within a couple of was paying $596/month in rent). work. If I was 20 years younger, years. This finding supports exis- After receiving several warnings, I would have gone two days wi- ting research suggesting that wi- she was evicted from her apart- thout work, it was easy for me. dowhood may be a particularly ment for hoarding and came to strong trigger for homelessness the women’s shelter. David’s wife ran the household in older men, many of whom be- and helped him manage his come “volitionally homeless” af- CASE STUDY 2 home-based business—he re- ter selling their property and ferred to her as his “right arm.” find it “too painful and upset- David, age 70: Serial, acute After her death, David isolated ting to remain in the house af- losses in later life contribu- himself from his friends and fa- ter the death of their spouse” ted to a rapid decline into mily who “reminded him of her.” (p. 9).11 While none of the wo- homelessness He explained that he no lon- men in the study experienced ger felt at home in his apart- widowhood, their homeless tra- David, age 70, was born in ment, because it also reminded jectories were also affected by Montreal. University-educated, a him of his late wife. After he reti- family breakdowns (i.e., separa- widower and father of two, David red, his home also reminded him tion and divorce). However, fa- attributed his homelessness to a of his lost professional role. He mily breakdowns seemed to have combination of losses, including eventually sold off all of his pos- a greater financial impact on the his retirement, followed by the sessions, got behind on his rent women, which in turn put them sudden deaths of his wife, daugh- and bills, and within two years, at a greater risk of homeless- ter and mother over the span of went from living in a stable home ness. Charlotte, for example, >

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had never worked full-time and PRACTICE the grieving process and put left the workforce after the birth RECOMMENDATIONS them at a greater risk of ho- of her son, whereas David main- melessness. More research is tained stable employment up un- It is suggested that service pro- needed to understand how mul- til his retirement at age 68, and viders ask newly homeless older tiple losses across the life course was not as financially affected by adults questions about losses that affect pathways into late-life ho- the death of his wife. occurred in the past, because, as melessness. If left unaddressed, Charlotte’s case demonstrates, issues related to grief and loss unresolved chronic losses greatly may continue to put older adults affect their present-day housing at risk of homelessness, and stability. For people like David, may also affect their stability fol- who experience acute losses in lowing re-housing. later life, a more systematic ou- treach is required to prevent ra- ACKNOWLEDGEMENTS pid disorganization and a decline into homelessness. Whether the A special thank you to the 15 person has experienced chro- participants in this study and to nic losses over their life course the funders that made this re- or a series of acute losses later search possible: FQRSC, SSHRC, in life, prompt, grief-focused in- CREGÉS and McGill University’s terventions are required to help School of Social Work. Old Man Grieving by Vincent Van Gogh (1890) them come to terms with their losses, gain a sense of security,

Charlotte’s case echoes existing and function in their living envi- 1. Latimer, E., McGregor, J., Méthot, C., & Smith, research suggesting that family ronments in the absence of lo- A. (2015). Dénombrement des personnes en situation d’itinérance à Montréal le 24 mars 2015. breakdowns (including divorce) ved ones. Montreal, Quebec: Ville de Montreal. are a primary trigger for homeles- 2. Burns, V. (2015) Oscillating in and out of place across housed-homeless trajectories: sness in women, as the latter CONCLUSION Experiences of newly homeless older adults tend to opt out of the workforce in Montreal, Quebec. Doctoral thesis, McGill University School of Social Work. 267pgs. more often due to caregiver res- This paper sheds light on the role 3. McDonald, L., J. Dergal, and L. Cleghorn (2007). ponsibilities, and are more finan- that grief and loss may play in pa- Living on the margins: Older homeless adults cially dependent.3 Nonetheless, thways to late-life homelessness. in Toronto. Journal of Gerontological Social Work,. 49(1-2), 19-46. Charlotte showed innate resi- Understanding how grief and 4. Cohen, C. (1999). Aging and homelessness. lience. Despite her precarious li- loss are associated with hou- The Gerontologist, 1999. 39(1), 5-15. ving situation (she was spending sing instability and homeless- 5. Cohen, C., Ramirez, M., Teresi, J., Gallagher, M., more than 80% of her income on ness marks a shift away from an & Sokolovsky, J. (1997). Predictors of becoming redomiciled among older homeless women. rent), she maintained a private individual-blaming discourse to- The Gerontologist, 37(1), 67-74. doi: 10.1093/ market rental for over 20 years. wards a more normalized unders- geront/37.1.67 tanding of homelessness. Older 6. MacNeil, K. and Darnell, J. (2010). Grief and loss as a contributing factor in the homelessness of people face multiple losses, in- older adults: A qualitative study. The Good Neighbours Club: Toronto, Ontario. cluding physical changes, health > problems, the loss of a job and loved ones, that may complicate

FALL 2015 – Vol. 6, N0 1 – Pluralages 47 7. Parsell, C. and M. Parsell (2012). Homelessness as a choice. Housing, Theory and Society, 49(4), 420-434.

8. Regehr, C. and Sussman, T. (2004). Intersections between grief and trauma: Toward an empiri- cally based model for treating traumatic grief. Brief Treatment and Crisis Intervention, 4(3), 289-309.

9. Glaser, B.G. and A.L. Strauss (1967). The discovery of grounded theory, Chicago, Ilinois: Aldine Publishing Company.

10. Crane, M., Byrne, K., Ruby, F., Lipmann, B., Mirabelli, F., Rota-Bartelink, A., Warnes, A. M. (2005). The causes of homelessness in later life: Findings from a 3-nation study. Journal of Gerontology: Social Sciences, 60B(3), 152-159.

11. Crane, M., & Warnes, A. M. (2010). Homelessness among older people and service responses. Reviews in Clinical Gerontology, 20(04), 354-363. doi: doi:10.1017/ S0959259810000225

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Collage: an art therapy intervention facilitating an experience of loss among hearing-impaired seniors

Marie-Soleil Blanchet, M. A. Art therapist Master’s in Creative Arts Therapies, Concordia University [email protected]

Collage is an artistic technique that involves choosing images in order to arrange and combine them in a new way. In art therapy, this technique has proven to be beneficial for a variety of clients, including seniors1, the bereaved2 and individuals with a hearing impairment.3 During my art therapy training at Concordia University, I completed an internship within the program for seniors at the Institut Raymond-Dewar, a rehabilitation centre specialized in deafness and communication. During this clinical experience, I witness how collage can be used to accompany the elderly through an experience of loss, particularly its potential in facilitating rehabilitation in hearing loss cases.

HEARING IMPAIRMENT to compensate for the loss” sadness and anger. Each person AMONG SENIORS [Translation].4 Seniors and those experiences the loss in his or her around them also have to learn own way and sometimes it may Sudden or progressive hearing entirely new ways of communica- be difficult to express these em- loss can cause a major iden- ting. For example, the hearing- otions. During my internship, I tity shift in seniors, resulting in impaired person will have to put discovered that collage was an a number of life changes. One into practice new communication effective therapeutic tool to fa- of the effects noted by hea- strategies or get accustomed to cilitate emotional expression, ring loss specialists is “a reduc- using a hearing aid. Losing one’s which is essential within a position in seniors’ social interactions sense of hearing can lead to fee- tive rehabilitation experience. > because of the effort required lings of powerlessness, isolation,

FALL 2015 – Vol. 6, N0 1 – Pluralages 49 Image 1. Title: It’s a cold collage. “It’s a story that speaks about people of a certain age . . . Soon, there will be too much water and the man won’t be able to walk as easily . . . We can’t see the consequences of the natural disasters . . . Since losing my hearing, I feel like I’m up against a wall.”

WHY CREATE COLLAGES to express themselves freely and storytelling for instance, in or- WITH AN ART spontaneously, which happens der to give meaning to the pro- THERAPIST? less often following a hearing duced images (Image 1). In art loss. Furthermore, a safe space is therapy, collage may simulta- Anyone can make a collage at essential to explore feelings that neously reveal conflicts and solu- home. However, in a therapeutic may be threatening for one. tions, the client’s preoccupations context, collage making is a sym- and strengths. The therapeu- bolically powerful activity, given Like a mirror reflecting an in- tic process allows one to name the personal meaning associa- ner reality, the collage creates their inner resources such as per- ted with images. As a witness a distancing effect, offering a severance and resilience, which to the client’s creative process, new perspective on the pro- could facilitate a grieving expe- the art therapist provides a fra- blem (hearing loss) and allowing rience (Image 2). The revealed mework—a free and safe space one to re-evaluate the impacts metaphors through collage may in which authentic expression is of this loss in his or her life.6 The bring awareness about concerns, received without judgement.5 person may then be invited to as well as positive aspects within This sense of safety allows clients talk about the collage, through their lives. >

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It is important to note that art like I’ve finally come out of my a sense of control and auto- therapists adapt interventions cave.” During a short-term fol- nomy throughout the creative to the client’s ability and needs. low-up, another client noted, “I process, and requires no artis-

Over the course of my art therapy internship with hearing-impaired clients, participants reported an enhanced sense of well-being in expressing feelings of sadness, anger and isolation related to their hearing loss.

With their extensive knowledge knew it was OK for me to express tic knowledge or skill to be en- of how art materials can be my anger in art therapy and that joyed: “It’s easier for me to use used7, art therapists ensure a it would give me wings afte- images to express my thoughts.” satisfying creative process. It is rwards. I had the right to be my- In other words, creating a col- not necessary to master artistic self.” Others were proud of their lage with an art therapist may re- techniques to benefit from art creative accomplishments: “I was duce the anxiety associated with therapy. In evaluating the hea- surprised to discover my creati- artistic performance, by simply ring-impaired client’s needs, the vity; it gave me self-confidence.” selecting, arranging and pasting art therapist offers the appro- Clients can generalize their dis- the images on paper. The artis- priate tools and guides the client covered or rediscovered skills tic value of the collage is by no toward a positive experience, fo- and strengths into other areas of means diminished: the work is cusing on his or her strengths their life—for instance, by perse- rich in meanings, symbols and and validating each steps of the vering in their efforts to learn li- eloquent metaphors. In art the- creative process. preading and integrating more rapy, collage is also an effective effective communication stra- way to foster reminiscence8, a THE BENEFITS OF tegies. Finally, I observed that need throughout adulthood9. COLLAGE IN ART providing a space for emotional Photographs may stir memories, THERAPY WITH THE expression also reduces the level giving freedom to travel beyond HEARING-IMPAIRED of anxiety, which allowed hea- body limitations and age. ring impaired seniors to engage Over the course of my art the- more easily in dialogues with lo- rapy internship with hearing- ved ones. The simple act of crea- 1. Hinz, L. D. (2009). Expressive Therapies impaired clients, participants ting “makes you want to be in Continuum: A framework for using art in therapy. New York, NY : Routledge. reported an enhanced sense of the present,” as one participant 2. Allen, P. B. (1995). Art is a Way of Knowing: a well-being in expressing fee- stated. guide to self-knowledge and spiritual fulfillment through creativity. Boston, MA : Shambhala lings of sadness, anger and isola- Publications. tion related to their hearing loss. Collage is a way to make pain 3. Silver, R. (2000). Studies in art therapy 1962-2000 As one participant stated, “I feel instantly visible, a healthy vehicle (2e éd.). Sarasota, FL : Ablin Press Distributors. free when I do this [collage]. This for expression during hea- 4. Pouliot, L. M., Beauregard, L., Boivert, J.M. et Plante-Jean, M-A. (2011). L’adaptation à la introspective work has allowed ring rehabilitation. This tech- perte auditive chez la personne aînée : une me to externalize my feelings. It’s nique is also easy to use, giving transformation profonde insoupçonnée. Vie et vieillissement, 9(3), 26-33. >

FALL 2015 – Vol. 6, N0 1 – Pluralages 51 5. Malchiodi, C. A. (2012). Handbook of art therapy, (2e éd.). Repéré à : http://0www.myilibrary. com.mercury.concordia.ca?ID=334047

6. White, M. et Epston, D. (1990). Narrative means to therapeutic ends. New York, NY : Norton.

7. Hinz, L. D. (2009). Expressive Therapies Continuum: A framework for using art in therapy. New York, NY : Routledge.

8. Woolhiser S. J. (2010). Collage as a therapeutic modality for reminiscence in patients with dementia. Journal of the American Art Therapy Association, 27(3), 136–140. http://doi.org/10.1 080/07421656.2010.10129667

9. Webster, J. D. et McCall, M. E. (1999). Reminiscence Functions Across Adulthood: A Replication and Extension. Journal of Adult Development, 6(1), 73–85. http://doi. org/10.1023/A:1021628525902

Image 2. Title: Where there’s a will, there’s a way. “Who would’ve thought that hearing is as important as sight? But even those who are hearing impaired can persevere and make their way in life.”

52 Pluralages – FALL 2015 – Vol. 6, N0 1 citizen’sforum

Being gay in a heteronormative society

Jean Lalonde

Vice-president of ARC (Aînés et retraités de la communauté) [email protected]

It is with pleasure and great humility that I share my thoughts with you today. I’m certainly not an expert on seniors and the grieving process. On a personal level, I have grieved the loss of loved ones. But my greatest grief is of an entirely different kind. I’ll come back to that in a minute.

Let me tell you a bit about my didn’t know why. I was living a greatest sadness is not being life. After dating a number of kind of personal and social schi- normal, according to our society. girls, I decided to settle down zophrenia: not understanding This sadness will stay with me for with a wonderful woman who who I was and often feeling like the rest of my life. told me from early on in our re- a fake. When I began to unders- lationship that I wouldn’t al- tand, I constantly found ways I decided I deserved to be my- low myself to be loved. “Finally, to hide it. What if it were just a self. It was a risky move, be- someone who understands me phase? What if I were bi? Did I cause I had to control my image better than I understand my- need therapy? To put things in and I wasn’t always sure how! self!” I thought. I was married for perspective: for most of my life, Over the past 16 years, I’ve been 23 years and I have four children homosexuality was a sin, a crime able to come out to my kids, my and seven grandchildren. They and a mental illness. It’s not a grandchildren and a few spe- certainly help to give the impres- great way to start out in life— cial people. I choose who I tell sion I’m “normal”! realizing you’re not like other and when. I came out of clo- set gradually and from time to time, but I often went back in- My greatest sadness is not being normal, side for fear of being judged and according to our society. This sadness will stay marginalized. with me for the rest of my life. I must confess I was somewhat It was 23 years and four child- people. At the time, I had no re- reluctant to tell you my story to- ren later that I finally under- ferences, no role models. day. I have good reason to be! stood and was able to explain to Am I completely out of the clo- my wife why I couldn’t be loved. I decided to be who I was and set? I’m not sure. I’ll no doubt I didn’t accept who I was, but I accept my homosexuality. My mention my children again >

FALL 2015 – Vol. 6, N0 1 – Pluralages 53 when I feel the need to come it. Initially I planned on telling you years later: across as normal. It works: “He their stories about grieving, but I can’t be gay; he has kids!” It’s a soon realized that, to be authen- “I deny myself joy / A joy that is false stereotype, but it comes in tic and engaging, I would have to not mine / A joy of mine that I very handy. focus on my own experience. can’t live / I deny myself a joyful me / I hear my light-hearted I still have trouble thinking about Divorce is a loss experienced by steps beside me / But I can’t how people see me and worrying many gay men—an often brutal switch places on the sidewalk / about being ostracized. I really rupture with a person they have I can’t walk in those shoes and don’t want people to see me as loved. It often involves a rupture say: this is me.”2 a “queen,” a pedophile or any- with children and friends as well. Hector de Saint-Denys Garneau thing in between. I’m grieving “That’s the price you pay for [Translation] the loss of a normal life, whate- being a hypocrite,” some mean- ver normal is, as the ad says. We minded folks might say. all know we live in a heteronor- 1. An observation made by Elisabeth Kübler-Ross mative world. A difficult stage for the vast ma- at a seminar/workshop given in Hull, Quebec, in the 1980s. jority of seniors is moving into a 2. Excerpt from the poem “Accompagnement,” Psychoanalyst Elisabeth Kübler- retirement home. Several losses by Hector de Saint-Denys Garneau, in Regards et jeux dans l’espace. Montreal: Biblio Fides, Ross, a pioneer in the field of are experienced at the same 2013, p. 81. death and bereavement, once time. For us gays, it could mean said, “Humans’ greatest fear is having to go back into the clo- not death; it’s being judged by set, because other residents in others.”1 that microsociety might be ho- mophobic. Even staff members My experience as a senior has of- are not always comfortable with ficially begun—I’m 65 years old! this reality! For a few months now, I’ve been vice-president of Aînés et retrai- Let’s talk now about real grief, tés de la communauté (ARC), an following death. You can read association founded 15 years some astonishing obituaries: ago with close to 200 members. “He joins Alice Robitaille on the We organize social, cultural and other side, leaving behind his sports activities to break gay son, Paul, and many relatives men’s isolation (www.algi.qc.ca/ and friends.” Oops . . . they for- asso/retraitegais). You’ll notice got to mention that he lived for that the word “gay” is conspi- 20 years with André. Was he his cuously absent from our asso- roommate? How is André coping ciation’s name. You could almost with his grief? say we’re a bunch of closeted gay seniors! When I was a teenager, I read a poem that touched me dee- I agreed to come and talk to you ply. I thought about this poem today, because nobody else in the other day and finally under- our association was willing to do stood its meaning, more than 50

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