ATTEND: Toward a Mindfulness-Based Bereavement Care Model

Article (PDF Available)inDeath Studies 36(1):61-82 · January 2012with644 Reads
DOI: 10.1080/07481187.2011.591275 · Source: PubMed
Abstract
Few, if any, mindfulness-based bereavement care models exist. The ATTEND (attunement, trust, touch, egalitarianism, nuance, and death education) model is an interdisciplinary paradigm for providers, including physicians, social workers, therapists, nursing staff and others. Using a case example to enhance the breadth and depth of understanding, this article focuses on attunement as a means to moderate the negative effects of traumatic bereavement, support the framework for posttraumatic growth in the bereaved, improve psychological outcomes for providers, and set the stage for the other aspects of the ATTEND model.
ATTEND: TOWARD A MINDFULNESS-BASED
BEREAVEMENT CARE MODEL
JOANNE CACCIATORE
School of Social Work, Arizona State University, Tempe, Arizona, USA
MELISSA FLINT
Clinical Psychology Program, Midwestern University,
Glendale, Arizona, USA
Few, if any, mindfulness-based bereavement care models exist. The ATTEND
(attunement, trust, touch, egalitarianism, nuance, and death education) model
is an interdisciplinary paradigm for providers, including physicians, social work-
ers, therapists, nursing staff, and others. Using a case example to enhance the
breadth and depth of understanding, this article focuses on attunement as a
means to moderate the negative effects of traumatic bereavement, support the
framework for posttraumatic growth in the bereaved, improve psychological out-
comes for providers, and set the stage for the other aspects of the ATTEND model.
I recommend almost dying to everyone ...you get a much clearer
perspective on what’s important and what isn’t, the preciousness and
beauty of life.
Carl Sagan (2006)
For decades researchers have attempted to define a model for the
treatment of traumatic bereavement that fully supports not only
the client, but also those working with the clients around their
trauma material. The impact of traumatic deaths, such as those
outlined by Walsh (2007), are far-reaching. Homicides, untimely
deaths (such as the deaths of children or premature conjugal
deaths), sudden deaths, or disenfranchised losses (Doka, 1989)
Received 15 March 2011; accepted 27 June 2011.
With gratitude to Dr. Vivian Cheung and in memory of Dr. Richard Spielman.
Address correspondence to Joanne Cacciatore, Arizona State University, School of
Social Work, 411 N. Central Avenue, 8th Floor, Phoenix, AZ 85004, USA. E-mail: joanne.
cacciatore@asu.edu
Death Studies, 36: 61–82, 2012
Copyright #Taylor & Francis Group, LLC
ISSN: 0748-1187 print=1091-7683 online
DOI: 10.1080/07481187.2011.591275
61
such as suicide, stillbirth, and AIDS have profound impact on sur-
vivors. Traumatic death, particularly when it is one that ‘‘violates
the natural order,’’ forces the survivor to face unique challenges
that resonate in both the biophysical and the psychosocial realms
(Neimeyer, 2002). These highly interconnected psychological,
physiological, and psychosocial facets of treatment prove to be
quite complicated at times. Not only do survivors suffer such medi-
cal complications as high blood pressure (Prigerson et al., 1997;
Prigerson & Jacobs, 2001), cancer (Prigerson et al., 1997), and
cardiac events (Prigerson et al., 1997), but they are also susceptible
to serious mental health outcomes (Horowitz & Siegel, 1997;
Raphael & Martinek, 1997) including heightened risk of suicide
(Ajdacic-Gross et al., 2008; Prigerson et al., 1997).
Although it is true that there is a proportion of individuals
who are able to accommodate their loss and return to a level of
functioning considered to be ‘‘normal’’ (Lindemann, 1944; Neria
& Litz, 2003), there is a subset ranging from 10%to 20%of the
bereaved who experience significant functional limitations from
their traumatic loss (Neria & Litz, 2003). In the literature, loss
has been typically explained through psychodynamic means,
positing that when ‘‘normal resolution’’ is somehow interrupted
and the necessary ‘‘grief work’’ is left undone (i.e., avoided), grief
will become ‘‘chronic, enduring, and disabling’’ (Neria & Litz,
2003, p. 74).
Because of the intensity of this type of trauma, it is necessary
for the clinician working with such clients to develop an awareness
of the impact of the trauma on the client, on the clinician–client
relationship, and on the clinician him- or herself outside the four
walls of the office. Despite the need for relationship-centered,
evidence-based practices for working with the bereaved, providers
often find themselves in a quandary: Budget restrictions may
oblige administrators to turn their attention away from
relationship-based care, incentivizing policies that are ‘‘inexpen-
sive and perforce, brief, superficial, and insubstantial’’ (Yalom,
2002, p. 4). Yet, poor psychosocial care has also been shown to
increase litigation risk, thereby raising economic and social costs
(Levinson, 1994). Mental health providers are also trained within
the context of the ‘‘HMO reality’’ and, likewise, may be pressured
by economic restrictions. This type of care often leads to
pharmacologically based, laconic interventions, ones that are
62 J. Cacciatore and M. Flint
hyperstandardized (Cacciatore, 2010; Yalom, 2002). Yet, provi-
ders are obligated to act ethically in the patient’s best interest, often
with particular attention to vulnerable populations, such as the
traumatically bereaved. Our modest goal in the present article is
to sketch an overarching model for meeting these client needs
while also recognizing their own, concentrating here on the most
basic of its foundational features: mindful attunement to both self
and other in the healing partnership.
Psychosocial Care and Suffering
Suffering, broadly defined, is an existential experience, and medical
pedagogy has tended toward antithetical views: The first is to
‘‘respond to suffering with objectivity and detachment’’ to avoid
becoming ‘‘overwhelmed and paralyzed by pain’’ and to ensure
that medical decisions about patient care are made with objectivity
(Coulehan, 2009, p. 592). Despite the fact that there is no empirical
evidence to suggest that detachment improves medical perfor-
mance and mitigates provider fatigue, these views remain widely
accepted. The other view is that providers should ‘‘form bonds
of compassionate solidarity with [patients]’’ (Coulehan, 2009,
p. 593). Compassion, suffering with the other, is considered by
some to be a ‘‘medical virtue’’ that can alleviate emotional angst
(Coulehan, 2009; Reich, 1989).
Effective psychosocial care that is mindful, humble, and
nuanced has the capacity to abate human suffering (Cacciatore,
2010) and ‘‘requires a degree of flexibility [and] fluidity’’ that entails
a focus on (a) clinical research and experience, (b) patient concerns
and well-being, and (c) best practice. This trilogy should construct
and inform evidence-based practice (Porter-O’Grady, 2010, p. 3).
Interestingly, there is a dearth of literature on mindfulness-based
bereavement care (MBC). Yet, research suggests that a compassion-
ate, mindful presence in the midst of the traumatic loss helps mod-
erate long-term, negative psychiatric sequelae for both providers
and clients (Rushton et al., 2009; Walsh, 2007).
Mindfulness-Based Interventions
The term mindfulness has its roots in the Pali word sati, meaning
awareness, attention, and remembering. However, researchers
A Mindfulness-Based Bereavement Care Model 63
and clinicians have struggled with an absolute definition of
mindfulness because it is a ‘‘subtle, nonverbal experience’’ for
both patient and provider (Germer, 2005, p. 6). Mindfulness
skills are mastered in the therapeutic relationship through ‘‘prac-
tice by the clinician rather than the client’’ (Turner, 2009, p. 96).
Although the current scientific literature is emergent, findings
are promising. Mindfulness-based cognitive behavioral therapy
and mindfulness-based stress reduction (MBSR) have been used
successfully to treat anxiety (Kabat-Zinn, Massion, Kristeller,
et al., 1992; Koszycki, Benger, Shlik, & Bradwejn, 2007; Lee
et al., 2007; Weiss, Nordlie, & Siegel, 2005), depression and
recurrent depression (Kenny & Williams, 2007; Teasdale et al.,
2000), eating disorders (Kristeller, Baer, & Quillian-Wolever,
2006), chronic pain (Kabat-Zinn, 1982), insomnia (Heidenreich,
Tuin, Pflug, Michal & Michalak, 2006), substance abuse (Bowen
et al., 2006), and domestic violence (Silva, 2007). There are also
many studies that demonstrate improvements in chronic health
conditions such as cardiovascular disease. One randomized con-
trolled trial found that MBSR reduced systolic and diastolic
blood pressure and heart rate for hypertensive individuals
(Manikonda et al., 2008). Yet, many mental health and medical
providers may not be familiar with mindfulness-based
approaches to physical, social, or psychological health, despite
the fact that these skills ‘‘can be cultivated by anyone’’ (Germer,
2005, p. 5).
Mindfulness emphasizes a process by which one develops a
deep awareness of self and other and responds nonjudgmentally
in the present moment with full acceptance (Kabat-Zinn, 1990).
This framework helps individuals ‘‘work with the universal vul-
nerabilities and challenges that are an inherent part of being
human’’ (Crane, 2009, p. 3). Mindfulness training cultivates empa-
thy in providers, increasing neuronal activity in brain regions
associated with compassion (Morgan & Morgan, 2005; Shapiro,
Schwartz, & Bonner, 1998) and decreasing rumination. Although
mindfulness practices do not ‘‘diminish the enormity’’ of suffering,
they do ‘‘provide a greater basket for tenderly holding and inti-
mately knowing’’ pain. This process is more likely to lead to resili-
ence and posttraumatic growth (Kabat-Zinn, 2005, p. 91; Siegel,
2010).
64 J. Cacciatore and M. Flint
ATTEND: A Mindfulness-Based Bereavement Care
Model
I help them be with what is true. The healing comes from that.
Robert Hall, MD
The ATTEND model is an MBC that fosters healing, rather than
retraumatizing, provider reactions. This paradigm is practical
and cost-effective, interdisciplinary, culturally competent, theoreti-
cally sound, pedagogically adaptive, and most importantly may
offer the bereaved a unique means through which they may fully
experience their grief, eventually reconstructing new meaning
and experiencing a higher likelihood of posttraumatic growth
(Cacciatore, 2010; Siegel, 2010).
The acronym, ATTEND, stands for (A)ttunement, (T)rust,
(T)herapeutic touch, (E)galitarianism (N)uance, and (D)eath edu-
cation. This model is tripartite in nature: That is, the primary focus
is on providers and the ‘‘subtle and profound’’ contemplative prac-
tices that often elude reductive quantification (Crane, 2009). Then,
providers integrate aspects of the model into the therapeutic
relationship with the patient. This is fostered through attunement
with the client. Finally, clients are encouraged, both implicitly
and when appropriate explicitly, to practice mindfulness on their
own. This article will introduce the ATTEND model briefly, then
focus on attunement as the basis for MBC.
Attunement in patient care is achieved through an emphasis on
mindfulness, responsiveness, empathy, and self-awareness.
Attuned providers are more likely to embrace contemplative prac-
tices, such as intentional, deep awareness of their own emotional
state, daily prayer or meditation, stress reduction activities, and
altruism. These practices enhance the provider’s ability to express
empathy and compassion, even in the presence of painful emo-
tions such as those following traumatic death. They also decrease
the likelihood of provider avoidance and distraction. Although
being an attuned provider does not ‘‘diminish the enormity’’ of
suffering for patient or provider, it does create a greater capacity
to hold and tolerate emotional pain (Fulton, 2005; Kabat-Zinn,
1990), and this often leads to resilience, posttraumatic growth,
and greater affect tolerance (Crane, 2009; Kabat-Zinn, 1982).
A Mindfulness-Based Bereavement Care Model 65
Certainly, if providers are unable to bear their own emotional
responses, it becomes increasingly difficult to tolerate others’
expressions of suffering (Fulton, 2005). Attunement represents soli-
darity with patients and their families and a willingness to be fully
present (Coulehan, 2009).
Trust in the therapeutic relationship is achieved through
compassionate and mindful communication that is relationship-
focused. Relational trust unfolds when a provider fosters emotional
intimacy, ‘‘letting the patient know that he or she has actually been
heard.’’ This process creates a ‘‘positive feedback loop’’ confirming
understanding through iteration (Coulehan, 2009, p. 598). Iteration
of compassion is embodied through a mindful awareness of per-
sonal space (proxemics), compassionate facial expressions, touch
and posture (kinesics), eye contact (oculesics), and voice intonation
(Cacciatore, 2010; Fulton, 2005). Silence can convey a subtle yet
profound presence when words are inadequate and seem
‘‘superfluous, inauthentic, and shallow’’ (Nouwen, 1981). For
example, a physician sitting quietly next to the parent of a termin-
ally ill child might use mindful speech that is soft, choosing words
carefully, speaking slowly, and allowing therapeutic silence when
appropriate.
Touch, a rather intimate gesture, is often viewed as anathema
in medical care. Yet, there is no more appropriate time for inti-
macy than when a family is facing traumatic death. Under these
circumstances, ‘‘touching should be considered an indispensable
part of the doctor’s art’’ (Montagu, 1986, p. 282) primarily because
touch reduces distress and improves therapeutic intimacy and
rapport. Providers should not expect intimate and healing relation-
ships to occur in the absence of touch, as ‘‘relying exclusively on
talking is an impossible endeavor’’ (Heuer, 2005, p. 108). Neutral
touches, such as the top of the hand, the nearest shoulder, or
upper, midback, are often appropriate, particularly when within
the safety of a trusting relationship that is sensitive to cultural
idiosyncrasies.
Egalitarianism refers to a humble relationship that balances
power between provider and patient, resulting in shared, informed
decisions about medical procedures, end-of-life care, and death
rituals (Cacciatore, 2010). This style requires collaborative com-
munication in which decisions are made mindfully and creatively,
unencumbered by pressure or fear and where the family’s desires
66 J. Cacciatore and M. Flint
take precedence. For example, a family may want to hold their
dying child in the hospital garden. In the absence of an egalitarian
relationship in which providers willingly share decision-making
power, parents may be fearful and reluctant to express their
desires, and thus, they may miss this important opportunity for
creative ritualization.
Nuance refers to an awareness of unique individual and cul-
tural differences rather than care that adheres to a rigid protocol.
Bereavement teams in hospitals sometimes use standardized
checklists in the delivery of care. Yet, these checklists are assump-
tive, often focusing on manualization rather than the nuances of
each family and circumstance. Nuanced care eschews arrogance
and assumptions. Mindfulness practices are universally appropri-
ate because of their high degree of personalization and adapta-
bility, recognizing those differences and tailoring psychosocial
care to meet each individual, familial, and circumstantial need.
This fosters a milieu in which culturally competent care and
interpersonal resonance flourish (Cacciatore, 2011).
Death education takes two paths. The first is psychoeducation
from the physician to the patient. When a patient dies, the family
may have questions related to seeing the body or about the post-
mortem evaluation. This type of psychoeducation helps family
members feel better prepared to deal with their losses. Physicians,
nurses, and other providers should also consider thanatologically
focused continuing education. It is particularly important to be pre-
pared to deal with traumatic death in order to allay avoidance,
stress behaviors, compassion fatigue, and poor work performance
(Kabat-Zinn, 1982; Crane, 2009), and to remain wholly present
with grieving family members.
Attunement
At the foundation of the ATTEND model lies attunement, and it is
this dimension of the work that we will now consider in some
detail.
The Attuned Clinician
Working with the traumatically bereaved takes a toll on providers.
According to Henri Nouwen (1981), it requires a degree of
A Mindfulness-Based Bereavement Care Model 67
compassion wherein ‘‘we go with others to the place where they
are weak, vulnerable, lonely, and broken’’ (p. 24). Yet, most people
seek ‘‘to do away with suffering by fleeing from it or finding a quick
cure for it.’’ Thus, ‘‘we ignore our greatest gift, which is our ability
to enter into solidarity with those who suffer’’ (Nouwen, 1981, p.
24). Yet, it may be this very gift that may help insulate providers
from the long-term effects of others’ suffering.
Researchers are now studying topics such as compassion fatigue,
vicarious traumatization,orsecondary traumatization, documenting the
risk for profound disruptions in worldview, frame of reference,
sense of identity, and spirituality of all types of providers, from
therapists and social workers, to physicians and nurses. The effects
may be emotional and psychological, such as crying, outbursts,
sadness, helplessness, or anxiety and, in some cases, indifference
to avoid emotional pain. There may also be physical symptoms
such as lethargy, tightening in the throat or chest, forgetfulness,
intrusive thoughts, and nightmares (Dobkin, 2009; Halbesleben
& Rathert, 2008; Rubel, 2003). Health care professionals who
encounter death are particularly vulnerable to depression, anxiety,
anger, helplessness (Coulehan, 2009; West, Tan, Habermann,
Sloan, & Shanafelt, 2009), lethargy, intrusive thoughts, and night-
mares. Unresolved provider stress has been shown to adversely
affect patient satisfaction, compliance, and even recovery
(Coulehan, 2005, p. 596). Administrators who ‘‘take proactive
steps to reduce’’ stress for their providers will realize immense
‘‘benefits in terms of patient satisfaction and recovery’’
(Halbesleben & Rathert, 2008, p. 29).
One of the most empirically validated ways to cope with
vicarious trauma is through MBSR. One 8-week randomized, con-
trolled trial with medical students showed the promising effects of
MBSR including a reduction of anxiety and depression and a con-
comitant increase of empathy when compared to a control group
(Shapiro et al., 1998). Other studies have shown that MBSR
reduces stress and burn-out in high-stress careers, overall improved
life satisfaction, increases in self-compassion, decline in ruminative
tendencies, and improved patient outcomes (Gilbert, 2005). In
particular, experiential avoidance exacerbates and prolongs post-
traumatic stress in providers, whereas ‘‘self compassion is asso-
ciated with greater willingness to engage painful thoughts’’ and
memories of trauma (Thompson & Waltz, 2006, p. 558).
68 J. Cacciatore and M. Flint
Of particular note is the fact that distress and fearfulness on
the part of the provider may prompt another type of experiential
avoidancethat of the provider avoiding particularly important
conversations with the client out of their personal distress. For
example, a therapist working with a bereaved mother may ask
her to recount painful details of her child’s death. This process
may rouse an intense emotional reaction. An attuned clinician
would pay careful attention to any internal sensations in the pres-
ence of such fierce emotion, ensuring that the response would not
be an attempt to ‘‘do for,’’ interrupting or distracting from the
moment because of his or her own discomfort. The mindful clin-
ician is ‘‘present with’’ rather than ‘‘doing for’’ (Segal, Teasdale
& Williams, 2004) and is able to tolerate the expression and
processing of painful, even traumatic, memories.
There are three broad categories that help enhance provider
attunement. The first is a conscious awareness of the present
moment through a systematic methodology of contemplative prac-
tices such as: (a) the 3-min breathing space or minimeditation
(3MBS; 3 min focused on the sensations of deep, slow breaths;
Turner, 2009); (b) meditation, prayer, or contemplative time; (c)
body scan (or autogenics, a progressive awareness of the body
and intentional relaxation); (d) Hatha yoga; (e) ‘‘eco-attunement’’
(Siegel, 2010) through barefoot nature walks; and (f) reading
poetry. Most of these can be practiced during work or home hours
and can have spiritual or secular meaning and effects. Turner’s
(2009) 3MBS exercise, for example, can be used effectively
in-between patients as a strategy to prepare for the next person,
or an abbreviated version can be used if 3 min are not available:
1. Take a few moments and feel the rise and fall of your breath
before the next patient.
2. As you walk to the door, imagine that on the other side is a
human being waiting.
3. This human being is suffering and believes you can help.
4. Approach this person with the intention to be mindful, present,
and compassionate.
The second category of mindful attunement is to strive toward
an attitude of ‘‘kindness, curiosity, and a willingness to be present
with the unfolding’’ experience of each moment. This means
A Mindfulness-Based Bereavement Care Model 69
tolerating uncertainty and inviting a place where the unfixable and
uncurable can be explored. Finally, the third broad category is an
‘‘embodied understanding of human vulnerability’’ that cultivates
mindful tolerance for the expression of very painful emotions
and thought patterns (Crane, 2009, p. 6). That is, human suffering
is inevitable for everyone, and by ‘‘opening to our own suffering
we can remain better open to the struggles of others’’ (Fulton,
2005, p. 81). Thus, providers should strive toward experiential
approaching rather than experiential avoidance both for the self
and the other. Rushton et al. (2009) found that this type of
approach in end-of-life care helped providers to stabilize the mind.
When coupled with contemplative practices on the part of the pro-
vider, they fostered a more comfortable approach to dying patients
and their families.
Self-compassion has been shown to reduce self-criticism and
ruminative tendencies and will improve a provider’s ability to
reflect and learn from an experience (Thompson & Waltz, 2008).
The same mindfulness practices that improve psychosocial care
for patients can be used to facilitate the provider’s self-compassion,
that is, attunement and self-awareness around loss. Mindful pro-
viders express deeper satisfaction with their work and suffer com-
passion fatigue less often, and they are happier in their professional
lives (Epstein, 2003; Zoppy & Epstein, 2002), more willing to
acknowledge and approach their own emotions. Some providers
find a degree of resolution to their own grief by following up with
the family, reviewing details of the incident, and sharing their feel-
ings with coworkers or other providers. Others may benefit from
journaling, psychotherapy, exercising, or learning a new hobby.
This inventory of self-compassion is based on a review of the litera-
ture on mindfulness-based strategies:
1. Spend at least 15 min daily in meditation, prayer, or quiet time
just being.
2. Allocate at least 20 min a day of exercise within your abilities.
3. Practice laughter. Every day, try to find humor in something,
even if it seems insignificant. Smile. Smile at others, smile at
yourself. Just smile.
4. Surround yourself with caring othersfamily, friends, and
work colleagues. Seek the company of others who are com-
passionate and kind.
70 J. Cacciatore and M. Flint
5. Get 20 min of sunshine every day.
6. Observe and truly experience nature. Notice the sky when
walking to your car. Listen to the sounds of birds. Pay atten-
tion to the trees, smell blossoming flowers, hear the buzzing
bees, and watch ants as they work.
7. Experience gratitude daily for even the simple things in life
that are easily taken for granted: good health, family, running
water, your home, and food.
8. Think positive thoughts whenever you can. Notice any nega-
tive self-talk, and see if you can counter them with positive
thoughts.
9. Show compassion, actively, toward others. Look for even
small opportunities to help. Open doors, offer to aid someone
carrying groceries, really listen to someone else’s story.
Actively, every day, seek to show kindness. And volunteer
for a good cause at least 1 day per month.
10. Support your brain: Eat a healthy diet and eliminate junk and
fast foods.
11. Express your love and affection for your mate, children,
friends, and=or family. Take the time to say ‘‘please’’ and
‘‘thank you.’’ Tell others how much they mean to you. Give
and accept praise.
12. Give yourself permission to experience self-compassion and
self-love. Practice forgiveness, especially to yourself, and be
your own best friend.
The Attuned Clinician–Client Relationship
Mindfulness strategies practiced daily may help improve provi-
ders’ ability to turn toward the patient, becoming more aware of
the patient’s moment-by-moment emotional and practical needs
in bereavement care. Additionallyand particularly important
when working with traumatic death survivorsit may help provi-
ders become aware of any personal anxiety or discomfort as it
arises. Affect exposure, tolerance, and the willingness to face pain-
ful feelings help reduce the power of those emotions, which can be
psychologically threatening to many providers (Zetzel, 1970). As a
result both the provider and the client may become ‘‘less pos-
sessed’’ by those emotions (Fulton, 2005). Affect tolerance may
A Mindfulness-Based Bereavement Care Model 71
also help a provider refrain from what Freud (1917=1957) termed
furor sanandi, that is, the rage to cure.
Attunement in the relationship fosters important therapeutic
moments for the patient where the providers can ‘‘stand fully
and simply with the patient in the full flame of suffering’’ (Fulton,
2005, p. 65) without being paralyzed by very intense emotional dis-
tress (Brenner & Homonoff, 2004). Providers’ own contemplative
practices provide a social learning model for clients in the dyad,
modeling the processing, thoughts and behaviors, and affective
states relative to a loss. Attuned providers are also intentional in
their communication, choosing words with care and asserting a
full, supportive presence through nonverbal expressions and
congruent facial and bodily gestures. Ultimately, attunement
‘‘helps us remain open to the other,’’ creating the ‘‘essential con-
dition of trust’’ (Siegel, 2010, p. 75) and equanimity. This may
include therapy that extends beyond the traditional four walls of
treatment, such as incorporating creative expression such as
poetry, art, music, ecotherapy (counseling sessions held in nature),
after-hours calls, and rituals.
The Attuned Client
Traumatic grief often produces a consistent pattern of experiential
avoidance, a key aspect of complicated bereavement (Shear, 2010).
Experiential avoidance is an unwillingness to be in contact with
‘‘private experiences’’ such as body sensations, emotions, thoughts,
and memories and actually take steps to ‘‘alter the form or fre-
quency of these events and the contexts that occasion them’’
(Hayes, Wilson, Strosahl, Gifford, & Follette, 1996, p. 1154) and
can incite dissociation. Although experiential avoidance may, at
times, be adaptive, overuse may incite a prolongation of the
mourning process (Shear, 2010). When prolonged, the bereaved
individual tends to interpret the experience as indicative of future
outcomes rather than related to the tragedy that occurred in the
past (Boelen, van den Bout, & van den Hout, 2010). Clients may
hold fears that they are ‘‘going crazy’’ or that if they confront the
gravity of their loss they will ‘‘die.’’ The resulting avoidance
behavior serves to interfere with the client’s ability to integrate
the gravity of the loss into their existing knowledge base (Boelen
et al., 2010) and, therefore, find their new ‘‘normal.’’ Helping the
72 J. Cacciatore and M. Flint
client to gently sit with and be supported through their experience
is a critical component to this model. Over time, this mindset is
modeled by the clinician in a gentle, safe environment. The client
who is attuned with his or her grief is more likely to reach a place
where of being with, surrending to, and doing with grief. These
individuals are more likely to discover ways to integrate the lost
loved one into their lives in a meaningful, future-oriented way with
newly defined aspirations and perspectives on life.
Case Example
Andrea is a 26-year-old single woman who experienced the tragic
death of her 9-month-old daughter, Maggie, nearly 2 years before
seeking counseling. She was in the process of moving from her
home following a protracted divorce when a large screen tele-
vision slipped from her grip. Unknowingly, Maggie, her only
child, followed her into the room, and was crawling underneath
when the television dropped. Horrified, she lifted the television
off her baby and frantically called paramedics. Maggie was
removed from life support later that day and died in her arms.
During the intake, she described herself as ‘‘very good at pretend-
ing it didn’t happen’’ noting that she ‘‘blocks’’ and avoids painful
memories related to her baby’s traumatic death. She stated that
she frequently changes the subject when someone talks about
Maggie and that she took down all her photos and reminders of
her in her home.
Andrea sought counseling from a provider who specializes in
MBC because she felt that she was ‘‘dying inside ...and the pain is
killing me.’’ At intake, Andrea scored 2.09 on the Impact of Event–
Revised (IES-R) scale to measure posttraumatic stress disorder
(threshold for diagnosis is 1.55) and 2.16 on the Hopkins Symp-
toms Checklist (HSCL) measuring anxiety and depression (thresh-
old for diagnosis is 1.75). Andrea’s counselor at the agency uses
the ATTEND model both personally and professionally. She
practices meditation daily and engages in other contemplative
practices including daily self-care and self-compassion strategies,
volunteering and service, art and poetry, and social justice and
activism.
The first few sessions were spent building trust in the relation-
ship through attunement. Andrea expressed a strong desire to ‘‘talk
A Mindfulness-Based Bereavement Care Model 73
about that day and stop running from it’’ and to ‘‘be able to look at
[Maggie’s] pictures again and put them back on the walls.’’ The
counselor listened intently as she recounted the traumatic circum-
stances surrounding Maggie’s death over the course of several
sessions. These descriptions, including the blunt force trauma to
Maggie’s head and the shame and guilt Andrea was suffering
because she ‘‘killed’’ her daughter, incited feelings of dread in
the counselor of which she was keenly aware. ‘‘I did it, I
killed her, I did it,’’ she would say repeatedly. Interestingly,
she told the story in rather broad strokes, lacking detail, and her
affective state seemed incongruent with the story. Andrea would
visually dissociate during the telling, and she was remarkably
phlegmatic. The counselor noticed this, as well as the absence of
eye contact with the counselor. The counselor focused her atten-
tion on remaining fully present, empathic, and tender with the
client and with her own emotional state, both inside and outside
of session.
The counselor felt that trust was established after three to four
sessions as Andrea began to tolerate and disclose more details
related to Maggie’s death. Slowly, Andrea’s emotional expression
became more congruent with the telling of the story. She became
openly sorrowful, sometimes laying on the ground for long periods
of time weeping. Her counselor would not interrupt but would sit
on the floor next to her quietly, occasionally touching her on the
back to assure her she was still there. One-by-one, Maggie’s pic-
tures were invited back into Andrea’s life. Together, the team
began to integrate some of the mindful bereavement practices:
(a) becoming attuned to her grief by being with her suffering, (b)
pausing and sitting quietly through it, (c) giving herself permission
to weep and mourn for Maggie, (d) journaling and writing letters to
Maggie, and (e) attending both intensive group and individual
counseling sessions, which included reviewing videos and photos
of Maggie from her birth to her death.
During the 10th session, Maggie and her counselor embarked
on a ‘‘barefoot walkabout,’’ hiking barefoot up a mountain trail, a
technique practiced monthly by her counselor. The goal of the
walkabout was to be in the present moment, paying attention to
every step and acceptingmetaphoricallyunpleasant sensations
along the path. She felt the walkabout ‘‘changed something’’ for
her, though inexplicably. In the next few sessions, the relationship
74 J. Cacciatore and M. Flint
focused on surrendering to grief, even when painful images
intruded, and learning to honor those. Andrea began to trust
herself, realizing that the darkness, though very frightening and
at times paralyzing, was something she could tolerate most days.
She began learning to tell her story, repeatedly, rather than
‘‘hiding’’ her daughter’s death and the intense shame and guilt
she experienced as a result of her ‘‘own hands.’’ She also attended
a candle lighting and other memorial rituals held by a local non-
profit organization for bereaved parents. During one surrendering
session, Andrea wrote a letter of apology to Maggie for the act that
took her life. She asked for her forgiveness. In a letter back to
Andrea that ‘‘Maggie’’ wrote, forgiveness was granted because
‘‘Maggie’’ realized that Andrea ‘‘loved her enough to give her
own life for her.’’
The next month, Andrea began serving others through ran-
dom acts of kindness in her community to honor Maggie as well
as to honor her grieving self. On one occasion, she went into a
local bakery and anonymously purchased a birthday cake for a lit-
tle girl who was the same age as Maggie. She described that as
‘‘powerful’’ and ‘‘emotional in both good and bad ways.’’ She
began baking treats every month for fellow support group
members and volunteered for several events such as a Mother’s
Day walk. She became a community volunteer and a leader in
her support group and began making memorial cards for other
families in memory of her daughter.
About a year after Andrea entered counseling, her IES–R
scored had dropped to 1.04, and her HSCL dropped to 1.68, both
outcomes below the threshold for psychopathology. Andrea
noticed that her priorities began to shift. She decided on a career
change and registered for school, planning to become a counselor
so she could ‘‘eventually help other parents who were hurting’’ in
the aftermath of child death. And, she took on a more active role in
supporting others’ grief during group sessions, shifting the focus
away from her own mourning to the more recently bereaved.
Though the road remains long and arduous for Andrea, her
chances of posttraumatic growthand a life of transcendence
are greatly improved. In addition, her counselor has experienced
the psychological benefit of witnessing her transformation, cer-
tainly an unintended consequence of attending to the suffering of
another.
A Mindfulness-Based Bereavement Care Model 75
Potential Outcomes
Human suffering, particularly when it includes traumatic bereave-
ment, ignites an existential crisis from which a wellspring of
concerns emerges. These are often important concerns related to
the ultimate struggle of spirituality, meaning, or purpose. The
ATTEND model, when applied to the provider–patient relation-
ship, is intended to reduce negative psychiatric sequelae for indivi-
duals and improve outcomes for families and communities.
Additionally, mindfulness practices demonstrate strong effect sizes,
suggesting they may improve life satisfaction, help manage stress,
relieve extraordinary distress, and increase overall well-being for
providers (Grossman, Niemann, Schmidt, & Walach, 2004).
Education on mindful provider care has been shown to improve
attitudes toward patients and increase emotional stability in both
mental and medical health professionals (Krasner et al., 2009;
Salyers et al., 2011) and decrease provider mood disturbances such
as depression, fatigue, tension, and emotional exhaustion (Krasner
et al., 2009).
Although there is as yet no empirical evidence for posttrau-
matic growth within the context of MBC, there is sufficient anec-
dotal data to warrant its exploration. For example, the type of
metacognitive awareness fostered in mindfulness training has been
associated with higher levels of self-esteem (Fennell, 2004). And
self-esteem was the greatest predictor of posttraumatic growth in
bereaved parents (Engelkemeyer & Marwit, 2008). These same
variables and outcomes could, ostensibly, be applied to providers
as well, intimating that mindfulness practice, overall, can help both
patients and providers. In addition, good psychosocial support is
associated with higher levels of self-esteem and lower levels of
depressive symptoms (Brown, Andrews, Harris, Adler, & Bridge,
1986). Transcendence and posttraumatic growth address that
which goes beyond the mundane of the material world and entails
finding hope amidst the hopelessness of grief. For the spiritual,
posttraumatic growth may be demonstrated by an enriched
relationship with the Creator or a deepened connection to the
Universe; it may also extend to meaning through a physical legacy
that will withstand time such as a work of art, writing a book, or
other type of enduring legacy in service to others (Corr, Nabe, &
Corr, 2006; Frankl, 1946=1985). However, it is difficult to
76 J. Cacciatore and M. Flint
accomplish meaning reconstruction in the absence of approaching
behaviors. And such meaning reconstruction, despite a person’s
individual spiritual orientation, may help a mourner reframe, inte-
grate, and better cope with the loss (Neimeyer, 2002; Neimeyer &
Sands, 2011). The bereaved need mindful providers willing to bear
witness to their pain in the moment, nonjudgmentally, and with
full acceptance of their emotional, social, and existential state. This
may then model a state of mindfulness practices for the bereaved,
increasing their own ability to be present with, tolerate, and grow
beyond their own experiences of traumatic death.
Conclusion
The rigidity through which care of the traumatically bereaved is
currently undertaken may not allow providers to be aware of
and fully present with the nuances of each individual and his or
her unique circumstances (Siegel, 2010). Mindfulness, by its very
nature, eschews assumptions and embraces acceptance. This results
in a higher-level of competency that arises with intrapersonal reson-
ance (Siegel, 2010). Siegel (2010) cited the acronym COAL
curiosity, openness, acceptance, and a ‘‘healing form of love ...and
and compassionate concern’’as a means through which a pro-
vider can provide the kind of care that recognizes individual clients
and their culture during suffering (p. 55). In other words, providers
should engage in sincere inquiry with an open attitude that is non-
judgmental. In this way, both individual and cultural sensitivity is
more likely.
The 19th-century Czechoslovakian-born poet, Rilke (1903=
1984), spoke poignantly about being with suffering:
if a sadness rises before you larger
than any you’ve ever seen, if an
anxiety like light and cloud shadows
moves over your hands and
everything that you do. You must
realize that something has happened
to you. Life has not forgotten
you, it holds you in its hands
and will not let you fall. Why do
you want to shut out of your life
any uneasiness, any miseries, or
A Mindfulness-Based Bereavement Care Model 77
any depressions? For after all, you
do not know what work these conditions
are doing inside of you.
There is, indeed, a more sane and compassionate framework
of bereavement care that may cultivate a therapeutic environment
in which the bereaved can grow within and beyond their losses. It
is also possible that this type of MBC, which arises from mindful-
ness practice, may enhance provider well-being both personally
and professionally. Althogh further research should be done on
MBC for the bereaved, the ATTEND model represents a para-
digm shift in the care of the bereaved that offers hope to patients
and providers suffering the inevitable and unavoidable experience
of death that unites us all.
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82 J. Cacciatore and M. Flint
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    • "A closely related principle to emptiness is the Buddhist concept of impermanence that comprises the following three dimensions: (a) the self (and indeed all phenomena) will ultimately die and cease to be, (b) phenomena (including the self) are constantly changing and do not remain in stasis for even the smallest scientifically meaningful moment of time (i.e., one Planck time [5.39 10 43 s]), and (c) the transiency of phenomena (i.e., the fact that they are constantly changing) means that they—and anything resembling a self that intrinsically exists within them— can never be located in time and space (Tsong-Kha-Pa, 2004). A number of trauma and grief treatment modalities have integrated impermanence awareness training (often in conjunction with mindfulness training) as a means of helping individuals come to terms with the fact that: (a) life is uncertain and sudden loss of life and/or traumatic events can (and do) happen, and (b) the only thing certain about life is that it will end in death (Cacciatore & Flint, 2012; Cacciatore, Thieleman, Osborn, & Orlowski, 2014; Cacciatore, Thieleman, Killian, & Tavasolli, 2015; Kumar, 2005; Wada & Park, 2009). An increased acceptance of the impermanent nature of existence may help to facilitate the earlier onset of the recovery and restorative phases of the grieving process (Wada & Park, 2009). "
    [Show abstract] [Hide abstract] ABSTRACT: In recent decades, there has been growing assimilation of ancient Buddhist practices and principles into Western research and applied psychological settings. One Buddhist principle currently receiving an increasing amount of scientific interest is emptiness. Emptiness asserts that all phenomena-including the "self"-are empty of intrinsic existence. We examine how logical inquiry and evidence from diverse psychological and scientific disciplines appear to be gradually adding credence to the notion of emptiness. We explicate how, if emptiness theory continues to be validated and accepted by Western psychologists, it will become necessary to reexamine some established beliefs in relation to the workings of both the psychological and physical world. Examples of how emptiness might develop and/or complement psychological and wider scientific understanding in this respect include coming to the acceptance that: (a) what is currently understood to be waking reality is effectively a shared dream, (b) the "self" does not inherently exist, © the underlying cause of mental illness is an individual's belief that they inherently exist, and (d) maladaptive psychosocial functioning and the absence of mental illness are not necessarily mutually exclusive occurrences. We conclude that there is a clear need for greater research into the validity and applications of emptiness. However, if supportive empirical findings relating to emptiness continue to emerge, it is possible that some of the next important scientific "discoveries" about mind and matter will emerge at the intersection of ancient Eastern contemplative practice, empirically grounded Western psychological insights, and quantum mechanics. (PsycINFO Database Record
    Full-text · Article · Mar 2016
    • "A closely related principle to emptiness is the Buddhist concept of impermanence that comprises the following three dimensions: (a) the self (and indeed all phenomena) will ultimately die and cease to be, (b) phenomena (including the self) are constantly changing and do not remain in stasis for even the smallest scientifically meaningful moment of time (i.e., one Planck time [5.39 10 43 s]), and (c) the transiency of phenomena (i.e., the fact that they are constantly changing) means that they—and anything resembling a self that intrinsically exists within them— can never be located in time and space (Tsong-Kha-Pa, 2004). A number of trauma and grief treatment modalities have integrated impermanence awareness training (often in conjunction with mindfulness training) as a means of helping individuals come to terms with the fact that: (a) life is uncertain and sudden loss of life and/or traumatic events can (and do) happen, and (b) the only thing certain about life is that it will end in death (Cacciatore & Flint, 2012; Cacciatore, Thieleman, Osborn, & Orlowski, 2014; Cacciatore, Thieleman, Killian, & Tavasolli, 2015; Kumar, 2005; Wada & Park, 2009). An increased acceptance of the impermanent nature of existence may help to facilitate the earlier onset of the recovery and restorative phases of the grieving process (Wada & Park, 2009). "
    Article · Jan 2016
    • "Cacciatore ( 2011 ) proposed the first mindfulness-based paradigm, its utility focused on the tripartite relationship. The model's utility and success have been demonstrated in several studies since its inception ( Cacciatore & Flint, 2012 ; Cacciatore, Thieleman, Osborn, & Orlowski, 2014 ; Thieleman, Cacciatore, & Wonch, 2014 ). For example, using this model, found a reduction in trauma, depressive, and anxious symptoms in a population of the traumatically bereaved after an average of just 14 h in counseling. "
    [Show abstract] [Hide abstract] ABSTRACT: Death and its resultant grief intrigue, terrify, preoccupy, and mesmerize human beings around the world. In Western culture, a great premium is placed on youth, happiness, and hedonism, and there exists a pervasive avoidance of aging, grief, and discomfort. Thus, suffering and mourning are treated as something to avoid altogether or from which we “move on” rather expeditiously. Using three case studies, this chapter proposes a mindfulness-based bereavement care model whose utility aids and deepens the provider-client relationship and creates a space within the dyad for exploration and eventual non-coercive healing. The chapter explores how mindfulness practices enhance relational authenticity, bringing us closer, even amidst tragedy, and can enhance the feeling of safety as we all seek solace for our experiences of unfathomable pain.
    Full-text · Chapter · Jan 2016 · Psychology of Religion and Spirituality
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