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![S U S A N S T U B E R , P H . D . M A R C H 2 2 , 2 0 1 3
GRIEF THERAPY
[Presented by Dr. Stuber at the Philadelphia Society of Clinical
Psychologists continuing education conference at the Philadelphia
College of Osteopathic Medicine, March 22, 2013.]
Copyright 2013 Susan Stuber, PhD
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Uploaded bySusan Stuber PhD
Grief therapy
This document summarizes a presentation on grief therapy given by Dr. Susan Stuber. It discusses research on normal grief versus complicated grief, assessments of complicated grief, debates around including prolonged grief disorder in the DSM-V, and additions related to grief in the DSM-5. The presentation covers critiques of Kubler-Ross's five stages of grief model, analyses of criteria for complicated or prolonged grief proposed by Prigerson and Shear, and risk and protective factors for complicated grief.
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Grief therapy
- 1. S U SA N S T U B E R , P H . D . M A R C H 2 2 , 2 0 1 3 GRIEF THERAPY [Presented by Dr. Stuber at the Philadelphia Society of Clinical Psychologists continuing education conference at the Philadelphia College of Osteopathic Medicine, March 22, 2013.] Copyright 2013 Susan Stuber, PhD 1
- 2. GRIEF THERAPY • Thelatest research in the field on grief therapy • The difference between normal grief and complicated or prolonged grief • Research and issues involved in the inclusion of “Prolonged Grief Disorder” in DSM-V • Cognitive behavioral techniques to treat prolonged grief • The importance of self-awareness and the necessity of self-care when providing grief counseling • Different cultural views of death Copyright 2013 Susan Stuber, PhD 2
- 3. ELISABETH KUBLER-ROSS • Background Copyright2013 Susan Stuber, PhD 3
- 4. POSITIVE EFFECTS OFKUBLER-ROSS’S 5- STAGE THEORY • Opened up the door to talk about grief • Supported the rise of the Hospice movement Copyright 2013 Susan Stuber, PhD 4
- 5. CRITIQUE OF KUBLER-ROSS’S5 STAGE THEORY • Authenticity disputed • Was formulated to describe the stages of dying, but then applied to stages of grief. • Was not research based • Implies a lock-step progression and a completion Copyright 2013 Susan Stuber, PhD 5
- 6. CRITIQUE OF KUBLER-ROSS’S5 STAGE THEORY • Bosconti’s (2004) graph of emotional fluctuations Copyright 2013 Susan Stuber, PhD 6
- 7. KUBLER-ROSS’S IMPACT • Whywas her 5-stage theory so popular? • Birth of the “Grief Industry” Copyright 2013 Susan Stuber, PhD 7
- 8. GET READY FORONE OF THE MOST IMPORTANT (AND SHOCKING) POINTS OF THE TALK Copyright 2013 Susan Stuber, PhD 8
- 9. GRIEF COUNSELING DOESN’TWORK • Currier, Neimeyer, and Berman (2008) meta-analysis • “Such evidence challenges the common assumption in bereavement care that routine intervention should be provided on a universal basis …” Chris Feudtner at Penn Center for Bioethics at CHOP Conclusion: Other than treating major depression with medication, there was no evidence for recommending bereavement interventions Copyright 2013 Susan Stuber, PhD 9
- 10. GRIEF THERAPY DOESN’TWORK (CONT.) • Stroebe, Stroebe, Schut et al. (2002) • “No evidence that disclosure facilitated adjustment … (and) the writing task did not result in a reduction of distress.” Copyright 2013 Susan Stuber, PhD 10
- 11. GRIEF THERAPY • Thelatest research in the field on grief therapy • The difference between normal grief and complicated or prolonged grief • Research and issues involved in the inclusion of “Prolonged Grief Disorder” in DSM-V • Cognitive behavioral techniques to treat prolonged grief • The importance of self-awareness and the necessity of self-care when providing grief counseling • Different cultural views of death Copyright 2013 Susan Stuber, PhD 11
- 12. COMMON GRIEF SYMPTOMSTHAT ARE WNL IN THE FIRST 6-12 MOS (SHEAR ET AL., 2011) • Recurrent, strong feelings of yearning, wanting very much to be reunited with the person who died; possibly even a wish to die in order to be with deceased loved one • Pangs of deep sadness or remorse, episodes of crying or sobbing, typically interspersed with periods of respite and even positive emotions • Steady stream of thoughts or images of deceased, may be vivid or even entail hallucinatory experiences of seeing or hearing deceased person • Struggle to accept the reality of the death, wishing to protest against it; there may be some feelings of bitterness or anger about the death • Somatic distress, e.g. uncontrollable sighing, digestive symptoms, loss of appetite, dty mouth, feelings of hollowness, sleep disturbance, fatigue, exhaustion or weakness, restlessness, aimless activity, difficulty initiating or maintaining organized activities, altered sensorium • Feeling disconnected from the world or other people, indifferent, not interested or irritable with others Copyright 2013 Susan Stuber, PhD 12
- 13. SYMPTOMS OF INTEGRATEDGRIEF THAT ARE WNL (SHEAR ET AL., 2011) • Sense of having adjusted to the loss • Interest and sense of purpose, ability to function, and capacity for joy and satisfaction are restored, • Feelings of emotional loneliness may persist • Feelings of sadness and longing tend to be in the background but still present • Thoughts and memories of the deceased person accessible and bittersweet but no longer dominate the mind • Occasional hallucinatory experiences of the deceased may occur • Surges of grief in response to calendar days or other periodic reminders of the loss may occur Copyright 2013 Susan Stuber, PhD 13
- 14. COMPLICATED GRIEF (SHEARET AL., 2011) • Persistent intense symptoms of acute grief • The presence of thoughts, feelings or behaviors reflecting excessive or distracting concerns about the circumstances or consequences of the death Copyright 2013 Susan Stuber, PhD 14
- 15. SHEAR’S WORDS TOCLIENTS • “ … think of the traveler as someone who has undergone a forced emigration. Grief is not a voyage from which people return, but rather a permanent place in which bereaved people must reside and redefine their lives. We do not experience a period of grief, come back, and return to life as usual. Instead, grief is a new homeland. Although life is permanently changed by an important loss, it is still possible to rediscover our potential for experiences that are rich and satisfying, if always at least a bit sadder.” Copyright 2013 Susan Stuber, PhD 15
- 16. THE FACE OFNORMAL AND COMPLICATED GRIEF • (Maercker and Lalor, 2012) • The tasks of normal grief • Able to remember the deceased with less pain • Reality of the death is acknowledged • Able to return to enjoyable relationships and activities • New symbolic relationship with deceased as deceased • The face of complicated grief • Difficulty accepting the death • Traumatic distress extending beyond 6 months • Repetitive loop of intense longing • Impairment to work, health and social functioning Copyright 2013 Susan Stuber, PhD 16
- 17. PREVALENCE OF CG 10%(Shear, 2011) Hard to tell based on lack on consensus about criteria. Other countries have lower estimates. Copyright 2013 Susan Stuber, PhD 17
- 18. WHAT’S IN ANAME? • Pathological • Unresolved • Protracted • Traumatic • Complicated • Prolonged Copyright 2013 Susan Stuber, PhD 18
- 19. INVENTORY OF COMPLICATEDGRIEF (0=NOT AT ALL; 4=SEVERE). CUT-OFF FOR CG=30 • 1. Preoccupation with the person who died • 2. Memories of the person who died are upsetting • 3. The death is unacceptable • 4. Longing for the person who died • 5. Drawn to places and things associated with the person who died • 6. Anger about the death • 7. Disbelief • 8. Feeling stunned or dazed • 9. Difficulty trusting others • 10. Difficulty caring about others • 11. Avoidance of reminders of the person who died • 12. Pain in the same area of the body • 13. Feeling that life is empty • 14. Hearing the voice of the person who died • 15. Seeing the person who died • 16. Feeling it is unfair to live when the other person has died • 17. Bitter about the death • 18. Envious of others • 19. Lonely Copyright 2013 Susan Stuber, PhD 19
- 20. RISK FACTORS FORCG • Female • Pessimistic • History of mood, anxiety, or personality disorders • History of insecure attachment • History of parental death or abuse • Excessively dependent relationship with the deceased • High stress • Low social support • More common if death of loved one was violent/disastrous, or in death of a child Copyright 2013 Susan Stuber, PhD 20
- 21. PROTECTIVE FACTORS FORCG • Dispositional resilience (Bisconti, 2007) • Optimism, active coping, positive reframing (Riley et al., 2006). Copyright 2013 Susan Stuber, PhD 21
- 22. GRIEF THERAPY • Thelatest research in the field on grief therapy • The difference between normal grief and complicated or prolonged grief • Research and issues involved in the inclusion of “Prolonged Grief Disorder” in DSM-V • Cognitive behavioral techniques to treat prolonged grief • The importance of self-awareness and the necessity of self-care when providing grief counseling • Different cultural views of death Copyright 2013 Susan Stuber, PhD 22
- 23. WHY CG SHOULDNOT BE ADDED TO DSM-V • It is wrong to stigmatize a process that virtually every person goes through in their lifetime. • Insufficient research • Potential abuse by drug companies and therapists motivated by financial gain. • Others? • Show of hands (pro vs. con at this point) Copyright 2013 Susan Stuber, PhD 23
- 24. WHY CG SHOULDBE ADDED TO DSM-V • If standardized criteria for “prolonged grief disorder” were agreed upon, researchers would be able to investigate the prevalence, risk factors, outcomes, neurobiology, prevention, and treatment of this disorder • Such criteria would also assist clinicians in the accurate detection and treatment of this disorder • As well as reimbursement for treatment • Meets criteria for “mental disorder” Copyright 2013 Susan Stuber, PhD 24
- 25. CAN CG BEINCORPORATED INTO AN EXISTING DIAGNOSIS? • CG has different, unique symptomatology • CG has a different response to treatment Copyright 2013 Susan Stuber, PhD 25
- 26. CG IS LIKEYET UNLIKE MDD • Similarities: symptoms of sadness, crying, hopelessness, sleep disturbance, and suicidal thinking. • 50 – 60% of those with CG meet criteria for MDD • Differences • Dopamine activation • Guilt, sleep disturbance and suicidality • Factor analysis Copyright 2013 Susan Stuber, PhD 26
- 27. CG IS LIKEAND UNLIKE PTSD • Similarities: traumatic event, intrusive images, avoidance, estrangement from others • Differences: • traumatic event • reduction of threat • different hallmark symptoms • Factor analysis Copyright 2013 Susan Stuber, PhD 27
- 28. CG IS LIKEYET UNLIKE AN ADJUSTMENT DISORDER • Response to stressor is unusually intense or prolonged. • But, unlike an adjustment disorder, CG is a discrete, recognizable syndrome, NOT a disperate group of symptoms that don’t fit elsewhere. Copyright 2013 Susan Stuber, PhD 28
- 29. THE PROLONGED, COMPLICATEDSAGA OF RESEARCHING PROLONGED COMPLICATED GRIEF!! • Research based criteria from Prigerson, et al., 2009 • Research based criteria from Shear, et al., 2011 • What DSM-V decided to do Copyright 2013 Susan Stuber, PhD 29
- 30. PRIGERSON ET AL.’S(2009) STUDY • Group of experts met in 1999; gave it the green light • 6 Phase longitudinal Yale Bereavement Study • 291 Participants interviewed at: • 0 – 6 months • 6 – 12 months • 12 – 24 months post-loss • Participant characteristics: • Average age: 62 • 74% female • 95% white • 60% educated beyond high school • 84% were spouses of the deceased • Measurements: ICG-R, other outcomes assessed Copyright 2013 Susan Stuber, PhD 30
- 31. AIMS OF THE6 PHASES • 1. To limit the set of symptoms for PGD to those that were informative and unbiased • 2. To identify a specific, optimum diagnostic algorithm for meeting criteria for PGD • 3. To evaluate the predictive validity of the final proposed criteria of PGC Copyright 2013 Susan Stuber, PhD 31
- 32. 1. DETERMINING THESYMPTOMS • How they did it: Item Analysis • Symptoms they included: • Yearning • Avoidance of reminders of the deceased • Disbelief or trouble accepting the death • A perception that life is empty and meaningless without the deceased • Bitterness and anger • Emotional numbness or detachment from others • Feeling stunned, dazed, or shocked • Feeling part of oneself died along with the deceased • Difficulty trusting others • Difficulty moving on with life • On edge or jumpy • Survivor guilt Copyright 2013 Susan Stuber, PhD 32
- 33. 2. IDENTIFYING THEDIAGNOSTIC ALGORITHM • “Yearning” a mandatory symptom • “Combinatorics” • 5 of the remaining 9 symptoms • Sensitivity = 1.00 • Specifity = 0.99 • Positive predictive value = 0.94 • Timing criterion: diagnosis not made until at least 6 months after the death • Another criterion: functional impairment Copyright 2013 Susan Stuber, PhD 33
- 34. 3. PREDICTIVE VALIDITYOF PGD • Those who MET criteria for PGD at 6 – 12 months post-loss were significantly more likely at the 12 – 24 month assessment to have a psychiatric diagnosis (MDD, PTSD, GAD), suicidal ideation, functional disability, or low quality of life (p < .o1) • Consistent with prior research: PGD associated with elevated rates of suicidal ideation and attempts, cancer, immunological dysfunction, hypertension, cardiac events, functional impairments, hospitalization, adverse health behaviors, and reduced quality of life. Copyright 2013 Susan Stuber, PhD 34
- 35. SHEAR CRITICIZES PRIGERSON •Small sample (n=291) • Non-representative sample • Only 28 in the sample had PGD • Some were bereaved < 6 months • Various critiques of her decisions about the item analysis • Questions “yearning”as a necessary symptom Copyright 2013 Susan Stuber, PhD 35
- 36. SHEAR ET AL.’S2011 STUDY • Sample recruited from Mass General Hospital, U of Pittsburgh, and Columbia U. • Presented ICG to: • 95 healthy controls with no diagnosis • 369 with mood or anxiety disorders, and • 318 with CG (self-identified, and clinical interview) • 70% of this group was white Copyright 2013 Susan Stuber, PhD 36
- 37. SHEAR ET AL.’S2011 STUDY • Factor analysis revealed a clear 6 factor solution: • 1. Yearning and preoccupation with the deceased • 2. Shock and disbelief • 3. Anger and bitterness • 4. Estrangement from others • 5. Hallucinations of the deceased, and • 6. Behavior change, including avoidance and proximity seeking. • See Hand-out of Shear et al.’s Diagnostic Criteria Copyright 2013 Susan Stuber, PhD 37
- 38. PRIGERSON CRITICIZES SHEAR •“these criteria have a rather modest empirical basis. • Question her analyses • Some of the criteria are too broadly formulated (see B3 with the four symptoms) • Some of the symptoms have been found to be poor markers or have not been examined at all • Majority of the sample had at least one other diagnosis Copyright 2013 Susan Stuber, PhD 38
- 39. DSM-5’S ADDITIONS ONGRIEF Copyright 2013 Susan Stuber, PhD 39
- 40. TWO GRIEF-RELATED ADDITIONSTO DSM-5 • Adjustment Disorder Related to Bereavement • Persistent Complex Bereavement- Related Disorder Copyright 2013 Susan Stuber, PhD 40
- 41. ADJUSTMENT DISORDER RELATEDTO BEREAVEMENT • Following the death of a close family member or close friend, the individual experiences on more days than not (any 1 or more of the following 3): • Intense yearning or longing for the deceased • Intense sorrow and emotional pain • Preoccupation with the deceased or the circumstances of the death • Duration of at least 12 mos. (6 mos. for children) • Symptoms should cause marked distress that is in excess of what would be proportional to the stressor and/or significant impairment in social, occupational, or other important areas of functioning Copyright 2013 Susan Stuber, PhD 41
- 42. ADJUSTMENT DISORDER RELATEDTO BEREAVEMENT • The person may also experience: • Difficulty accepting the death • Intense anger over the loss • A diminished sense of self • A feeling that life is empty, or • Difficulty planning for the future or engaging in relationships or activities Copyright 2013 Susan Stuber, PhD 42
- 43. PERSISTENT COMPLEX BEREAVEMENT RELATEDDISORDER •See Hand-Out Copyright 2013 Susan Stuber, PhD 43
- 44. CLEVER COMPROMISE ORSACRIFICIAL SATISFICING? • The name is a compromise • The symptom criteria are a compromise Copyright 2013 Susan Stuber, PhD 44
- 45. PROBLEMS WITH DSM-5’SPROPOSALS • Lack of evidence • Extreme heterogeneity/risk of over-diagnosing • PCBRD – 37,650 possible combinations • Shear et al. – 3,705 possible combinations • Prigerson et al. – 256 possible combinations • Significant discontinuity in clinical practice • Lack of developmentally informed criteria Copyright 2013 Susan Stuber, PhD 45
- 46. GRIEF THERAPY • Thelatest research in the field on grief therapy • The difference between normal grief and complicated or prolonged grief • Research and issues involved in the inclusion of “Prolonged Grief Disorder” in DSM-V • Cognitive behavioral techniques to treat prolonged grief • The importance of self-awareness and the necessity of self-care when providing grief counseling • Different cultural views of death Copyright 2013 Susan Stuber, PhD 46
- 47. STROEBE AND SCHUT’SDUAL PROCESS MODEL(1999) • Loss-oriented coping • Restoration-oriented coping • OSCILLATION – a dynamic regulatory coping process involving confronting and avoiding • Need for dosage of and respite from grieving Copyright 2013 Susan Stuber, PhD 47
- 48. STROEBE AND SCHUT’SDUAL PROCESS MODEL(1999) • Pathology is explained by disturbances of OSCILLATION • Complicated Grief or “Loss-Orientation Syndrome” • Focus only on Loss-Orientation to the exclusion of Restoration-Orientation • “Absent” or “Inhibited” Grief • Focus only on Restoration-Orientation to the exclusion of Loss-Orientation Copyright 2013 Susan Stuber, PhD 48
- 49. WHAT’S NEW INTHIS PARADIGM? • “Not talking” about grief at times is a good thing • Talking can intensify distress • Talking can interfere with active coping • NOT talking can function as a resilient way of distracting self from loss • Family considerations Copyright 2013 Susan Stuber, PhD 49
- 50. BOELEN’S COGNITIVE-BEHAVIORAL CONCEPTUALIZATION (2006) •Three processes that contribute to CG: • 1. Insufficient integration of the loss into existing autobiographical knowledge • 2. Negative beliefs and catastrophic misinterpretations of grief reactions • 3. Anxious and depressive avoidance Copyright 2013 Susan Stuber, PhD 50
- 51. BOELEN’S COGNITIVE-BEHAVIORAL CONCEPTUALIZATION (2006) •Three processes that contribute to CG: • 1. Insufficient integration of the loss into existing autobiographical knowledge • 2. Negative beliefs and catastrophic misinterpretations of grief reactions • 3. Anxious and depressive avoidance Copyright 2013 Susan Stuber, PhD 51
- 52. BOELEN’S COGNITIVE-BEHAVIORAL CONCEPTUALIZATION (2006) •Three processes that contribute to CG: • 1. Insufficient integration of the loss into existing autobiographical knowledge • 2. Negative beliefs and catastrophic misinterpretations of grief reactions • 3. Anxious and depressive avoidance Copyright 2013 Susan Stuber, PhD 52
- 53. BOELEN’S COGNITIVE-BEHAVIORAL CONCEPTUALIZATION (2006) •Three processes that contribute to CG: • 1. Insufficient integration of the loss into existing autobiographical knowledge • 2. Negative beliefs and catastrophic misinterpretations of grief reactions • 3. Anxious and depressive avoidance • CBT Interventions to address CG: • 1. Imaginal exposure • 2. Cognitive restructuring • 3. Behavioral activation (setting goals)Copyright 2013 Susan Stuber, PhD 53
- 54. BIBLIOGRAPHY (1) • Bisconti,T.L., Bergeman, C.S., and Boker, S.M. (2004). Emotional well-being in recently bereaved widows: A dynamical systems approach. Journal of Gerontology, 59B, (4), 158-67. • Currier, Joseph M., Neimeyer, Robert A., and Berman, Jeffrey S. (2008). “The Effectiveness of psychotherapeutic interventions for bereaved persons: A comprehensive quantitative review. Psychological Bulletin, 134, (5) 648-61. • Forte, A. L., Pazder, R., and Feudtner, C. (2004). Bereavement care interventions: A systematic review. BMC Palliative Care, 3, (3). • Konigsberg, R.D. (2011). The truth about grief: the myth of its five stages and the new science of loss. New York, Simon and Schuster. • Maercker, A. and Lalor, J. (2012). Diagnostic and clinical considerations in prolonged grief disorder. Dialogues in Clinical Neuroscience, 14, (2), 167-76. Copyright 2013 Susan Stuber, PhD 54
- 55. BIBLIOGRAPHY (2) • Riley,L., LaMontagne, L., Hepworth, J., Murphy, B.A. (2006). Parental grief responses and personal growth following the death of a child. Death Studies, 31, 277-99. • Rossi, N.E., Bisconti, T.L., and Bergman, C.S. (2007). The role of dispositional resilience in regaining life satisfaction after the loss of a spouse. Death Studies, 31, (10), 863-83. • Stroebe, M., Stroebe, W., Schut, H, Zech, E., and van den Bout, J. (2002). Does disclosure of emotions facilitate recovery from bereavement? Evidence from two prospective studies. Journal of Consulting and Clinical Psychology, 70, (1), 169-78. • Wortman, C.B. and Silver, R.C. (1989). The myths of coping with loss. Journal of Consulting and Clinical Psychology, 57, (3), 349-57. Copyright 2013 Susan Stuber, PhD 55
- 56. S U SA N S T U B E R , P H . D . M A R C H 2 2 , 2 0 1 3 GRIEF THERAPY A copy of the full presentation notes accompanying these slides may be obtained by contacting Dr. Stuber at sstuber@susanstuberphd.com . Copyright 2013 Susan Stuber, PhD 56
Editor's Notes
- #3 Actually I am going to address the latest research in the field as I talk about the more substantive points of complicated grief and research based interventions.But since I talked about Elisabeth Kubler-Ross in my talk summary, and since her work has had such a profound affect on the culture, I want to talk about her famous stage theory, how it came about, and the subsequent pos and neg effects.
- #4 EKR was born in Switzerland in 1926 , and struggled to establish a separate identity from her triplet sisters, Erika and Eva. She met her American husband a the U. of Zurich medical school, and moved to Long Island where they both had internships. She was planning on a pediatric residency, but then found out she was pregnant, and was not allowed to go forward with that plan due to the physical rigor of the internship. Scrambling for a job, she took a residency at the psych ward of Manhattan State hospital. In 1962, they moved to CO to work at the U of Denver Med School. While substitute teaching for a colleague, she desired to close the gap between the detached approach doctors took with their patients and patients’ feelings and fears. She brought in a 16 year old girl with terminal leukemia, and conducted an interview that left the young doctors in a stunned, emotional silence. Soon after that, they moved to Chicago to work at Billings Hospital, connected with the U of Chicago. Her work in Denver made its way t the Chicago Theological seminary, and she was approached to teach seminarians about handling death. She undertook regular seminars, interviewing dying patients, and talking to the students about it. An editorial assistant at Macmillan Book Co was combing through journals for book ideas when he came across an article KR had written about her seminars for the Chicago Theological Seminary Register. She accepted the book offer, and shortly after that, the 5 stages were born! On Death and Dying was published in 1969, and it caught on like wildfire!
- #6 Beatriz (BZ) Cobb, a psychologistworking with cancer pts in the mid-60’s at MD Anderson in Houston taught the exact same stages – no evidence EKR ever knew of themBritish psychiatrist Collin MurryParkes gave a lecture at U of Chicago in 1965 and was there introduced to EKR. He presented his stages of grief from work with John Bowlby studying widows’ phases of grief; EKR used these same stages in her book. Parkes of EKR: “She was not very good at acknowledging sources of help, and had a somewhat abrasive relationship with her medical colleagues.”EKR never did any research at all on these stages; she never published one study on death or grief in a peer-reviewed journal in her entire careerOf course people have these thoughts and feelings throughout grief, but to call it a “stage” implies a lock-step condition for something that is much less orderly “Acceptance” as the last stage also implies that grief has an end, and a little later I will share a quote with you from Kathy Shear, one of the top researchers of grief, on her view that grief is never completed.
- #7 Toni Bisconti and her colleagues at U of Akron in Ohio looked at widows and asked them to fill out questionnaires on their moods every single day for three months, and there were VAST fluctuations, even within one day. Swings were large in the beginnintg but diminished over time, with overall mood going up.Describe difference between this impirical finding and the kind of grapy EKR’s stages suggest (W)
- #8 Why was it so popular? One of BZ Cobb’s students thoughts on the matter: “What sells is simplicity, making life a little more simple, so if you can give something that’s very complex and individual and unique a simple plan, it’ll stick.” It was a neat and tidy formulation of something that is overwhelming, and it seems intuitively correct. Also, it melded with the self-help movement that promised relief and self actualization if you followed proscribed formulas in experts’ books.There was an article on her and her book in Nov. 1969 in Life magazineAlso, she was a charismatic and extremely sought-after lecturer; got fired from U of Chicago because of her inattention to her job duties while on the lecture circuit.Grief Industry: Today grief counseling is ubiquitous. Mandated for a minimum of one year ever since Congress passed the Medicare hospice legislation in 1982. There are hundreds of thousands of Hospice counselors and volunteers around the country. Most funeral homes offer “after care services” which often includes grief counseling. 40 years ago, there were not grief counselors (role of friends, clergy, family). But after EKR’s book, the study of death and dying exploded. The Assoc. for Death Ed. And Counseling (ADEC) was founded in 1976, and its membership is around 1,700, though there are many grief counselors who aren’t members. Its certification program in grief therapy doesn’t require a master’s degree. Basically, everyone thinks grief counseling is important.
- #9 This is just in case anyone had started to doze off … WAKE UP! You won’t want to miss this!
- #10 For grief counseling to be effective, it should either:-- help the grief phase to be shorter or less intense , or-- help prevent long-term complications, such as prolonged grief or other psychopathology (AHA! Did you catch me? Is PGD psychopatholoty? Stay tuned!)Currier (psych prof at U of Memphis) et al. reviewed over 60 controlled studies on grief intervention and found no consistent pattern of preventive effect. They looked at different kinds of intervention: guided imagery, CBT, peer groups, psyc. Debriefing, even supportive phone calls. On avg., those who got help experienced NO LESS DISTRESS, NOR RECOVERED MORE QUICKLY that those who didn’t. (Quote in slide)Feudtner, from CHOP, in addition to an MD, has a Ph.D. in the history of the sociology of science, and says, “There are many examples in medicine where the idea sounded good but the treatment turned out not to be helpful.” So he conducted a similar meta-analysis with colleagues, and concluded (see slide). He found in the research a wide variety of interventions and a lack of detail, resulting in a dearth of replication studies. He suggested that, “The bereavement care literature may be too invested in and reliant on THEORETICAL justifications of the treatments.”
- #11 Much good research comes out of Utrecht U. in the Netherlands on grief outcomes and these guys put together a model of grief which underlies the effective research-based interventions – we’ll get to that later.In this study, they asked 379 bereaved widowed individuals under the age of 66 to complete questionnaires on how much they have talked to others and expressed their emotions about their spouse’s death. They were also given an established measure of psychological health, and assessed at 4, 11, 18, and 25 months after the death of their partners. As a second study in this paper, 157 widowed individuals agreed to complete a diary writing task 4-8 months after the death of their spouses. They were assigned to one of three writing conditions or to a control group. Those in the diary groups were asked to write for 10 – 30 min every day for a week about their loss (either their feelings, problems caused by the death, or both). They were also given the same psych. Measure as above, as well as a measure of response to trauma.See results above.Key point: these guys were not screened for CG. We will see later that a very similar writing task, conducted on a sample of people with CG showed very nice results!Which brings us to our next topic, which is to define CG.
- #12 So just when you may have started thinking we could all go home because there’s nothing more to say, I will fill you in on the fact that Grief Therapy has been found repeatedly in the research to work effectively on those with more intense, prolonged grief -- a grief that, rather than resolving of its own course, continues at a high pitch, or intensifies. But the research only supports certain specific CBT interventions, and only for those individuals identified to have CG, as opposed to the wider bereaved population.We will spend much of the rest of the talk learning how to identify those with CG and what specific interventions have been found to be effective for them.
- #13 Grief over the death of a loved one is such a universal experience; virtually everyone goes through it in their lifetime. Grief is a normal and unavoidable reaction to loss. Common characteristics of grief include sadness, anger, guilt, anxiety, and despair. A grieving person may think constantly about the deceased person and about the events that led up to the death. They may have physical reactions during grief as well: problems sleeping or illness. Socially, they may find it difficult to be around people or to return to work.
- #15 For most people, these painful thoughts and feelings gradually diminish, usually within 6 months or so after the death. But for some, the normal grief reaction lingers and becomes increasingly debilitating. This is referred to as Prolonged Grief Disorder (more later on this new proposed diagnostic category) or complicated grief. People with PGD characteristically have a painful yearning for the presence of their deceased loved one, and intrusive thoughts and images of him or her. They may feel desperately lonely and adrift, that they want to die themselves, or, in a different presentation, they may deny their loss. Can have extreme avoidance of reminders of the loss, or the converse, extreme preoccupation with the deceased. Shear cites Bonnano and Wortman’s (2002) work on resilience along with 4 other studies in support of the claim that most grieving people experience acute grief syptoms that attenuate naturally over a period of time. Although there is variability, for most people grief intensity is fairly low by a period of about six months. This does not imply that grief is completed or resolved, but rather that it has become better integrated, and it no longer stands in the way of ongoing life.If the 6 month criterion makes these researchers look too cold and analytical, let me share a quote from Kathy Shear’s treatment manual for CG which I thought was good. This is how she suggests framing the grieving process for clients presenting with CG: (next)
- #16 Shear goes on to explain that the job of the CG therapist is to help people who feel they are stuck in their grief, blocked from moving forward, in need of better support or of more tools.
- #17 Two Swiss researchers from the U of Zurich recently wrote an excellent paper reviewing the history of the theory and research on CG, and they give a fuller picture, above and beyond the symptom picture.For normal grief, it is assumed that grieving individuals are able to move from the acute grief states in the early aftermath of a death, to states of integrated or abiding reminiscences where the deceased is more easily called to mind., the reality of the death is acknowledged, and the bereaved person is able to return to enjoyable relats and activities. … able to form a new symbolic relationship with the deceased whereby they are able to accept them back into their lives, as deceased. This relates to brain re-wiring, creating new memories and associations.Conversely, some bereaved individuals can exp a prolonged or intense form of grief in which the bereaved person has difficulty accepting the death, and intense separation and traumatic distress usually lasting well beyond 6 months. The bereaved find themselves in a repetitive loop of intense yearning and longing, which become the major focus of their lives. They may also believe that their life is over, and that the intense pain they perceive will never end. Overall, there is a significant preoccupation with the deceased, the picture being either overinvolved or excessively avoidant. CG is associated with substantial impairment to work, health, and social functioning.
- #18 Note that prevalence is hard to know for sure since the construct does not have a universally agreed-upon set of diagnostic criteria. Data in some other countries estimate CG as lower than 10%.
- #19 First, let’s talk about all the names this phenomenon has been called and decide what we’re going to call it for discussion purposes todayReflects trends of the times in mh to some degreeCalled “traumatic” in the late ‘80’s when trauma was a popular cause for many syndromes (MPD)-- conceptually likened to PTSD Problem: sudden, violent, unexpected deaths didn’t always result in pathological reactions, AND pathological reactions sometimes followed deaths from old age or protracted illness)Prigerson is using Prolonged and Shear and from what I could tell, most other people are currently using Complicated, but don’t worry about it too much because DSM-V has some new words for the word soup and those will probably be the ones we need to know!Shear defends “complicated”because it is in line with the existing literature (pubmed: 304 under complicated and only 48 under prolonged) and because “grief is often prolonged in ways that are not complicated or pathological.For the sake of our discussion, I am also using mostly CG, but sometimes interchanging PGD, esp when presenting Prigerson’s model.
- #20 In the next section I will tell you all there is to know about diagnostic criteria for CG, but to give you an idea of how it has been measured in studies, I will now show you the ICG which is the most commonly used scale (though not the only one, which as you will see later, is part of the problem). It was developed by Holly Prigerson and her colleagues and published in 1995 . It is intended to screen criteria specific to grief as opposed to sx of depression and anxiety. Moreover, the ICG was designed to distinguish between normal reactions and more pathological forms.Talk about 19 itmes, self-report, 0 – 4 rating and cutoff.Its convergent and discriminant validity yeilded excellent results. High ICG values were associated with a lower quality of life. Scores at 6 mos post loss predicted risk of cancer, heart trouble, smoking, and eating problems 1 to 2 years later.Reliability established: Chronbach’s alpha > .90 and test-retest reliability coefficient = .80.Prior research has also established this measure to have acceptable criterion validity.
- #21 Read list.One study found hx of childhood separation anxiety to be a unique predictor of CG in later life.On high stress, this could be related or unrelated to the death, but consider that often the situation of the death creates terrible practical stressors for the bereaved: financial, having to sell house, sell a business, helping bereaved children in the case of a spouse, etc.On last point: although still the vast majority of those whose loved ones die suddenly or traumatically move through the grief process with satisfactory resolution in 6 months time.
- #22 Toni Bisconti (U of Akron) looked at 55 widows one month after the death of their spouses, and found that those who had the lowest amount of stress had the personality trait of “dispositional resilience” which was defined by three components:they remained connected to other people rather than isolatedthey felt their grief was manageable and under controlthey embraced and learned from new experiences rather than avoiding or feeling threatened by them.She and her colleagues encourage grief counselors to promote resilience.In another study by Linda Riley at U of Alabama and her nursing colleagues, they looked at 35 bereaved mothers, and examined the relat between dispositional factors, grief reactions, and personal growth. They found that more optimistic mothers reported less distress and less intense grief reactions, with optimism defined as general expectation of pos future outcomes and that adversity can be dealt with successfully). They also found that mothers with a tendency to cope actively (by taking direct action, planning, and problem solving) had less intense grief responses.. Finally, they found that mothers who managed distress by acceptance and REFRAMING of the negative experience in a positive light reported less intense grief experiences and less CG. These 3 dispositional factors were also linked with personal growth, a pos dimension of grief: can see multiple benefits related to their loss and describe positive changes within themselves (increase in empathy and compassion, and a need for adjusted values and reprioritized goals)This is a foreshadowing of the components of intervention we will see later …
- #23 But before we talk about the interventions recommended for CG, let’s look a bit more closely at the research on this construct, and come to an understanding of where our field is going with it in DSM-V, which of course we’re all gearing up for in May!
- #24 (These are some of the “issues”DSM-IV has not included grief as a disorder because it was judged to be “an expectable and culturally sanctioned response to a particular event” (DSM-IV). Instead, it is included in the “V” Codes, which, as we know, are “other conditions that may be a focus of clinical attention”. Similarly, in the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), bereavement is classified as a “Z” code, referring to “occasions when circumstances other than a disease or injury result in an encounter or are recorded by providers as problems or factors that influence care.”
- #25 No doubt about it that in the absence of universally agreed upon criteria, it is hard to compare one study to another to draw a consensus in the field. As with every disorder, the harm done by stigmatization has to be balanced by the good done by identification and treatment.Not EVERYONE who experiences grief would get the diagnosis – only the minority who are suffering the most.As the research has shown, a significant minority of people experience “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability. You probably recognize this as the requirement for meeting the definition of a “mental disorder , which is found right in the DSM-IV itself.I think the most compelling reason is that there is research-backed evidence of interventions that help this population. How can we not act on that information to help people who are suffering?
- #26 Before we go further into the development of the criteria, let’s talk about whether prolonged grief might just as well be characterized as major depression or some other known diagnostic category. Prior research has repeatedly shown PGD symptomatoloty to be different from the other DSM-IV disorders. For example, in studies of bereaved people from various different countries, yearning loads highly on the grief factor, but not on depression or anxiety factors, whereas sadness loads ONLY on a depression factor , and feeling nervous and worried loads only on an anxiety factor. A study on negative cognitions among the bereaved found that being overwhelmed by loss (eg., “If I fully realize what the death of ______ meant, I would go crazy.”) was a cognition specific to PGD, but not depression. Further, PGD doesn’t “act” like “normal” grief or depression in terms of its course and response to treatment. Studies have shown that treatment with antidepressants alone and with psychotherapy are ineffective relative to a placebo for the reduction of PGD symptoms. By contrast, randomized controlled trials of psychotherapy designed specifically for PGD have demonstrated efficacy in diminishing PGD symptoms. This efficacy of a PGD-specific treatment shows how important it is to get an accurate diagnosis.
- #27 Read point 1,Re pont 2, what about the other 40 – 50% who DON’T have MDD?Yearning in CG related to activation of dopamine circuitry, whereas in MDD there is reduced capacity for activation of reward pathways.Guilt in CG is specific to the death, where with MDD it’s pervasive and multi-facetedSleep disturbance in MDD associated with REM abnormalities, but not with CGSuicidal thinking in CG is related to imagined union with the loved one, whereas with MDD it’s related to pervasive hopelessness.Furthermore, factor analysis shows that MDD and CG load on separate factors.
- #28 Differences: the traumatic event in CG is not outside the range of normal human experience, and confrontation with physical danger is fundamentally different from losing a sustaining relationshipReduction of threat. With PTSD, after the traumatic event is over, the actual threat of harm (except in certain ongoing cases of violence like combat or domestic violence) is markedly reduced. But with CG, Not so with CG. Also, the adaptive response called for to adjust is different.Hallmark sxin PTSD is fear, but in CG is sadness and yearning.Factor analysis shows CG differing from PTSD as well as MDD.
- #31 In 1999, as a first step on gaining a consensus on criteria for PGD, a group of experts in bereavement, mood and anxiety disorders, and psychiatric nosology(classification of diseases) met to review the existing evidence to justify the development of diagnostic criteria. They concluded that the evidence justified the development of a diagnostic algorithm for a grief disorder, and then set about to formulate consensus criteria and perform some preliminary testing. Next, the longitudinal Yale Bereavement Study was conducted as a field trial to evaluate diagnostic algorithms for PGD based on symptoms proposed by the consensus panel. The study aimed to propose criteria for PGD that were backed by psychometric validity. Participants were recruited from the Greater Bridgeport/Fairfield AARP Widowed Persons Service, a community-based outreach program, and from various Pastoral Care offices in the New Haven area. Participants were interviewed within 6 months of their loss, and again for follow-ups in the 6 – 12 months and 12 – 24 months post-loss. Average age: 62; 74% female; 95% white, 60% educated beyond high school, and 84% were spouses of the deceased. PGD symptoms were assessed using the Inventory of Complicated Grief, Revised, which is a structured interview designed to assess a wide variety of potential PGD symptoms. It includes all the symptoms proposed by the consensus panel, and some others enabling the testing of alternative diagnostic algorithms. Other psychiatric disorders and other outcomes (eg., adls and physical functioning, suicidality) were also assessed.
- #32 The psychometric validation of diagnostic criteria for PGD went through six phases, each with its own distinct aim. I will summarize the main points for you so that you don’t die of boredom:Read slide.
- #33 You have copies of the Prigerson criteria as a hand-out, and you can see these items in criteria B and CRegarding #1 above, the choice of items: Three different very complicated sounding forms of item analysis (believe me, I am shielding you here) were applied to the 22 grief symptoms to find out which ones yielded maximum “peak” information, lowest measurement error, and greatest measurement precision. The following 12 informative, unbiased symptoms were retained for consideration in a diagnostic algorithmCronbach’s alpha = .82
- #34 For several reasons, “yearning” was specified as a mandatory symptom. 1. It was the consensus opinion of the expert panel; 2. Statistical results showed that yearning was the most common (68%) and most informative of the symptoms analyzed. Then, “combinatorics”, the branch of mathematics that studies the number of different ways of arranging sets, was used to look at alternative sets of the remaining 11 nonmandatory symptoms and come up with the ideal algorithm of symptom criteria for PGD. 4,785 algorithms were enumerated! Algorithims requiring “yearning”, AND as few as three of five, and as many as eight of nine, additional symptoms were considered. Maximizing the sensitivity and specifity, the optimal, most efficient algorithm included yearning and at least 5 of the 9 following: avoidance of reminders of the deceased; disbelief or trouble accepting the death; a perception that life is empty and meaningless without the deceased; bitterness or anger related to the loss; emotional numbness; feeling stunned, dazed, or shocked feeling part of oneself died along with the deceased; difficulty trusting others (sensitivity = 1.00; specifity = 0.99; positive predictive value = 0.94 To reduce the likelihood of false-positives, a timing criterion was added, such that a diagnosis not be made until 6 months have passed since the death. This would rule out those who may initially have high levels of grief which decline in intensity at and beyond the 6 month post-loss mark. Also to be conservative in the diagnosis, another criterion was added: the symptomatic distress must be associated with functional impairment.
- #35 Those who MET criteria for PGD at 6 – 12 months post-loss were significantly more likely at the 12 – 24 month assessment to have a psychiatric diagnosis (MDD, PTSD, GAD), suicidal ideation, functional disability, or low quality of life (p < .o1) This is consistent with prior research which demonstrated the validity of PGD in its association with elevated rates of suicidal ideation and attempts, cancer, immunological dysfunction, hypertension, cardiac events, functional impairments, hospitalization, adverse health behaviors, and reduced quality of life, after controlling for the effects of depression and anxiety.As a footnote on the Prigerson study: re.concernabout financial conflict of interest in psychiatric research, esp. that involving pharmaceutical manufacturs, they clarify that the study was federally funded by NIMH, and no part of the study was funded by producers of a potential therapeutic remedy for PGD)
- #36 Sample was almost exclusively older (evg. 62), white (95%), widows (84%) with 60% educated beyond high school. Not generalizable to other groups.Only 28 had PGD – greatly limits the ability to explore any potentially informative symptom patterns for determining diagnostic criteria.<6 mos: ït is questionable whether CG criteria should be derived using data from individuals considered ineligible for the dx!Yearning alone has a specifity of 88.5%, so that 11.5% of individuals who Shear’s driteria judge to have CG would be excluded according to Prigerson.
- #38 They maintained the division of CG sx into Separation Distress (Criberion B) and associated symptoms (Criterion C) because of the Prigerson group’s proposal, but a single list of sx could also be used. Their factor analyses guided the modification of B and C criteria. Details of the FA and sensitivity and specifity analyses were provided in a companion paper.Differences from Prigerson et al.:They found no evidence that yearning was a unique sx, but found that it clustered with a group of 4 sx in factor 1 (related to separation distress)They thought it important to include suicidality (symptom B-3) since they found strong evidence that it was associated with CG, so included it in the sep. distress section.They include 2 sx in Criterion C that are not on the ICG – C-1 -“rumination about the circumstances or conseq of the death” and C-7“emotional activation upon exposure to reminders. They base this on other data about the importance of these sx, as well as their clinical experience.Requiring 1sx from B and 2 sx from C yeilds 95% sensitivity and 98% specifity.They add Criterion D that the duration of the sx and impairment are at least 1 mo.
- #39 As an example of #2, she notes that Shear used ICG as the items for her IRT, but then in the end came up with symptoms that aren’t on that measure.With too many ways to qualify for the diagnosis, the diagnosis gets over-used.Re. the last one: “deriving criteria for complicated grief from such a mixed sample seems akin to an analysis that would attempt to derive the elements of the color yellow from the color brown.”
- #40 So now for the moment you’ve all been waiting for…What did the DSM-5 work group decide to do with this research?As a caveat, I have to say, the official DSM-5.org site has taken down current proposed criteria for the time being since it has taken in feedback, and is conducting its final revisions. Scholars have written in on what was proposed, and so there may yet be changes in what we see in May.This information is based on a paper by Boelen and Prigerson, June 2012, and includes diagnostic categories that were posted on DSM-5.org at that time.
- #41 The work group on anxiety, obsessive-compulsive spectrum, posttraumatic and dissociative disorders made the following propositions: Adjustment disorder related to bereavement is proposed to be added to the Adjustment Disorders section of the manual, and Persistent complex bereavement-related disorder is proposed for inclusion in Section III where conditions that require further research will be placed.
- #44 Criterion A: Experienced a death of a close family member/friend at least 12 mos. AgoCriterion B: Experiences at least one of these four sx. They seem to represent separation distress, though they’re not explicitly referred to as such. Consistent with Prigerson and Shear.Criterion C: at least 6 of 12 sx must be present.of these 12: 6 sx of reactive distress (shocked, stunned, numb)6 sx of soccial/identity disruption (desire to die, feeling alone and detached from others)Criterion D: Must cause distress or functional impairmentCriterion E: out of proportion or inconsistent with cultural, religious, or age-apropriate normsSpecification for Traumatic Bereavement: the death occurred under traumatic circumstances such as suicide, homicide, disaster, or accident)
- #45 Persistent Complex Bereavement-Related Disorder) seems to be a compromise of Prigerson’sand Shear’s work. Prolonged and Complicated seem to have been turned into Persistent and ComplexCompromise in criteria.Some are in both setsSome in one or the otherSome new criteria (difficulty in positive reminiscing and maladaptive appraisals of oneself)Timing criterion of >/= 12 mos differs from both
- #46 Lack of evidence. This is craziness! Can’t just pick and choose! Empirical evidence that PCBRD criteria are reliable and valid are lacking. For instance, there’s no evidence that the 12 mo. Post-loss timing criterion effectively or efficiently distinguishes people who do versus do not recover from their loss. Several studies have shown that if sx are present at 6 mos, they are very likely to be present at 12 mos. Would lead to missed cases of dysfunctional grief, as well as lack of provision of services to those suffering.Also, no evidence that some of the new sx are valid markers of dysfunctional grief.Also, no rationale or validation of the algorithm. How do we know that 1 of 4 in B and 6 or 12 in C provide the best distinction between case=ness and non-case-ness? So many ways to qualify – makes it look like we haven’t learned anything about this construct. Discontinuity in rsch and practice, esp. with the 12 month criteria. Will diminish the use of the ICG, if the field is using a dx with different sx.Julie Kaplow and colleagues weighed in with a paper saying that developmental research about how children grieve wasn’t considered, and gave their suggestions. Keep your eyes open in May, though, because researchers have weighed in, so we won’t know until then what the work group has decided!
- #47 First, I will talk some about the theoretical underpinnings of the research-based studies found to be effective in treating (hoo boy, not what are we going to call it!)think I’ll still call it CG for simplicity’s sakeWhat do we think is happening as clients process and heal from their grief experiences, and what do we think is happening when they appear to be stuck? This can help us understand why we re doing what we are doing, and to articulate it to patients so they are informed and empowered (lots of “psychoeducation”components in Shear’s manual.Then I will talk about three of the most effective studies, describing them and the interventions that were found to be effective
- #48 Kathy Shear’ and colleagues 2005 JAMA study is the one all papers point to as an empirically supported tx of CG (I will describe this one to you first when I get to the studies) and in it they say, “the dual process model of coping of S&S forms the framework for our approach.” She also spends a lot of time in her manual as a rationale for clients about what works best.Loss orientation refers to focus on the feelings associated with the loss of the meaningful relationshipL rumination about the deceased, about how life was, about events surrounding the death, yearning, looking at old photos, crying. Can be pleasurable reminiscing but also despair at being left along.Restoration-orientation refers to attention to the secondary sources of stress: mastering the tasks the deceased did, reorganizing a new life without the loved one, Involves a range of emotions from pride to despair.In the early days, neg. affect tends to predoninate; but as time goes on, pos affect plays an increasingly important role. Not a phase model, but a waxing and waning, an ongoing flexibility over time.Benefits of denial are acknowledged – evidence of phisical and mental costs of unremitted grieving.
- #49 Oscillation between the two types of processes, along with some time off, are associated with adjustment, and disturbances of oscillation are associated with problems in grieving. The absent or inhibited grief is not expanded, but it would have to be associated with some other sx to be considered pathological.
- #50 The “Grief Work” model initiated by EKR was swinging the pendulum from one extreme (keeping grief mum) to the other – talking about grief and never keeping anything in. (Withholding, conspiracy of silence)An Hooghe and her colleagues in Leuven, Belgium wrote a beautiful paper supporting the importance of “not talking” at times for the above reasons.Mention 1 - 3They specifically focus on family considerations, which isn’t often developed in the “grief work” schema – it’s more like each person is considered in isolation.Might have to be a good role model for childrenMight want to not bring your spouse down if your grief expression would have an adverse affect on him or her on a given dayHilde talked about reasons she internalized her grief at times rather than sharing with her family: to escape the suffocating climate in the house where no one could breathe, to be alone and not feel pressure to be whole: “On my own I could just be broken.”, to avoid the frustration of unmet expectations for comfort at from her husband. “For us, internalizing my grief was the best way to go on as a family, and to give our relationship and our family a future.
- #51 Back to our colleague, Prof. Boelen in Utrecht, he postulates that three processes are critical in he maintenance and exacerbation of CG sx:This first one is very key. In normal grief, the separation from the deceased is gradually connected with information about the self in the past, present, and future. This process of “conceptual processing” reduces the ease with which info about the deceased intrudes into awareness, and facilitates the formation of more complex retrieval routes in memory – when info about the deceased comes to mind, it is embedded in other information.This blends with Bolwby’s attachment theory, which claims that people form mental representations of attachment figures, and when the attachment is threatened, emotional and behavioral responses (distress/searching) are activated until closeness is restored. In normal grieving, these processes gradually subside as the mourner increasingly realizes that trying to restore proximity is futile. It is postulated that in CG, poor integration of the loss with other knowledge causes these responses to persist. So in CG pts, sorrow continues at the same level as in the immediate aftermath of the death, and the loss feels reversible, and there is reflexive searching, or a sense that the loved one is around somewhere.So, in sum, the separation is not sufficiently integrated in to the general database of autobiographical knowledge.
- #52 Unlike normal grievers, CG pts have particularly negative cognitions that contribute to the maintenance of CG sx. In light of the death of the loved one, they may believe “life is senseless”, “I am worthless”, “The future is blank” and these thoughts serve to keep the focus on what was lost, and keep attention away from the present. This serves to maintain the easily accessible route to the painful affect of the loss.Catastrophic misinterpretations of grief reactions – I will always feel this way – generate fear and distress and strengthen the urge to engage in counterproductive efforts to control thoughts and feelings related to the loss.
- #53 Relatedly, anxious avoidance occurs when mourners think that to confront the reality of the loss would be intolerable or have disastrous consequences. So they then avoid situations or people that would remind them of the loss. They also may use cognitive avoidance strategies , ruminating about their own actions or why the loss occurred to keep the pain of the permanent loss at a distance.Avoidance of the loss isn’t harmful by definition, only when it’s related to this kind of fear of disastrous consequences; this is because the fear maintains the avoidance, which interferes with the processing and integration of the loss.Depressive avoidance occurs when mourners withdraw and refrain from activities that would facilitate adjustment because they have negative expectations: nothing will make me feel better; I am unable to reclaim my social contacts. Depressive avoidance is likely to strengthen the urge to yearn for what is lost, and to maintain the feeling that life has lost all its joy and purpose (self-fulfilling prophesy). Prevents mourners to create new memories without the deceased loved one, and thus interferes with the integration of the loss into the body of knowledge about the self in the present and the future.
- #54 I’ll leave the processes up there and also add the recommended CBT interventions so that you can see how they go together.Incidentally, these are the very intervention components in all the studies which have shown proven efficacy in treating CG!Imaginal exposure. First, ask the pt to tell the story of the loved one’s death from the beginning to the end, with an eye for “hot spots” or the most painful parts of the memory. Teach and use SUDS so that you can check in and help modulate the experience. Tx then focuses on reprocessing and working through the hot spots. Talk about what is missed most and how it impacts the pts life in the present and future – powerful for making the loss real and integrating it with the pts autobiography. Impt to take steps to help the pt not be overwhelmed: monitor through SUDS, use writing exercises, mobilizing social supports. Also good to extend with in vivo exposure to situations that are reminders of the loss (more on the details later.Cogn restructuring. Explain the rationale of this early on in tx: the role of unhelpful thoughts in maintaining his or her problems, and the importance and possibility of changing them.Lastly, BA is used to help the pt re-engage in healthy activities, and rebuild social, occupational, and recreational areas of life. Setting goals and making schedules is part of this.