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Introduction Ch. Stroebe, Robert O. Contemporary Scientific Approaches and Issues Ch.

Robert A. Neimeyer on Constructivist Therapy and Grief Therapy

Weiss Ch. Shaver Ch. Field Ch. Neimeyer, Nancy S. Contemporary Societal and Practice Concerns Ch. Evidence supports the existence of a minimal grief reaction—a pattern in which persons experience no, or only a few, signs of overt distress or disruption in functioning. Empirical support also exists for chronic grief, a pattern of responding in which persons experience symptoms of common grief but do so for a much longer time than the typical year or two. It may look very much like major depression, generalized anxiety, and possibly post-traumatic stress.

In addition to these theoretical and empirically supported patterns of grief reactions, much emphasis has been placed on distinguishing normal grief from complicated grief. Most clinicians will be focused on understanding the differences between normal and complicated grief reactions: What is the difference? In current form it does not consist of formal diagnostic criteria and is generally considered a normal reaction to loss via death. In an attempt to clearly distinguish between normal grief and complicated grief, a consensus conference has developed diagnostic criteria for a mental disorder referred to as prolonged grief disorder, proposing that it be included in the next revision of the DSM.

These criteria have not been formally adopted, and thus there is no formal diagnostic category for prolonged grief disorders in the DSM. However, these criteria help in specifying symptoms, the severity of symptoms, and how to distinguish complicated grief from normal grief. JAMA 7 : , Bonanno GA: Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol 59 1 : , A test of incremental validity. J Abnorm Psychol 2 : , In: Rando TA, ed. Lexington, Mass: Lexington Books, , pp New York: Wiley-Interscience Publication, Silverman PR: Widow-to-widow.

Springer Series on Social Work. Vol 7. New York: Springer Publishing Company, Bowlby J: Attachment and Loss. Rando TA: The increasing prevalence of complicated mourning: the onslaught is just beginning. Omega Westport 26 1 : , JAMA 24 : ; author reply , Br J Med Psychol , London, United Kingdom: Martin Dunitz, , pp One study of caregivers of terminally ill cancer patients investigated the presence of predeath complicated grief and its correlates. Results revealed the following variables associated with higher levels of predeath complicated grief:. Of these correlates, pessimistic thinking and severity of stressful life events were independent predictors of predeath complicated grief.

Other research has focused on predictors of outcomes such as symptoms of depression and overall negative health consequences. Three categories of variables have been investigated:. Although theory suggests that a sudden, unexpected loss should lead to more difficult grief, empirical findings have been mixed. Bereaved persons with secure attachment styles would be least likely to experience complicated grief, while those with either insecure styles or anxious-ambivalent styles would be most likely to experience negative outcomes.

In a study of 59 caregivers of terminally ill spouses, the nature of their attachment styles and marital quality were evaluated. Results showed that caregivers with insecure attachment styles or in marriages that were "security-increasing" were more likely to experience symptoms of complicated grief. Theory has proposed that strong religious beliefs and participation in religious activities could provide a buffer to the distress of loss, via two different mechanisms:. However, empirical results about the benefits of religion in coping with death tend to be mixed, some showing positive benefit and others showing no benefit or even greater distress among the religious.

Studies that show a positive benefit of religion tend to measure religious participation as regular church attendance and find that the benefit of participation tends to be associated with an increased level of social support. Thus it appears that religious participation via regular church attendance and the resulting increase in social support may be the mechanisms by which religion is associated with positive grief outcomes.

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In general, men experience more negative consequences than women do after losing a spouse. Mortality rates of bereaved men and women are higher for both men and women compared to nonbereaved people; however, the relative increase in mortality is higher for men than for women. Some researchers have suggested that the mechanism for this difference is the lower level of social support provided to bereaved men than that provided to bereaved women.

In general, younger bereaved persons experience more difficulties after a loss than do older bereaved persons. These difficulties include more severe health consequences, grief symptoms, and psychological and physical symptoms. The reason for this age-related difference may be the fact that younger bereaved persons are more likely to have experienced unexpected and sudden loss. However, it is also thought that younger bereaved persons may experience more difficulties during the initial period after the loss but may recover more quickly because they have more access to various types of resources e.

However, as mentioned above, lack of social support is a risk factor for negative bereavement outcomes: It is both a general risk factor for negative health outcomes and a bereavement-specific risk factor for negative outcomes after loss. For example, after the death of a close family member e. Psychooncology 17 2 : , Stroebe W, Schut H: Risk factors in bereavement outcome: a methodological and empirical review.

J Nerv Ment Dis 9 : , J Pers Soc Psychol 72 4 : , The following information concerns treatment of grief after the death of a loved one, not necessarily death as a result of cancer. Some controversy continues about whether normal or common grief reactions require any intervention by medical or mental health professionals. Researchers disagree about whether credible evidence on the efficacy of grief counseling exists.

Most bereaved persons experience painful and often very distressing emotional, physical, and social reactions; however, most researchers agree that most bereaved persons adapt over time, typically within the first 6 months to 2 years. Thus, the question is whether it is wise to devote professional time to interventions for normal grief when resources are limited and the need for accountability is great. One approach is to use a spectrum of interventions, from prevention to treatment to long-term maintenance care. In this model, preventive interventions could be one of the following:. In contrast, formal treatment of bereaved persons would be reserved for those identified as experiencing complicated or pathologic grief reactions.

Grief, Bereavement, and Coping With Loss (PDQ®)

Finally, longer-term maintenance care may be warranted for persons experiencing chronic grief reactions. Another approach has focused on families. This brief, time-limited approach four to eight minute sessions over 9 to 18 months identifies families at increased risk for poor outcomes and intervenes, with emphasis on improving family cohesion, communication, and conflict resolution. Adaptive coping, with efforts to strengthen family solidarity, and frequent affirmation of family strengths are emphasized.

Family functioning was classified into one of five groups:. Results showed modest reductions in distress at 13 months postdeath for all participants, with more significant reductions in distress and depression in family members who had initially higher baseline scores on the Brief Symptom Inventory and Beck Depression Inventory.

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Handbook of Bereavement : Theory, Research, and Intervention

Overall, global family functioning did not change, yet participants classified as sullen or intermediate showed more improvement than those classified as hostile. Results recommend caution in dealing with hostile families to avoid increasing conflict in such families. With the development of proposed diagnostic criteria for complicated grief i. Both studies are of interventions for bereaved persons whose loved ones died from mixed not necessarily cancer-related causes. The first study [Level of evidence: I] compared complicated grief treatment CGT with interpersonal psychotherapy IPT in 83 women and 12 men, aged 18 to 85 years prescreened, who met the criteria for complicated grief.

Both interventions consisted of 16 weekly sessions spread out over an average of 19 weeks per participant. IPT is a widely researched, empirically supported treatment intervention for depression. IPT therapists used an intervention delivered as described in a published manual, using an introductory phase, a middle phase, and a termination phase. During the introductory phase, symptoms were identified, and an inventory of interpersonal relationships was completed, with a focus on interpersonal problems.

Connections between symptoms, interpersonal problems, and grief were identified and discussed. During the middle phase, these interpersonal problems and issues of grief were addressed. Patients were encouraged to develop a realistic relationship with the deceased, to recognize both positive and negative aspects of the loss, and to invest in new, positive relationships. During the termination phase, gains were identified and reviewed, future plans were made and feelings about termination were discussed. CGT was also delivered according to a manual protocol, also organized into three phases.

In the introductory phase, therapists described the distinctions between normal and complicated grief. They also explained the concept of dual processing, or the notion that grief progresses best when attention alternates between a a focus on loss and b a focus on restoration and future. Thus, the introductory phase included both a discussion of the loss and an identification of future goals and aspirations. A unique characteristic of CGT was the concept of revisiting loss via retelling the story of the death.

This concept was particularly important for persons inclined to avoid thinking about the trauma of the loss. Specific procedures that were modeled after the "imaginal exposure" component of interventions for post-traumatic stress disorder were utilized for retelling. No significant differences in outcomes were found for those on antidepressant medications.

The second study of complicated grief [Level of evidence: II] compared cognitive-behavioral therapy CBT , offered in two different sequences, with supportive counseling for 54 bereaved persons, all prescreened and found to be experiencing complicated grief. With researchers hypothesizing that maladaptive thoughts and behaviors are an important component of complicated grief, the CBT interventions consisted of two components exposure therapy and cognitive restructuring designed to directly impact grief-related thoughts and behaviors.

Participants were randomly assigned to receive one of three treatments:. Results showed that both CBT groups experienced more improvement in symptoms of complicated grief and general psychopathology than did the supportive counseling group. In component analyses, the exposure therapy component was more effective than the cognitive restructuring component; the sequence of exposure therapy first, followed by cognitive restructuring, produced the best results.

The clinical decision on whether to provide pharmacologic treatment for depressive symptoms in the context of bereavement is controversial and not very extensively studied. Some health care professionals argue that distinguishing the sadness and distress of normal grief from the sadness and distress of depression is difficult, and pharmacologic treatment of a normal emotional process is not warranted. However, three open-label trials and one randomized controlled trial of treatment of bereavement-related depression with antidepressants have been reported see Table 1.

The open-label trials evaluated desipramine, nortriptyline, and bupropion sustained release. All studies evaluated intensity of grief using select grief assessment questionnaires.

Delft Institute of Positive Design | Design for Loss

Data from these studies suggest that antidepressants are well tolerated and improve symptoms of depression. Data also suggest that the intensity of grief improved but that the improvement was consistently less in comparison with the symptoms of depression. Limitations of these studies include open-label treatment and small sample sizes. The only randomized controlled study conducted to date [Level of evidence: I] compared nortriptyline with placebo for the treatment of bereavement-related major depressive episodes.

Nortriptyline was also compared with two other treatments, one combining nortriptyline with IPT and the other combining placebo with IPT.

Handbook of bereavement theory, research and intervention

The item HDRS was used to assess depressive symptoms. Remission was defined as a score of 7 or lower for 3 consecutive weeks. The combination of nortriptyline with IPT was associated with the highest remission rate and highest rate of treatment completion. The study did not show a difference between IPT and placebo, possibly owing to specific aspects of the study design, including short duration of IPT mean no.


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The high remission rate with placebo was another important limitation of the study. Consistent with previous open-label studies and for all four groups, improvement in grief intensity was less than improvement in depressive symptoms. In summary, all of the antidepressant studies conducted to date suggest that the magnitude of reduction and rate of improvement in grief symptoms are slower than the decrease in magnitude and rate of improvement in depressive symptoms. One group of researchers provides possible explanations for this phenomenon, arguing that depressive symptoms may be more responsive to pharmacological intervention because they are directly related to biological dysregulation and neurochemical changes.

The other possibility is that the persistence of grief without depressive symptoms is not pathological—it might be a normal and necessary consequence of the bereavement process. An evaluation of the empirical foundations of the new pessimism. Prof Psychol Res Pr 38 4 : , Prof Psychol Res Pr 39 3 : , Am J Psychiatry 7 : , JAMA 21 : , J Consult Clin Psychol 75 2 : , A pilot study. Psychiatr Clin North Am 10 3 : , J Clin Psychiatry 52 7 : , J Clin Psychiatry 62 4 : , Am J Psychiatry 2 : , At one time, children were considered miniature adults, and their behaviors were expected to be modeled as such.

Today there is a greater awareness of developmental differences between childhood and other developmental stages in the human life cycle. Differences between the grieving process for children and the grieving process for adults are recognized. It is now believed that the real issue for grieving children is not whether they grieve, but how they exhibit their grief and mourning.

The primary difference between bereaved adults and bereaved children is that intense emotional and behavioral expressions are not continuous in children. The work of mourning in childhood needs to be addressed repeatedly at different developmental and chronological milestones. Because bereavement is a process that continues over time, children will revisit the loss repeatedly, especially during significant life events e. Children must complete the grieving process, eventually achieving resolution of grief.

Children do not react to loss in the same ways as adults and may not display their feelings as openly as adults do. In addition to verbal communication, grieving children may employ play, drama, art, school work, and stories. Bereaved children may not withdraw into preoccupation with thoughts of the deceased person; they often immerse themselves in activities e. Families often incorrectly interpret this behavior to mean the child does not really understand or has already gotten over the death.

Neither assumption may be true; children's minds protect them from thoughts and feelings that are too powerful for them to handle.

Definitions of Terms

Grief reactions are intermittent because children cannot explore all their thoughts and feelings as rationally as adults can. Additionally, children often have difficulty articulating their feelings about grief. Strong feelings of anger and fear of abandonment or death may be evident in the behaviors of grieving children. Children often play death games as a way of working out their feelings and anxieties in a relatively safe setting. These games are familiar to the children and provide safe opportunities to express their feelings.

Death and the events surrounding it are understood differently depending on a child's age and developmental stage see Table 2. Although infants do not recognize death, feelings of loss and separation are part of a developing death awareness. Children who have been separated from their mothers and deprived of nurturing can exhibit changes such as listlessness, quietness, unresponsiveness to a smile or a coo, physical changes including weight loss , and a decrease in activity and lack of sleep. In this age range, children often confuse death with sleep and can experience anxiety.


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In the early phases of grief, bereaved children can exhibit loss of speech and generalized distress. In this age range, children view death as a kind of sleep: the person is alive, but in some limited way. They do not fully separate death from life and may believe that the deceased continues to live for instance, in the ground where he or she was buried and often ask questions about the activities of the deceased person e.