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(2) To Work Through to the Pain of Grief ... Some people find loss so painful that hey make a pact with themselves never to love again. ... – PowerPoint PPT presentation

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Title: Bereavement

  • Holmes and Rahe (1967) most stressful life
    event death of spouse

Bereavement (DSM-IV)
  • This Category can be used when the focus of
    clinical attention is a reaction to the death of
    a loved one. As part of their reaction to the
    loss, some grieving individuals present with
    symptoms characteristic of a Major Depressive
    Episode (e.g. feeling of sadness and associated
    symptoms such as insomnia, poor appetite, and
    weight loss). The bereaved individual typically
    regards the depressed mood as normal, although
    the person may seek professional help for relief
    of associated symptoms such as insomnia or
    anorexia. The duration and expression of
    normal bereavement vary considerably among
    different cultural groups.
  • The diagnosis of Major Depressive Disorder is
    generally not given unless the symptoms are still
    present 2 months after the loss.

  • Sadness
  • Anger
  • Guilt self-reproach
  • Anxiety
  • Loneliness
  • Fatigue
  • Helplessness
  • Shock
  • Yearning
  • Emancipation
  • Relief
  • Numbness

  • All the above represent normal grief feelings and
    there is nothing pathological about any one of
  • However, feelings that exist for abnormally long
    periods of time and at excessive intensity may
    portend a complicated grief reaction.

Bereavement (DSM-IV, cont)
  • However, the presence of certain symptoms that
    are not characteristic of a normal grief
    reaction may be helpful in differentiating
    bereavement from a Major Depressive Episode.
    These include
  • 1) guilt about things other than actions taken or
    not taken by the survivor at the time of death
  • 2) thoughts of death other than the survivor
    feeling that he or she would be better off dead
    or should have died with the deceased person
  • 3) morbid preoccupation with worthlessness
  • 4) marked psychomotor retardation
  • 5) prolonged and marked functional impairment
  • 6) hallucinatory experiences other than thinking
    that he or she hears the voice of, or transiently
    sees the image of, the deceased person.

Physical Sensations
  • Hollowness in the stomach
  • Tightness in the chest
  • Tightness in the throat
  • Oversensitivity to noise
  • A sense of depersonalization
  • Breathlessness, feeling short of breath
  • Weakness in the muscles
  • Lack of energy
  • Dry mouth

  • Disbelief
  • Confusion
  • Preoccupation
  • Sense of presence
  • Hallucinations

  • Searching calling out
  • Sighing
  • Restless overactivity
  • Crying
  • Visiting places or carrying objects that remind
    the survivor of the deceased
  • Treasuring objects that belonged to the deceased
  • Sleep disturbance
  • Appetite disturbances
  • Absent-minded behavior
  • Social withdrawal
  • Dreams of the deceased
  • Avoiding reminders of the deceased

Grieving Reactions over time
  • Annual incidence of bereavement in the
    population 5 9
  • Byrne and Raphael (1994)
  • 76.5 of bereaved elderly mean had intrusive
    memories of their spouses at 13 months
  • 49 reported feelings of distress
  • 43 were preoccupied with mental images of their
  • 41 were still yearning for their spouses, and
  • 25 had looked for their spouse in familiar

  • Overall about 20 of bereaved individuals will
    develop a psychiatric disorder, primarily

Predictors of Poor Bereavement Outcome
  • Perception of poor social support
  • Prior psychiatric history
  • High initial distress with depressive symptoms
  • Unanticipated death
  • Other significant life stresses and losses
  • Prior high dependency on the deceased who
    provided key support
  • Death of a child

Predictors of Negative Bereavement Outcome
  • Age and education
  • Social support
  • Opportunities for anticipatory grieving
  • Relationship with spouse
  • Number of concurrent life stressors
  • Time since death
  • Financial status

Xx Lindemann (1944)
  • First described anticipatory grief.
  • Spouse becomes so concerned with their adjustment
    in the face of a potential death, that they go
    through all the phases of grief prior to the
    actual death. While this reaction was felt to be
    a safeguard against the impact of a sudden death,
    it can be problematic when pts follow a more
    protracted terminal course than originally
  • Generated considerable debate over anticipatory
  • Lindemann E. Symptomatology and management of
    acute grief. Am J Psychiatry. 1944 101 141-8.

Bowlby (1961) Attachment Theory
  • Observed children who were separated from their
    parents in institutional settings.
  • Mary Ainsworth (1991) the way in which a child
    of 18 months reacts when separated for a few
    minutes from his mother in a strange situation
    predicts how it he will be coping with other
    relationships 10 years later.

Mary Ainsworth (1991)
  • Strange situation test
  • Babies take little notice when their mother
    leaves the room and often ignore her when she
    returns. But their self-reliance does not
    protect them from feeling anxious, and their
    apparent independence is associated with a
    racing heart and other physical sings of fear.
  • Other babies have mothers who are insensitive to
    their bids for attention they show every
    manifestation of distress when separated from
    their mother and cling to her in an angry way
    when she returns. They too are excessively
    insecure and seem to feel that they have no hope
    of survival unless they stay close to their
  • Securely attached children will tolerate short
    periods of separation quite well they may
    whimper for a short time when their mother leaves
    the room but, provided she does not stay away too
    long, they will continue to play with toys, their
    heart rate will not rise unduly and they will
    greet her return with a hug and a smile.
    Securely attached children are more relaxed and
    adventurous than insecurely attached children
    they learn more quickly, do better at school and,
    in due time, the transition from childhood
    dependency to adult autonomy proceeds relatively
  • By contrast insecurely attached children are
    generally anxious and insecure they are often
    underachievers, doing less well at school

Parkes Weiss (1983)
  • Unexpected loss syndrome
  • Dependent grief syndrome
  • Conflicted grief syndrome

  • Lindemann (1944), Bowlby (1961), and Parkes
    Weiss (1983) suggest that grief is a process
    involving phases, stages, or dimensions which
    culminate in reorganization, resolution, or
    reentry into everyday living.

  • Worden (1991) described tasks which individuals
    complete in order to facilitate the mourning
    process. The goal is to achieve a restored
    balanced in life through grief resolution.
    Descriptions of phases, tasks, or manifestations
    of grief generally include experiences of
    disorganization for the bereaved resulting in the
    inability to restore past order and meaning to
  • The experience is characterized by feelings of
    anguish and being overwhelmed (Parkes, 1987).

The Tasks of Mourning (Worden)
  • Task I
  • To Accept the Reality of the Loss
  • Opposite not believing through some type of
  • Task II
  • To Work Through To the Pain of Grief
  • Opposite not to feel

The Tasks of Mourning (cont'd)
  • Task III
  • To Adjust to An Environment in Which the Deceased
    is Missing
  • Opposite not adapting to the loss by promoting
    their own helplessness, or by withdrawing from
    the world
  • Task IV
  • To Emotionally Relocate the Deceased Move on
    With Life
  • Hindered by holding on the past attachment

Janoff-Bulman (1992)
  • 3 basic assumptions beliefs about ourselves,
    external world, and the relationship between the
  • The world is benevolent, meaningful. The self is
  • Meaningfulness found in predictable life patterns
    or expected life roles.
  • The world is benevolent when one feels in
    control the story-book world.
  • Crisis, such as loss, invalidates certain
    assumptive structures and challenges individuals
    to affirm or reconstruct a personal world of
    meaning (Neimeyer, 1997). Rebuilding an
    assumptive world after trauma as both an
    emotional and cognitive process or reestablishing

  • Rondo (1984) to understand the unique nature and
    meaning of loss we must view the loss from the
    individuals frame of reference age,
    psychosocial context, and sense of meaning and
    fulfillment, characteristics of the relationship
    and roles the deceased performed in the mourners
    life, personal behaviour, presence of other
    lifes stressors.

Dual-Process view of bereavement
  • Stroebe and Schut (1999) grief work is seen as a
    loss-oriented process that alternates with
    restoration-oriented processes (e.g. denial,
    suppression and distraction).
  • Loss orientation engages in intensive grief
    work, experiencing, exploring and expressing the
    range of feelings associated with loss in an
    attempt to grasp its significance for his of her
  • Restoration orientation the griever focuses on
    the many external adjustments required by the
    loss, concentrating on work and home
    responsibilities, establishing and maintaining
    relationships, while tuning out the waves of
    acute grief that may come again.
  • Some degree of avoidance of the reality of loss
    may be both helpful and common, and will be
    experienced throughout the adjustment process,
    rather than confined solely to its initial

The Four Tasks of Mourning
  • Worden, 1991

(1) To Accept the Reality of the Loss
  • Vs. not believing through some type of denial
  • Searching behavior
  • Mummification
  • Distortion
  • Deny meaning of the loss
  • Minimize significance
  • Selective forgetting
  • Deny that death is irreversible
  • Spiritualism chronic hope for reunion
  • Involves emotional acceptance
  • Funeral

(2) To Work Through to the Pain of Grief
  • Necessary to acknowledge and work through this
    pain, otherwise symptoms
  • Vs. Not to feel
  • Idealize the dead
  • Avoid reminders
  • Use alcohol or drug

(3) To Adjust to an Environment in Which the
Deceased is Missing
  • Vs. Not adapting to the loss by promoting their
    own helplessness, or by withdrawing from the
  • Adjust to the loss of roles played by the
  • Adjust to own sense of self
  • Lowered self-esteem
  • Sense of the world new beliefs may be adopted or
    old ones modified to reflect the fragility of
    life and the limits of control

(4) To Emotionally Relocate the Deceased and
Move on With Life
  • Vs. holding on to past attachments
  • A survivors readiness to enter new
    relationships depends not on giving up the dead
    spouse but on finding a suitable place for the
    spouse in the psychological life of the bereaved
    a place that is important but that leaves room
    for others. (Shuchter Zisook, 1996)
  • Some people find loss so painful that hey make a
    pact with themselves never to love again.

Identifying the At-Risk Bereaved
Identifying the At-Risk Bereaved
  • Bereavement Risk Index (Parkes Weiss, 1983)
  • More young children at home
  • Lower social class
  • Employment little if any
  • Anger high
  • Pining high
  • Self-reproach high
  • Lacking current relationships
  • Coping assessment by rater requiring help

Diagnosing Complicated Grief
  • The person cannot speak of the deceased without
    experiencing intense and fresh grief.
  • Some relatively minor event triggers off an
    intense grief reaction.
  • Themes of loss come up in a clinical interview.
  • Unwilling to move material possessions belonging
    to the deceased.

Complicated Grief (Contd)
  • Developed physical symptoms like those the
    deceased experienced before death.
  • Radical changes in their lifestyle following a
  • Long history of subclinical depression
    persistent guilt and lowered self-esteem, severe
    hopelessness, self blame.

Complicated Grief (Contd)
  • A compulsion to imitate the dead person.
  • Self-destructive impulses.
  • Unaccountable sadness occurring at a certain time
    each year.
  • Phobia about illness or about death is often
    related to the specific illness that took the

Complicated Grief (Contd)
  • Real delay in grief reactions.
  • Severely out of touch with feelings.
  • Intense anger.
  • Social withdrawal.
  • Loss of interest or planning for future.
  • Substance abuse.

Counseling Principles
  • Principle One Help the survivor actualize
    the loss
  • Principle Two Help the survivor to identify
    and express feeling
  • Principle Three Assist Living Without the
  • Principle Four Facilitate Emotional
    Relocation of the Deceased

Counseling Principles
  • Principle Five Provide time to grieve
  • Principle Six Interpret normal behavior
  • Principle Seven Allow for individual
  • Principle Eight Provide continuing support
  • Principle Nine Examine defense coping
  • Principle Ten Identify pathology and refer

Useful Techniques
  • Evocative language
  • Use of symbols
  • Writing
  • Drawing
  • Role playing
  • Cognitive restructuring
  • Memory book
  • Directed imagery

When Should One Reach Out for Help?
  • Substantial guilt, about things other than the
    actions you took or did not take at the time time
    of a loved ones death.
  • Suicidal thoughts which go beyond a passive wish
    that you would be better off dead or could
    reunite with your loved one.
  • Extreme hopelessness, a sense that no matter how
    hard you try, you will never be able to recover a
    lift worth living.
  • Prolonged agitation or depression, a feeling of
    being keyed up or slowed down that persists
    over a period of months.
  • Physical symptoms, such as stabbing chest pain or
    substantial weight loss, that could pose a threat
    to your physical well-being.
  • Uncontrolled rage, that estranges friends and
    loved ones or leaves you plotting revenge for
    your loss
  • Persistent functional impairment in your ability
    to hold a job, or accomplish routine tasks
    required for daily living.
  • Substance abuse, relying heavily on drugs or
    alcohol to banish the pain of loss.
  • Neimeyer (2000) Lessons of Loss

Neimeyer (2000)
  • Death as an event can validate or invalidate the
    constructions on the basis of which we live, or
    it may stand as a novel experience for which we
    have no constructions.
  • Grief is a personal process, one that is
    idiosyncratic, intimate, and inextricable from
    our sense of who we are.
  • Grieving is something we do, not something that
    is done to us. (experience of grieving itself
    may be rich in choice)
  • Grieving is the act of affirming or
    reconstructing a personal world of meaning that
    has been challenged by loss. (assimilate loss
    into pre-existing frameworks of meaning,
    ultimately reasserting the viability of the
    belief system that previously sustained us, or we
    can accommodate our life narative to correspond
    more closely to what we perceive as a changed
  • Feelings have functions, and should be understood
    as signals of the state of our meaning making
    efforts in the wake of challenges to the adequacy
    of our constructions. (Denial, depression,
    anxiety, guilt, hostility, threat).
  • We construct and reconstruct our identities as
    survivors of loss in negotiation with others.
  • Neimeyer (2000). Lessons of Loss p. 98-97

  • Position of not knowing, rather than imposition
    of expert knowledge.
  • Grieving is an active process, a period of
    accelerated decision-making. Encourages
    caregivers to assist bereaved individual in
    identifying conscious and unconscious choices
    they confront, and then helping them sift through
    their options and make difficult decisions.
  • Neimeyer (2000). Lessons of Loss p.111-2

Mourning never ends. Only as time goes on, it
erupts less frequently.
  • - Widow in her 60s

Thank you.