Grief therapy

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SUSAN STUBER, PH.D. MARCH 22, 2013 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

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Review of the latest research in the field on grief therapy and practice tips for practitioners. Topics include: • 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 Presented by Susan Stuber, Ph.D. at the Philadelphia Society of Clinical Psychologists continuing education conference at the Philadelphia College of Osteopathic Medicine, March 22, 2013. A copy of the full presentation notes accompanying these slides may be obtained by contacting Dr. Stuber at [email protected].

Transcript of Grief therapy

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Copyright 2013 Susan Stuber, PhD

1S U S A N S T U B E R , P H . D . M A RC 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.]  

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GRIEF THERAPY

• The latest 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

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ELISABETH KUBLER-ROSS

• Background

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POSITIVE EFFECTS OF KUBLER-ROSS’S 5-STAGE THEORY

• Opened up the door to talk about grief• Supported the rise of the Hospice movement

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CRITIQUE OF KUBLER-ROSS’S 5 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

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CRITIQUE OF KUBLER-ROSS’S 5 STAGE THEORY

• Bosconti’s (2004) graph of emotional fluctuations

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KUBLER-ROSS’S IMPACT

• Why was her 5-stage theory so popular?• Birth of the “Grief Industry”

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GET READY FOR ONE OF THE MOST IMPORTANT (AND SHOCKING) POINTS OF THE TALK

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GRIEF COUNSELING DOESN’T WORK

• 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 CHOPConclusion: Other than treating major depression

with medication, there was no evidence for recommending bereavement interventions

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GRIEF THERAPY DOESN’T WORK (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.”

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GRIEF THERAPY

• The latest 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

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COMMON GRIEF SYMPTOMS THAT 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

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SYMPTOMS OF INTEGRATED GRIEF 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

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COMPLICATED GRIEF (SHEAR ET 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

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SHEAR’S WORDS TO CLIENTS

• “ … 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.”

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THE FACE OF NORMAL 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

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PREVALENCE OF CG

10% (Shear, 2011)

Hard to tell based on lack on consensus about criteria.

Other countries have lower estimates.

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WHAT’S IN A NAME?

• Pathological• Unresolved• Protracted• Traumatic• Complicated• Prolonged

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INVENTORY OF COMPLICATED GRIEF (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

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RISK FACTORS FOR CG

• 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

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PROTECTIVE FACTORS FOR CG

• Dispositional resilience (Bisconti, 2007)• Optimism, active coping, positive reframing (Riley

et al., 2006).

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GRIEF THERAPY

• The latest 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

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WHY CG SHOULD NOT 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)

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WHY CG SHOULD BE 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”

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CAN CG BE INCORPORATED INTO AN EXISTING DIAGNOSIS?

• CG has different, unique symptomatology• CG has a different response to treatment

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CG IS LIKE YET 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

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CG IS LIKE AND UNLIKE PTSD

• Similarities: traumatic event, intrusive images, avoidance, estrangement from others• Differences:• traumatic event• reduction of threat• different hallmark symptoms• Factor analysis

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CG IS LIKE YET 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.

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THE PROLONGED, COMPLICATED SAGA 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

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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

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AIMS OF THE 6 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

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1. DETERMINING THE SYMPTOMS

• 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 

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2. IDENTIFYING THE DIAGNOSTIC 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

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3. PREDICTIVE VALIDITY OF 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.

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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

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SHEAR ET AL.’S 2011 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

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SHEAR ET AL.’S 2011 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

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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

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DSM-5’S ADDITIONS ON GRIEF

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TWO GRIEF-RELATED ADDITIONS TO DSM-5

• Adjustment Disorder Related to Bereavement

• Persistent Complex Bereavement-Related Disorder

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ADJUSTMENT DISORDER RELATED TO 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

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ADJUSTMENT DISORDER RELATED TO 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

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PERSISTENT COMPLEX BEREAVEMENT RELATED DISORDER

•See Hand-Out

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CLEVER COMPROMISE OR SACRIFICIAL SATISFICING?

• The name is a compromise• The symptom criteria are a compromise

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PROBLEMS WITH DSM-5’S PROPOSALS

• 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

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GRIEF THERAPY

• The latest 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

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STROEBE AND SCHUT’S DUAL 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

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STROEBE AND SCHUT’S DUAL 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

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WHAT’S NEW IN THIS 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

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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

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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

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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

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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)

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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.

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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.

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56S U S A N S T U B E R , P H . D . M A RC 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

[email protected] .