Grief therapy

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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 sstuber@susanstuberphd.com.

Transcript of Grief therapy

  • 1. 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 1

2. 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 Copyright 2013 Susan Stuber, PhD 2 3. ELISABETH KUBLER-ROSS Background Copyright 2013 Susan Stuber, PhD 3 4. POSITIVE EFFECTS OF KUBLER-ROSSS 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-ROSSS 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 Copyright 2013 Susan Stuber, PhD 5 6. CRITIQUE OF KUBLER-ROSSS 5 STAGE THEORY Boscontis (2004) graph of emotional fluctuations Copyright 2013 Susan Stuber, PhD 6 7. KUBLER-ROSSS IMPACT Why was her 5-stage theory so popular? Birth of the Grief Industry Copyright 2013 Susan Stuber, PhD 7 8. GET READY FOR ONE OF THE MOST IMPORTANT (AND SHOCKING) POINTS OF THE TALK Copyright 2013 Susan Stuber, PhD 8 9. GRIEF COUNSELING DOESNT 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 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 DOESNT 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. Copyright 2013 Susan Stuber, PhD 10 11. 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 Copyright 2013 Susan Stuber, PhD 11 12. 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 Copyright 2013 Susan Stuber, PhD 12 13. 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 Copyright 2013 Susan Stuber, PhD 13 14. 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 Copyright 2013 Susan Stuber, PhD 14 15. SHEARS 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. Copyright 2013 Susan Stuber, PhD 15 16. 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 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. WHATS IN A NAME? Pathological Unresolved Protracted Traumatic Complicated Prolonged Copyright 2013 Susan Stuber, PhD 18 19. 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 Copyright 2013 Susan Stuber, PhD 19 20. 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 Copyright 2013 Susan Stuber, PhD 20 21. PROTECTIVE FACTORS FOR CG Dispositional resilience (Bisconti, 2007) Optimism, active coping, positive reframing (Riley et al., 2006). Copyright 2013 Susan Stuber, PhD 21 22. 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 Copyright 2013 Susan Stuber, PhD 22 23. 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) Copyright 2013 Susan Stuber, PhD 23 24. 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 Copyright 2013 Susan Stuber, PhD 24 25. CAN CG BE INCORPORATED 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 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 Copyright 2013 Susan Stuber, PhD 26 27. 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 Copyright 2013 Susan Stuber, PhD 27 28. 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 dont fit elsewhere. Copyright 2013 Susan Stuber, PhD 28 29. THE PROLONGED, COMPLICATED SAGA OF RESEARCHING PROLONGED COMPLICATED GRIEF!! Research based criteria from Prigerson, e