Christopher Hall Director Australian Centre for Grief and Bereavement

1. Beyond Kübler-Ross: Recent developments in our understanding of grief and bereavement Christopher Hall Director Australian Centre for Grief and Bereavement

2. Grief is… …our response to loss • a multi-faceted experience: • Feelings • Physical • Cognitions • Behaviour • Interpersonal • Spiritual or philosophical 2

3. Health Problems Problems: PrevalencesStroebe, M., Stroebe, M., Schut & Stroebe (2007) The Lancet 3

4. Common elements of the new approach to grief and bereavement 1. Scepticism about the universal and predictable “emotional pathway” that leads from distress to “recovery”. Grief is a more complex process of adapting to loss. 4

5. Common elements of the new approach to grief and bereavement 2. A shift away from the idea that successful grieving requires “letting go” of the one who has died, and toward a recognition of the potentially healthy role of maintaining continued symbolic bonds with the deceased 3. Attention to broadly cognitive processes involved in mourning, adding to the traditional focus on the emotional consequences of loss 5

6. Common elements of the new approach to grief and bereavement 4. Greater awareness of the implications of major loss for the bereaved individual’s sense of identity. Grief often produces a deep revision in the bereaved persons sense of self. 5. Increased appreciation of the possibility of life-enhancing “post-traumatic growth” as one integrates the lessons of loss 6

7. Common elements of the new approach to grief and bereavement 6. Broadening the focus of attention to include not only the experience of individual grievers, but also the impact of loss on families and broader cultural groups. 7

8. Historical and Theoretical Milestones 8

9. Sigmund Freud Views mainly found in Mourning and melancholia (1917) Grief work untying the ties that bind, internal rearrangement. Three main tasks: 1. Freeing the bereaved from bondage to the deceased; 2. Readjustment to new life circumstances without the lost person; 3. Building new relationships. 9

10. Attachment Theory • Attachments vary in: • Strength • Security • Two primary functions: • Safe haven in times of stress • Secure base from which to explore the world Give rise to “working models” of close relationships stored in memory 10

11. Attachment Theory Securely attached children: tend to develop working models of relationships in which others are viewed as available and dependable, and the self is viewed as resourceful and resilient. Insecurely attached children(those with anxious, ambivalent attachments, often as a response to parental undependability, loss, neglect or abuse): tend to develop working models of relationships as precarious or dangerous and corresponding patterns of dependency or compulsive self-reliance. 11

12. Elisabeth Kübler-Ross (1969) Interviewed dying patients in hospital. Exposed neglect and isolation. Author of On Death and Dying. Adapted from Bowlby via Parkes, Kübler-Ross conceptualised “The Five stages of receiving catastrophic news” (anticipatory grief). Mutated into “The five Stages of Grief”. 12

13. William Worden (2009) Author of Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (2009) - 4th Ed. 13

14. Mediators of Mourning 1. Who the person who died was 2. Nature of the attachment (Relationship Factors) Strength of Attachment Security of Attachment Ambivalent Relationship Conflicts with the deceased Dependent relationships 14

15. Mediators of Mourning 3. How the person died Proximity Suddenness or unexpectedness Violent/traumatic deaths Multiple losses Preventable deaths Ambiguous deaths Stigmatised deaths 15

16. Mediators of Mourning • 4. Historical Antecedents • What Has Gone On Before • How Was It Dealt With • 5. Personality Variables • Age and Gender • Coping Style • Attachment Style • Cognitive Style 16

17. Mediators of Mourning • 5. Personality Variables (cont.) • Self-Esteem and Self-Efficacy • Assumptive World: Beliefs and Values • 6. Social Mediators • Support Satisfaction • Social Role Involvements • Religious Resources and Ethnic Expectations 17

18. Mediators of Mourning 7. Concurrent Stresses (Accumulative Stressors) Financial Difficulties Life Change Events, Job Loss etc. 18

19. Tasks of Mourning 1. To accept the reality of the loss 2. To process the pain of grief 3. To adjust to a world without the deceased - External adjustments - Internal adjustments - Spiritual adjustments 19

20. Tasks of Mourning 1. To accept the reality of the loss 2. To process the pain of grief 3. To adjust to a world without the deceased 4. To find an enduring connection with the deceased in the midst of embarking on a new life (Worden, 2009, pp. 39-53) 20

21. Systemic Contexts of Grieving 21

22. Family System Myths, rules & hierarchies that constrain and enable grief Self System Coping styles, resources, narratives of bereaved individual Social System Cultural, religious & linguistic discourses that shape private and public mourning Systemic Contexts of Grieving 22

23. Disenfranchised Grief • Grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. • The concept of disenfranchised grief recognises that societies have sets of norms—in effect, “grieving rules”—that attempt to specify who, when, where, how, how long, and for whom people should grieve. (Doka, 1989, p. 4) 23

24. Styles of Grieving Instrumental Active Cognitive Solitary Problem-solving activity Managing Cognitions Masculine Blended • Intuitive • Emotive • Affective • Social • Seeking Support • Managing Feelings • Feminine (Martin & Doka, 2000) 24

25. Dual Process Model 25

26. Everyday life experience Loss- oriented Restoration- oriented Oscillation: Normal grief Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief New roles/identities/ relationships Grief work Intrusion of grief Relinquishing-continuing-relocating bonds/ties Denial/avoidance of restoration changes Absent or inhibited grief Chronic grief Figure 1 Dual Process Model of Coping with Bereavement: Normal & Complicated Grief 26

27. Changing Lives of Older Couples (CLOC) study • Used longitudinal, prospective data from the Changing Lives of Older Couples (CLOC) study.1,532 married individuals in Detroit, USA. This study used 118. • Looked at data on average 3 years prior to the death of a spouse and again 6 and 18 months after the spouse’s death. 27

28. Depression (CES-D) 10.7% of sample Figure 1. Patterns of depression from pre-loss to 18-months postloss 28

29. Depression (CES-D) 45.6% of sample Figure 2. Patterns of depression from pre-loss to 18-months postloss 29

30. Depression (CES-D) 15.6% of sample Figure 3. Patterns of depression from pre-loss to 18-months postloss 30

31. Depression (CES-D) 7.8% of sample Figure 4. Patterns of depression from pre-loss to 18-months postloss 31

32. Depression (CES-D) 10.2% of sample Figure 5. Patterns of depression from pre-loss to 18-months postloss 32

33. Other Findings • “...individuals who were not depressed prior to loss but have acute and enduring grief reactions should focus on fostering the processing and the construction of new meanings around the loss” (p. 269). • “...among respondents with enduring depression, interventions should perhaps focus on bolstering these individuals’ self-esteem and assisting them in dealing with the day-to-day strains associated with widowhood” (p. 269). 33

34. The Effectiveness of Grief and Bereavement Interventions 34

35. Effects of Intervention (Schut, Stroebe, van der Bout & Terheggen, 2001) • Primary Preventive Interventions- Aimed at all bereaved • Secondary Preventive Interventions- Aimed at bereaved at risk • Tertiary Preventive Interventions- Aimed at bereaved suffering from complicated or pathological grief. Universal Selective Indicated 35

36. Who Benefits from BereavementInterventions? “The general pattern emerging from this review is that the more complicated the grief process … the better the chances of bereavement interventions leading to positive results.” Schut, Stroebe, Van den Bout, Terheggen 2001 “most uncomplicated grief is probably naturally self-limiting…. one of the most important trends in these reviews is the recognition that there are subgroups of mourners who are at elevated risk for dysfunction and who respond well to formal interventions.” Jordan and Neimeyer 2003 36

37. Why Not to Intervene? • Stroebe’s, Walter and others concerned that professional intervention: • Thwarts natural assistance from family and friends • Inhibits bereaved person’s self-esteem and sense of efficacy • Implies certain forms of griefare not socially acceptable; intervention gets unruly grief in line with cultural expectations • Wastes resources • Stigmatising 37

38. If Uncomplicated, or Too Soon to Diagnose, Suggest Proven Strategies... • Develop new routines and skills - learn cook, clean, car/home repairs - develop competencies • Seek company of empathic friends, groups, develop new friendships • Maintain active daily routine - distracted, engaged, better sleep • Maintain good hygiene - nutrition, adequate sleep, exercise • Encourage expression - narrative disclosure (keep journal) • Explore involvement in support groups 38

39. ConclusionsWhat to do for whom? • For low risk bereaved, recommend: • Stable sleep, exercise routines, daily schedules • Possibly support group • For MDD or GAD: usual treatments (eg SSRIs; CBT) • For PGD, promising interventions: • Pharmacotherapy RCT for grief • Complicated Grief Therapy • Attachment-based psychotherapy • Pre-loss preparation • Meaning based therapies 39

40. Worst case scenario scenario (Schut, Stroebe, van der Bout & Terheggen, 2001) Unsolicited, routine referral, shortly after bereavement for no other reason than that the person has suffered a bereavement. 40

41. In Summary • Intervention needs to be focussed on: • Risk groups • Individuals suffering from complicated grief 41

42. Complicated Grief 42

43. “Although mourning involves grave departures from the normal attitude toward life, it never occurs to us to regard it as a pathological condition and to refer it to a medical treatment. We rely on its being overcome after a certain lapse of time, and we look upon any interference with it as useless or even harmful” — Freud, 1917 43

44. How is CG Different From Typical Grief? • Acute grief is almost always painful and disruptive – to the extent that famous clinicians (e.g. Bowlby, Parkes, Engel and others) have suggested it should be considered an illness – analogous to an injury • How is CG different? • Severe symptoms persist without progress in coming to terms with the loss or restoring a sense of purpose or satisfaction in life (currently estimated at six months) • Certain kinds of dysfunctional thoughts, behaviours or emotions gain a foothold in the mind and derail the healing process 44

45. Two Triggers for Complicated Grief • Sudden, violent death that assaults the person’s assumptive world, even for a person without pre-existing vulnerability • Any significant loss for a person with vulnerabilities in attachment style, models of self and world. 45

46. Proposed Diagnostic Criteria forProlonged Grief Disorder (PGD) DSM V(Prigerson et. al, 2006) • Criterion C • The above symptom disturbance causes marked and persistent dysfunction in social, occupational, or other important domains. • Criterion D • The above symptom disturbance must last at least six months • Complicated Grief Diagnosis • Criteria A, B, C and D must be met. Criterion A • Chronic and disruptive yearning, pining, longing for the deceased Criterion B (abbreviated) • Four of the following eight at least several times a day to a degree intense enough to be distressing and disruptive: 1. Trouble accepting the death 2. Inability to trust others 3. Excessive bitterness or anger related to the death 4. Uneasy about moving on 5. Numbness/Detachment 6. Feeling life is empty or meaningless without deceased 7. Bleak future 8. Agitated 46

47. What Interventions Work with CG? Four research-informed grief-specific interventions have been found to be efficacious:Focused Family Grief Therapy (FFGT; Kissane & Bloch, 2002); Complicated Grief Treatment (CGT; Shear, Frank, Houch, & Reynolds, 2005)Cognitive Behavioural Therapy (CBT) for CG (Boelen, van den Hout, & van den Bout, 2006)Meaning reconstruction approaches to grief therapy (Neimeyer, 2000). 47

48. Complicated Grief Therapy (Shear, 2005) • RCT of manualised therapy for bereavement • Psycho-education about normal and CG • Dual process of adaptive coping – adjust to loss & restoration of satisfying life (goals defined with motivational enhancement) • Model: Grief is a trauma, people avoid trauma; exposure-based therapy reduces/desensitises distress re: trauma • Exposure for traumatic avoidance – imagined conversation with deceased; retelling the death scene 48

49. Reauthoring life narratives: Grief therapy as meaning reconstruction From a constructivist standpoint, grieving entails reconstructing a world of meaning that has been challenged by loss. (Neimeyer) 49

50. Although bereavement may be a choiceless event, the grieving experience understood as an active coping process is permeated by choice. — Thomas Attig 50