Grief and bereavement

[hamlake]

I am interested in how others clinically approach and conceptualize grief and bereavement in practice. I am not particularly interested in a discussion about over- or under-pathologizing grief as I think that debate is a bit overdone in other settings.

From the literature that I have reviewed, it seems that most experts in grief have moved beyond the popularized stage-based theory of grief, i.e. Kubler-Ross, as it is flawed and can even be harmful if applied rigidly. So far I have read J. William Worden's "Grief Counseling and Grief Therapy" and some of Katherine Shear's work on complicated grief which is based on an attachment model and incorporates techniques from prolonged exposure and IPT. I am using some of these concepts and techniques in my own treatment of patients and am curious about how other people approach grief as a clinical issue. Also, what articles or books on the topic would you recommend? See below for some of the work by Shear. Thanks.

"Complicated grief" by Shear in NEJM 2015
http://www.nejm.org/doi/full/10.1056/NEJMcp1315618

"An attachment-based model of complicated grief including the role of avoidance" by Shear in Eur Arch of Psych & Clin Neurosci 2007
http://www.ncbi.nlm.nih.gov/pubmed/17629727

Two RCTs of complicated grief treatment by Shear
http://www.ncbi.nlm.nih.gov/pubmed/15928281
http://www.ncbi.nlm.nih.gov/pubmed/25250737

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[F0nzie]

I typically back off and let them express their grief, validate their experience, acknowledge moments of avoidance of emotion and expression, expand on positive times if it is overly negative, gently reappraise distortions that may be resulting in excessive guilt. Not sure I am following any model with that. But that's what I do in a nutshell.

 

[F0nzie]

Btw not sure that I have ever worked with pure grief with no real Axis I or II.

 

[hamlake]

Btw not sure that I have ever worked with pure grief with no real Axis I or II.

That has generally been my experience in residency. However, I have one patient who I would consider pure complicated grief though other clinicians might argue that the diagnoses are really MDD and grief.

 

[splik]

The classics on grief are Erich Lindemann's paper on the Cocoanut Grove fire, Colin Murray Parke's text Bereavement: Studies of Grief in Adult Life and Bowlby's Attachment and Loss and of course Freud's mourning and melancholia. The Worden book you mention is probably the standard text and is excellent.

I like Stroebe's dual process theory of grief : http://www.ncbi.nlm.nih.gov/pubmed/10848151

I like the narrative approach to grief work therapeutically. Unlike prior modernist approaches, its is grounded in social constructivism and takes the view that dead never really die as relationships continue with the dead long after they are gone, telling stories about the dead enriches life, biological death does not equate with psychological death, It is influence a lot my Michael White's narrative therapy and Myerhoff's idea of re-membering. This is helpful for normal grief reactions.

In contrasting normal with pathological grief, I find it helpful to look at this idea of remembering and forgetting. Patients with normal grief have an intense fear of forgetting the lost object whereas those with pathological grief often wish to completely forget, to have the memories entirely obliterated because remembering hurts too much.

I don't think it is helpful to blur grief and depression (as anxiety is the cardinal symptom of grief rather than depression), and while we don't want to medicalize a normal reaction, grief has significant medical implications. Patients often present with somatic and psychological manifestations/disturbances following grief including the symptoms the lost object had, there is an increased risk of mortality, there are clear physiological syndromes (such as Takutsubo's cardiomyopathy) and other cardiovascular risk following bereavement, and grief can be associated with the development of psychological disturbances including panic disorder and even mania (possibly a paradoxical grief reaction in some cases?). This has been my clinical experience anyway. If people are coming along for treatment something is going on and we need to explore this and find out what this means. It is rare for someone to see a psychiatrist with uncomplicated grief alone, but on the occassions this does happen, all the more reason to explore carefully the reason they are really presenting

 

[smalltownpsych]

I am interested in how others clinically approach and conceptualize grief and bereavement in practice. I am not particularly interested in a discussion about over- or under-pathologizing grief as I think that debate is a bit overdone in other settings.

From the literature that I have reviewed, it seems that most experts in grief have moved beyond the popularized stage-based theory of grief, i.e. Kubler-Ross, as it is flawed and can even be harmful if applied rigidly. So far I have read J. William Worden's "Grief Counseling and Grief Therapy" and some of Katherine Shear's work on complicated grief which is based on an attachment model and incorporates techniques from prolonged exposure and IPT. I am using some of these concepts and techniques in my own treatment of patients and am curious about how other people approach grief as a clinical issue. Also, what articles or books on the topic would you recommend? See below for some of the work by Shear. Thanks.

"Complicated grief" by Shear in NEJM 2015
http://www.nejm.org/doi/full/10.1056/NEJMcp1315618

"An attachment-based model of complicated grief including the role of avoidance" by Shear in Eur Arch of Psych & Clin Neurosci 2007
http://www.ncbi.nlm.nih.gov/pubmed/17629727

Two RCTs of complicated grief treatment by Shear
http://www.ncbi.nlm.nih.gov/pubmed/15928281
http://www.ncbi.nlm.nih.gov/pubmed/25250737

There are definitely problems with applying Kubla-Ross too rigidly as with any purportedly universal theory, but it is a good starting point in conceptualizing and treatment. Just letting the patient know that grief is a process and giving them an example of some of the feelings that they will experience as they go through it can decrease anxiety. It is especially helpful to let them know that anger is often a part of the process as many people have difficulty with that part. One important aspect of grief is that it is very personal and many people get frustrated as they go through it because others are trying to tell them what they should feel, how they should act, and how long it takes. My experience is that a major loss results in a year of major emotional and functional disruption as they go through each of the dates and markers, the second year is when the person begins stop reeling and the new life without that person starts to be rebuilt. Prior losses, disruptions to attachment, and other pathological processes have the potential to get person stuck in their process and the better I understand the person's interpersonal style the better I can help them become unstuck. A lot of patients get stuck because they want to "feel better" or "get past it". Not going to happen with a big loss and paradoxically when people accept that, they feel some relief. There are a lot of other aspects of grief treatment and most of them I have learned from my patients and I think that might be the most important thing to remember as a clinician is that it is the patient's loss and it is not our job to fix it especially since we can't. Rather it is a privilege to be allowed to share such a personal and intimate process. I should write a book about grief and call it "It's okay to feel ___".