1. Bereavement

2. Holmes and Rahe (1967): most stressful life event: death of spouse

3. 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.

4. Feelings Sadness Anger Guilt & self-reproach Anxiety Loneliness
Fatigue
Helplessness
Shock
Yearning
Emancipation
Relief
Numbness

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

6. 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; and
6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person.

7. 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

8. Cognitions Disbelief Confusion Preoccupation Sense of presence
Hallucinations

9. Behaviors Searching & calling out Sleep disturbance 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

10. 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 spouse;
41% were still yearning for their spouses, and
25% had looked for their spouse in familiar places.
* Chochinov, Holland and Katz. (1998) Bereavement: A special isssue in oncology. In Psycho-oncology
Lindemann (1944): acute grief lasts for about 6 weeks.
Clayton etal (1974): found crying, depressed mood, and sleep disturbance as the cardinal symptoms during the first year of bereavement. Depression was a problem for 45% of the survivors at some time during the first year, and 13% were still depressed at a year.

11. Depression
Overall about 20% of bereaved individuals will develop a psychiatric disorder, primarily depression *
* Chochinov, Holland and Katz. (1998) Bereavement: A special isssue in oncology. In Psycho-oncology.

12. 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
* Chochinov, Holland and Katz. (1998) Bereavement: A special isssue in oncology. In Psycho-oncology.

13. 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
Benight etal. (2001). Bereavement coping self-efficacy in Cancer Widows. Death Studies, 25: , p

14. 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 anticipated.
Generated considerable debate over anticipatory grief.
Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry ; 101:

15. 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 is a student of John Bowlby.
Psychologist. She did a classic series of experiments.

16. 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 mother.
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 smoothly.
By contrast insecurely attached children are generally anxious and insecure; they are often underachievers, doing less well at school

17. Parkes & Weiss (1983) Unexpected loss syndrome
Dependent grief syndrome
Conflicted grief syndrome
CM Parkes and RS Weiss (1983). Recovery from Bereavement. New York: Basic Books.
Unexpected loss syndrome: pattern of grieving in which attempts to avoid, repress, and delay grief continue for months or years, but do not prevent high levels of anxiety and tension.
These reactions can be reviewed as a type of PTSD.
3 symptom clusters:
A. Intensive recollections of the dying: flashbacks, nightmares, intrusive memories
B. Detachment restricted affect, sense of a foreshortened future, decreased interest in activities, and avoidance of feelings, thoughts or activities which arouse recollections of the event
C. Persistent hyperarousal:difficult sleeping, irriability, and difficulty concentration
Dependent Grief Syndrome: The self-esteem, confidence, and identity of one or both partners was dependent on the relationship; when this system is disrupted, the survivor is left with a gaping wound.
Conflicted Grief Syndrome: survivors had ambivalent feelings towards the deceased. The angry component of the ambivalence is turned inward resulting in guilt, self blame, and self derogation. (critics: nature of this syndrome unclear)
Classic bereavement study (1983)

18. 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.

19. 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 life.
The experience is characterized by feelings of anguish and being overwhelmed (Parkes, 1987).

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

21. 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

22. Janoff-Bulman (1992)
3 basic assumptions: beliefs about ourselves, external world, and the relationship between the two.
The world is benevolent, meaningful. The self is worthy.
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 equilibrium.
Cognitive accommodation strategies include revising and restructuring assumptions (Rando, 1999).

23. Rondo (1984): to understand the unique nature and meaning of loss we must view the loss from the individual’s frame of reference: age, psychosocial context, and sense of meaning and fulfillment, characteristics of the relationship and roles the deceased performed in the mourner’s life, personal behaviour, presence of other life’s stressors.

24. 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 life.
“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 process.
Shift back and forth between two contrasting modes
Extent to which the bereaved person would engage in loss- or restoration-oriented processes depends on various factors e.g. personality, cultural expectations and practices.

25. The Four Tasks of Mourning
Worden, 1991

26. (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

27. (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

28. (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 world
Adjust to the loss of roles played by the deceased
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
Case of Wong Ying Ying
Helpless: not tell direction of east and west, follow tram
Fall easily.
Brassier. People tell her to look ahead. Find meaning.

29. (4) To Emotionally Relocate the Deceased and Move on With Life
Vs. holding on to past attachments
“A survivor’s 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.
Bring along purse, photo. For remembrance.
Stuck: stay home all day, no interest to go out. Case of Lam Oi Fong

30. Identifying the At-Risk Bereaved

31. 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

32. 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.

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

34. Complicated Grief (Cont’d)
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 deceased.

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

36. 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 Deceased
Principle Four: Facilitate Emotional Relocation of the Deceased

37. Counseling Principles
Principle Five: Provide time to grieve
Principle Six: Interpret “normal” behavior
Principle Seven: Allow for individual differences
Principle Eight: Provide continuing support
Principle Nine: Examine defense & coping styles
Principle Ten: Identify pathology and refer

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

39. 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 one’s 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

40. 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 reality.
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

41. 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

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

43. Thank you.