General Aspects of Grief Therapy
Most of the support that people receive after a loss comes from friends and
family, but physicians and nurses can identify and orchestrate mechanisms for
support and healing and make an important difference.[1] For those who are
experiencing particularly difficult problems in their bereavement, specific
interventions may be considered. Psychotherapeutic interventions for grief
vary widely and include individual and group methods. Treatment methods found
to be effective with various populations of bereaved individuals include
time-limited dynamic psychotherapy, cognitive-behavioral intervention,
hypnotherapy, and trauma desensitization.
Grief counseling and grief therapy are distinguished from each other.[2] Grief
counseling guides uncomplicated (normal) grief to a healthy completion of the
tasks of grieving within a reasonable time frame, usually without a
time-limited template. Grief counseling can be provided by professionally
trained individuals or in self-help groups in which bereaved persons offer
help to other bereaved persons. All of these services can be offered in
individual or group settings. Grief counseling seems to be most useful for
bereaved persons who perceive their families as unsupportive or who, for
other reasons, are thought to be at special risk.
The goals of grief counseling as outlined by one author [2] include the following:
- Helping the bereaved to actualize and to accept the loss, most often by
helping him or her to talk about the loss and the circumstances surrounding
it.
- Helping the bereaved to identify and express feelings related to the
loss (e.g., anger, guilt, anxiety, helplessness, or sadness).
- Helping the bereaved to live without the deceased and to make independent
decisions.
- Helping the bereaved to withdraw emotionally from the deceased and to begin
new relationships.
- Providing support and time to focus on grieving at critical times such as
birthdays and anniversaries.
- Normalizing appropriate grieving and explaining the range of individual
differences in this process.
- Providing ongoing support, usually not on a time-limited
basis (as with grief therapy).
- Helping the bereaved to understand his or her coping behavior and style.
-
Identifying problematic coping mechanisms and making referrals for
professional grief therapy.
Bereavement is among the most disruptive of all life processes, and it is
difficult to put an arbitrary limit on its expected duration.[3]
Grief therapy is used with people who have abnormal or complicated grief
reactions (refer to the Complicated Grief section of this summary for more
information). The goal of grief therapy is to identify and resolve the
conflicts of separation that interfere with the completion of the tasks of
mourning. The conflicts of separation may be absent or masked as somatic or
behavioral symptoms; delayed, inhibited, excessive, or distorted mourning;
conflicted or prolonged grief; or unanticipated mourning (though this is
usually not present with cancer deaths).
Grief therapy can be provided on an individual basis or in group therapy.
Regardless of setting, a therapeutic contract is established with the patient
to define the time-limited basis of the therapy, any fees, and the
expectations and focus of the therapy. If the patient presents with physical
complaints, medical illness must be ruled out.
Grief therapy requires talking about the deceased and recognizing whether
there are minimal or exaggerated emotions surrounding the loss. Persistently
idealized descriptions of the deceased can be indicators of the presence of
more ambivalent, angry feelings. Grief therapy may allow the individual to see
that anger, guilt, or other negative or uncomfortable feelings do not
preclude more positive ones, and vice versa.
The focus of grief therapy depends on an assessment of the four tasks of
mourning. Human beings tend to make strong affectional bonds or
attachments with others.[2] When these bonds are severed, as they are in
death, a strong emotional reaction occurs. The tasks of mourning serve as a
means whereby grief may be resolved. After one sustains a loss, certain tasks of mourning must be accomplished for equilibrium to be
established and for the process of mourning to be completed.[2] Adaptation to
loss may be seen as involving the following four basic tasks:
- Acceptance of the reality of
the loss.
- Working through and experiencing the physical and emotional pain
of grief.
- Adjusting to an environment in which the deceased is missing.
- Emotionally relocating the deceased and moving on with life.
It is
essential that the grieving person complete these tasks before mourning can be
accomplished.
Six tasks of grief [4] have been identified to help focus problem-specific
therapeutic interventions for bereaved spouses:
- Develop the capacity to
experience, express, and integrate painful grief-related affects.
- Use the
most adaptive means of modulating painful affects.
- Establish a continuing
relationship with the deceased spouse (not necessarily to decathect from
the dead person).
- Maintain one’s own health and continued functioning.
- Achieve a successful reconfiguration of altered relationships and understand
why others may have difficulty empathizing with the bereaved.
- Achieve
an integrated, healthy self-concept and stable worldview.
Complications in grief may arise because of unresolved grief related to
earlier losses. The grief from these previous losses must be managed so that the current grief can be resolved. Additionally, identification of
transitional or linking objects that allow the relationship with the deceased
to be maintained externally is useful because the objects may be interrupting
successful completion of the grieving tasks. One author [5] notes that grief
therapy includes dealing with resistances to the mourning process, identifying
unfinished business with the deceased, and identifying and accommodating
secondary losses resulting from the death. Ultimately, the bereaved is helped
to accept the finality of the loss and to picture what his or her life will be
like after the bereavement period. It is helpful to acknowledge that repetition may
be a part of treatment, but only when in the service of working through the
grief.
References
-
Casarett D, Kutner JS, Abrahm J, et al.: Life after death: a practical approach to grief and bereavement. Ann Intern Med 134 (3): 208-15, 2001.
[PUBMED Abstract]
-
Worden JW: Grief Counseling and Grief Therapy. New York: Springer Publishing Company, 1991.
-
Zisook S: Understanding and managing bereavement in palliative care.. In: Chochinov HM, Breitbart W, eds.: Handbook of Psychiatry in Palliative Medicine. Oxford: Oxford University Press, 2000, pp 321-34.
-
Shuchter SR, Zisook S: Treatment of spousal bereavement: a multidimensional approach. Psychiatr Ann 16 (5): 295-305, 1986.
-
Rando TA: Treatment of Complicated Mourning. Champaign: Research Press, 1993.
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