Table of Contents
Virtually, all lives entail a loss of a loved one, and practically, all psychologists’ practice engages parents for whom a loss of a child causes peculiarly prolonged and distressing grief. The growing amount of literature on complicated grief alternatively referred to as prolonged grief disorder (PGD), traumatic grief and pathological grief points that grief causes significant emotional and physical effects on parents and families (Boelen, de Keijser, van den Hout, & van den Bout, 2007; Dyregrov & Regel, 2012; Jordan & Litz, 2014). For that reason, there has been significant development in evidence-based grief assessment instruments and interventions. This paper critically analyses the assessment, treatment and social context when approaching clients with complicated or prolonged grief due to loss of their son 8 years ago. The paper begins with an overview of both uncomplicated and complicated grief reactions. The analysis then describes the diagnostic or assessment criteria for complicated grief. Next, the paper outlines the treatments that have demonstrated efficacy in managing complicated grief symptoms. The paper concludes by discussing the therapeutic principles, best practice guidelines and ethical considerations taken by practicing psychologists. The research achieves this effect through a critical analysis of scholarly articles, particularly peer reviewed journals.
An Overview of Uncomplicated Grief Reactions
As mentioned earlier, this paper focuses on the parents’ reaction to the loss of a child through death. The loss of child has a profound effect on the psychological functioning of the parents and family (Boelen & van den Bout, 2008). Parents often find themselves longing intensely for the lost child. For example, the clients under study lost a son 8 years ago but still yearn for him. Typically, this grief begins to subside weeks, months, or couple of years after the loss. Parents progressively reengage in delightful activities and reattach with each other. In other words, grief should begin to abate several months after the loss, whereby grief and depression symptoms reduce (Shear, Frank, Houck, & Reynolds, 2005). In fact, some parents do not exhibit significant impairment or distress shortly after their loss (Jordan & Litz, 2014). According to Jordan and Litz (2014), the decline of distress shortly after the loss does not guarantee that the parent will experience resurgence of grief. It follows that the bereaved should confront loss stressors by learning to cope with the incidences of loss stressor. For example, parents may seek new pleasurable activities that serve as sources of emotional support. Failure to complete restoration-focused tasks and coming to acceptance of the fact that the lost is irrevocable, parents may suffer from prolonged grief disorder.
Despite the natural resilience and recovery demonstrated by most parents, psychotherapy aims at alleviating grief reactions irrespective of the chronicity or severity. According to Currier, Neimeyer and Berman (2008), long-term control conditions produced significant reductions in distress and grief symptoms compare to active psychotherapies. Advocates for normative (uncomplicated) grief counselling contend that there is insignificant research on the inefficiency of interventions designed to redress normative grief reactions (Dyregrov & Regel, 2012; Malkinson, 2010). However, there is consensus that universally applied grief treatments are likely to be ineffectual; hence, treatment of uncomplicated grief should focus on clinically or self-referred patients (Wetherell, 2012). For this reason, this paper will employ a flexible approach to the couple’s condition because each client has a unique story behind the persistence of grief symptoms. The section that follows concentrates on understanding and identifying complicated grief before describing the appropriate assessment instruments and treatments for the couple that have illustrated efficacy in managing the problem.
Complicated grief or prolonged grief disorder is marked by persistence in bereavement difficulties (Jordan & Litz, 2014; Neimeyer & Currier, 2009). In other words, distress and grief symptoms grow instead of subsiding with time. The clients in the case under analysis meet this definition because it is 8 years after the loss of their child. Studies indicate that prevalence of complicated grief varies between 10 % and 20 % of bereaved individuals (Shear, Frank, Houck, & Reynolds, 2005). Some of the risk factors linked to complicated grief include a history of anxiety disorder, a history of loss or trauma, a violent cause of the loss such as suicide or homicide, and inadequate social support after the loss (Dyregrov & Dyregrov, 2008; Mancini, Griffin, & Bonanno, 2012). Based on these observations, the diagnosis and assessment will imply the analysis of the mentioned risk factors because they have a greater influence in predicting the likelihood of developing complicated grief. Additionally, these factors seem to predispose parents towards intense yearning for the deceased, frustrating the functional restoration and loss-processing task that normally results in abatement of grief symptoms. Arguably, the failure of the couple to come into terms with the loss of their son contributed to the prolonged emotional reactivity to the loss-stressor. Additionally, the couple’s unwillingness to engage in new pleasurable activities as well as an aversion to seeking social or group-base psychotherapy may have constricted their behavioral repertoire and prevent them from identifying new sources of pleasure. Furthermore, being disengaged from the social arena may have narrowly fixed the couple’s attention on the past and their meaning of life before the loss.
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Diagnostic Criteria and Assessment Instruments
Despite the fact that psychologists have noted the unique phenomenology of complicated grief reactions, detailed research on its clinical features that have accumulated over the past decade and the previous versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) are yet to include diagnoses corresponding to complicated grief problems. However, they acknowledge that traumatic grief or prolonged bereavement as one of the reasons for individual to seek mental health care. Table 1 represents the diagnostic criteria that will be used for the clients under study.
Diagnostic Criteria for Parents with Suspected Complicated Grief
|Diagnostic Criteria for Complicated Grief|
|A||Death of a significant other|
At least one of the following observations is registered for over a year after the loss:
1. Persistent yearning for the son
2. Preoccupation with the departed son
3. Intense sorrow in response to the loss
4. Preoccupation with the circumstances leading to the death
At least six of the following observations on most days for more than 12 months after the loss:
1. Difficulty in accepting the loss
2. Emotional numbness
3. Avoidance of the loss-stressors
4. Feeling of emptiness or meaningless life after the loss
5. Difficulty in moving on with life, including pursing interests and making friends
6. Anger and bitterness related to the loss
7. A desire to die to be with the son
8. Confusion about their role on life
9. Difficulty to plan for the future
|D||The interruption of the grief causes clinically significant distress and impairment in occupational and social functioning|
|E||The grief symptoms must be out of proportion with religious or cultural norms|
|F||The interruption induced by the loss is not accounted for by PSTD and major depressive disorder.|
The criteria are based on the recently released edition of DSM and other evidence-based researches that have proven efficacy in managing complicated grief (American Psychiatric Association, 2013; Jordan & Litz, 2014; Wittouck, van Autreve, Jaegere, Portzky, & Heeringen, 2011; Zisooki & Shear, 2009). It is important to note that the disruption caused by grief can trigger numerous disorders including posttraumatic stress disorder (PTSD) and major depression (Boelen & van den Bout, 2008; Shear, Frank, Houck, & Reynolds, 2005). For that reason, it is important to identity co-occurring disorders for effective diagnosis. Even though comorbidity is widespread, complicated grief may occur in isolation and is marked by reduced quality of life, sleep disturbance, occupational and social impairments, and increased risk of cancer and cardiac events. In contrast to major depression and PSTD, which is characterized by anger, guilt, fear and shame combined with exaggerated reactivity, complicated grief is marked chiefly by emptiness and yearning. Expectedly, the couple may be experiencing voluntary and intrusive thoughts about various aspects of their relationship with their son including the time they spent playing together and other activities they long for.
Given that nearly 30% of individuals seeking mental health care show moderate levels of complicated grief symptoms (Jordan & Litz, 2014), assessing for unresolved grief in the clients is a wise clinical practice even if the conditions do not allow full diagnostic criteria. One of the assessment instruments that will be used to identify significant clinical symptoms of complicated grief is the Inventory of Complicated Grief (ICG). The ICG entails statements regarding grief-related behaviors and thoughts and response options indicating various levels of severity. In line with the guideline for complicated grief, the ICG should be administered for around 6 to 12 months after the loss. In the present context, where time is scarce, the Brief Grief Questionnaire (BGQ), which is a briefer instrument than the ICG, will be used (Shear, Frank, Houck, & Reynolds, 2005).
Treatments for Complicated Grief
In meta-analysis of RCTs of psychotherapy for adults with complicated grief, Wittouck, van Autreve, de Jaegere, Portzly and van Heeringen (2011) and Boelen and van den Bout (2008) found that cognitive-behavioral grief-targeted (CBGT) interventions were more effective than supportive and other non-therapeutic interventions for managing complicated grief symptoms. In identifying and recommending complicated grief psychotherapies for the client, the following subsections emphasize evidence-based interventions. In other words, the section highlights interventions that have received strong support and acceptance in RCTs. In absence of a universal diagnostic criterion and assessment instrument for complicated grief, researches vary in their inclusion criteria (Currier, Neimeyer, & Berman, 2008). For that reason, variations in the outcomes of the psychotherapies may partly be due to variations in the chronicity or severity of complicated grief that underlined each research sample.
Individual psychotherapy. In a ground-breaking study by Shear, Fran, Houck and Reynolds (2005), a significant portion of the participants (men and women) who received either interpersonal therapy (intervention effective for depression) or multifaceted treatment customized to traded complicated grief showed that grief-specific treatment is more effective than interpersonal therapy. In other words, individual psychotherapy is more effective in reducing grief symptoms than interpersonal therapy. Additionally, pilot studies have also pointed that the grief-specific therapy used in this pioneering study is efficacious in various populations diagnosed with complicated grief including people with comorbid substance use disorders (Jordan & Litz, 2014). For this reason, a multifaceted grid-specific therapy will be tailored for the client. The tailored therapy will include components that motivate the couple to address the restoration and loss-focused tasks of bereavement. Additionally, key therapeutic work will be done during the 1-hour weekly sessions. At the beginning, therapeutic work will center on psychoeducation regarding grief stressing the significance of the client processing the loss and striving to restore life functioning. During these sessions, the clients will narrate the shared history with their son and brainstorm the present day aspirations and life goals. Restoration-focused tasks for the client will include a written plan for moving towards meaningful life aspirations and restoring pleasurable activities.
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The other individual psychotherapy that has demonstrated considerable efficacy for complicated grief blends exposure and cognitive reform mechanisms (Boelen, de Keijser, van den Hout, & van den Bout, 2007). The authors demonstrated that this variant of individual psychotherapy was better than supportive counselling. In line with this study, the client will receive cognitive behavioral treatment of 6 weeks sessions of exposure therapy followed by 6 weeks sessions of cognitive restructuring. Expectedly, the exposure component is likely to produce better symptom reduction than the cognitive component of the treatment (Boelen, 2006). In contrast to the exposure component, which focuses on restoration, the cognitive component will help the client to identify and counter negative emotions that occur indeed every day.
Group-based psychotherapy. Group-based psychotherapies can reduce grief symptoms compared to conventional treatment methods, especially in cases with comorbid complicated grief (Piper, Ogrodniczuk, Joyce, Weideman, & Rosie, 2007). It is significant to note that group-based psychotherapies are anchored on the success elements of individual complicated grief therapies that have demonstrated efficacy in other RCTs (Jordan & Litz, 2014; Shear, Frank, Houck, & Reynolds, 2005). In reference to these studies, the key components of the group-based psychotherapy recommended for the client will entail psychoeducation regarding the grieving process, building motivation for a positive change, confronting the loss, understanding and minimizing avoidance, and confronting negative thoughts.
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Several open-label trial and case series have suggested the use of selected antidepressants to help in the management of grief symptoms (Jordan & Litz, 2014). Until detailed evidence from significant controlled trials is available, the efficacy of pharmacotherapy in the treatment of complicated grief will remain uncertain. However, there is consensus that pharmacotherapy will be a valuable adjunct to the existing psychotherapy approaches in the treatment of complicated grief. For this reason, the treatment for the client will use a combined approach including psychotherapy and pharmacotherapy.
Best Practices and Ethical Concerns
In the current sociocultural context where evidence-based practices are required to provide empirical justification for claims of treatment efficiency (Larson & Hoyt, 2007), grief counselors and therapists are required to uphold the highest standards of professionalism including maintaining patient-doctor confidentiality (Gamino & Ritter, 2009). To that end, the therapist will prevent boundary violations in clinical practice (Gutheil & Brodsky, 2008). For instance, The Best Practice and Ethical Practice by the American Counselling Association (ACA) are designed to clarify the application ACA's Code of Ethics in in group-based psychotherapies by charting the responsibilities and scope of practice group psychotherapists while covering respective interventions and strategies. When screening the clients as potential candidates for complicated grief therapy, it is important to guarantee the confidentiality of the shared information to improve their engagement. Additionally, the therapist should employ risk-factor algorithm to identify factors that might be controlled or influenced by psychotherapy, as well as factors that cannot be controlled by the therapist. To recap, the therapist will maintain high level of professionalism by referring to professional standards and codes of ethics.
Grief following loss through death is an expected human reaction as well as a more individual-based reaction occluding within a sociocultural context. Loss of a child constitutes one of the major events encountered by psychologist or therapists. Given that unending grief due to loss of a child induces profound emotional effects on parents, it is important to identify evidence-based assessment instruments and treatments to alleviate the misery brought by complicated grief. The variation as well as comorbidity of symptoms translates to a variation in the treatment methods. Additionally, the absence of a universal diagnostic criterion also calls for a tailored approach to treatment. For this reason, a therapist should tailor intervention based on the grief symptoms and the sociocultural context of a client. A hybrid of psychotherapy and pharmacotherapy is recommended because the latter serves as an adjunct of the former. Psychotherapies can be either individual-based or group-based.