Psychological Intervention For Unresolved Grief
By Edward J. Callahan, Ph.D.
NCP Clinical Quarterly 5(2/3): Summer 1995
Dealing with death is an unavoidable aspect of human experience. While grieving is usually painful, its disruptiveness is ordinarily time-limited and manageable. The course of grieving reflects prior experience with loss and the selection and use of coping techniques. In a culture with no single ritual for response to loss, many people use avoidance to cope. However, coping by avoidance is associated with poor adjustment to loss (1). Unresolved grief can present by self or family identification, or it can lead an individual to seek medical help for undocumentable complaints (2).
The current paper grows out of treating unresolved grief in primary care, but treatment would be similar across settings. Treatment of unresolved grief reflects how grief is conceptualized. The intervention described below stems from a behavioral conceptualization of grieving (3).
Behavioral Conceptualization Of Grieving
Grief is observed among all social living creatures (4). Developmental theorists such as Bowlby (5) argue for the importance of learning secure attachment in early development with gradual shaping of increasing separation from parents as preparation for loss. A disturbance in attachment learning would predispose an individual or organism to problems with loss. Loss is an aversive event which affects people on biological, behavioral and cognitive levels.
In the animal laboratory, disruption of ongoing learning occurs with the introduction of any aversive event including shock, noise, time out from positive reinforcement, etc. Separation functions as an aversive event as well. For example, the withdrawal of rat pups from their mothers produces profound physiological and behavioral changes reflecting distress on the part of both the pups and the mother (6). When that separation is permanent, a longer term and more powerful impact is expected.
Human grieving can be understood by considering behavior associated with traumatic aversive events. Classically conditioned stimuli associated with the deceased were once predominantly positive, but may now provoke uncomfortable physiological, behavioral, and cognitive changes as conditioned emotional responses (CERs). Continued exposure to CERs results in a diminution of the disruptive power of those stimuli. Avoidance of the stimuli leaves the disruptive power of the stimulus intact; this disruption can even increase over time.
Aversive events can be made less powerful through adaptation or made more powerful through sensitization. In adaptation, the aversive event is presented in small doses with gradual increases in intensity. By pairing electric shock with the availability of reward, Miller observed that animals withstood greater intensity shock over time without a disruption in performance (7). Conversely, when the aversive event was presented rapidly and at great intensity, without being linked with a reward, the animal's reward-seeking behavior was increasingly disrupted by lesser and lesser intensity aversive events. This phenomenon is known as sensitization (8). In human terms, individuals can learn to adapt to loss across the life span; for example, elderly widows are less disrupted by the death of their husbands than younger widows (9). Losing young children appears to be the most disruptive loss that parents can experience. Similarly, young children whose parents die are profoundly affected by these losses which shape the later life course (10).
Those who experience loss that is out of the normal developmental sequence and those who learn avoidance as a primary coping technique may be particularly vulnerable to unresolved grieving. If loss is an aversive event which must be confronted to allow resolution, then avoidance or escape from grief stimuli increases the probability of unresolved grief.
Individuals who cope using avoidance may fail to experience and hence, work through, their loss. Under such circumstances, a pronounced focus on bodily symptoms may occur, making presentation to primary care a possible course for unresolved grief. "Somatic amplification" can be a primary means of medical attention-seeking for personally unrecognized grief (11). Not all unresolved grief will manifest in somatic complaints. However, it is important to have a sense of what pathologic grief is in order to allow effective intervention.
Pathological Grief
Pathological grief is any response to loss which is excessive in duration, intensity, or topography. However, there is no clear definition of normal grief. Length of time spent grieving over a loss does not define unresolved grief alone -- degree of disruption of function must be considered as well. A normal response can include a long term sense of loss, often persisting through a lifetime. Grievers are commonly assumed to take a full year to work through grief. However, some widows experience their most intense symptoms of loss in their second year of grief (12). If individuals experience extreme loss of function, unresolved grief can be noted even soon after a loss. Time is an element also -- a person who becomes dysfunctional with tears and cannot cope for two to three days after a loss is accepted as having a normal response to the loss. Becoming dysfunctional one to two years later would be an excessive response to the loss.
Any grieving response which involves physical harm to self or others may be pathological grief. A woman who had been anticipating the death of her alcoholic mother appeared after her mother's death with deep scratches on her face and chest. She agreed to do no further harm to herself without first consulting her therapist. This grief response was considered excessive in our culture; in other cultures, such self scratching is expected. Thus, in determining whether grief is pathological, one must consider time course, intensity, form of the grief and the culture. While the absence of a clear definition of pathological grief is unsettling, it should not prevent consideration of treatment.
Intervention
The basic rationale for treatment of unresolved grief is similar to that of the rationale for flooding procedures. Flooding involves prolonged exposure to intense stimuli which had been avoided (13). Through exposure, these stimuli lose their power and adaptive functioning returns. Special considerations in flooding with human clients around grieving are outlined below.
Rationale
Flooding is a corrective procedure used when excessive avoidance and escape prevent the griever from prolonged exposure to the feared stimuli, thus maintaining disruption of behavior. In the animal laboratory, flooding can be accomplished rapidly simply by blocking escape in the presence of the aversive stimulus. With humans, flooding requires moderated presentation of aversive events with gradually increasing exposure. Moderation maintains the cooperation of the patient. A therapeutic rationale to enlist the patient is a key part of the treatment plan: "Wounds fail to heal if not adequately cleaned and exposed to the air. If you continue with that wound unexposed and avoid the cleaning process, the wound can deepen and fester. With unresolved grief it is important to open the wound by exposure to many reminders of the loss. This painful exposure will lead step by step to thorough and healthy healing."
Critical to this therapeutic rationale is that it counters accepted theory about loss. The Freudian notion was that one had to end attachment to the person who died in order to make a successful adjustment to life (14). An alternate rationale is to attach to the deceased so they no longer need to be avoided: Saying hello again rather than saying good-bye (15). Through discussion the therapist helps the griever recall what was special about the lost relationship so that the loss can be more fully appreciated. Discussion of the relationship facilitates exposure to stimuli associated with the loss.
Taking a Detailed History
Another powerful way of accomplishing extinction around loss is to ask the patient to present the story of the loss in great detail. This story can describe the relationship, bringing out issues that may not have been discussed for years.
Immigrants seen for war-related Post Traumatic Stress Disorder often report that they have never told their story to anyone else. Merely taking the history begins the process of flooding and immersion in the stimuli associated with the loss(es). Information about the relationship with the losses will become apparent.
A stumbling block to experiencing emotions around loss can be anger. Children from abusive and violent homes may have more difficulty grieving the loss of a parent. Without safe expression of anger while the parents lives, the grieving child may have difficulty experiencing a sense of loss. Anger can trigger feelings of guilt since attacks on the deceased are not accepted culturally: Grieving thus becomes more complicated. Recognizing anger at the deceased can be helpful. Use of the Gestalt "empty chair technique" serves as a form of flooding for dealing with anger. With this technique, the deceased can be invited to participate in the session and sit quietly in an empty chair. The therapist can model expression of anger if needed. Similarly the patient can write the deceased a letter, expressing feelings not stated earlier. This letter can be sent through ritual burning or any way that symbolically make sense to the patient, with physical burning reflecting a parallel extinction of CERs. Thus, focus on unresolved attachment may be a necessary beginning to grieving. By expressing anger, the name and image of the deceased comes up more frequently and prompts extinction. Images and memories are brought to the fore rather than being avoided both in therapy and outside. Expression of anger appears to facilitate the focus on the deceased as an opening for a wider array of affective response to the person who died. This wider spectrum of emotion may include a sense of loss.
Pacing
Pacing is critical in flooding therapy. Excessive exposure to aversive images can lead to therapeutic dropout: The patient has an established pattern of avoidance as a means of coping. Indeed, excessive exposure may be dangerous with actively suicidal patients. Thus it is critical that the exposure be paced so that the client does not become overwhelmed. However, experiencing strong emotion is often reported as very therapeutic and sets the stage for the experience of greater emotion. While flooding in the laboratory emphasizes full exposure of events at high intensity to force extinction, the therapist modulates exposure to aversive events in gradually increasing intensity which is not overwhelming to the patient.
Therapeutic Contact
Patients with unresolved grief may have suicidal ideation or plans. These need to be determined early in the therapeutic relationship to ensure development of a safe environment for flooding. A written contract may be needed but is important to obtain at least verbal agreement that the patient will not hurt him or herself without first calling the therapist. Thus, the therapist must be available to the patient in a controlled fashion should a crisis arise. The patient can agree to write out antecedents and potential coping efforts whenever a suicidal thought arises as a bridging step in this process aimed toward greater patient self-control. Patients can use this process to increase their understanding of their urges to hurt themselves and to decrease the need to call the therapist. Contacting and writing can serve as therapeutic tools for fighting against avoidance.
Relaxation Training
Relaxation training was initially advocated with implosive therapy and flooding. Many therapists later decided that a relaxed state is not necessary for these procedures to work. Relaxation training, however, may be useful in bringing the patient to a comfortable place for imagery presentation to provide a safe place to return the patient. Much of the work with unresolved grief involves bringing the patient in conversation to the same places (in thought and emotion) that formerly were reachable only by presenting strong imagery. Once able to reach this level of emotional arousal through discussion, relaxation training is no longer necessary.
Guided imagery can be used for selective aspects of the story around the loss. The elements to be dealt with in guided imagery are selected from the areas of the patient's story in which the greatest avoidance was triggered.
Teaming Social Support
To expand the therapeutic process beyond the four walls of the treatment room, referral to a bereavement group or other form of support can be useful. Similarly, inviting the patient to discuss the loss with others facilitates extinction.
Conclusion
Unresolved grief may result from earlier sensitization to loss and an overuse of avoidance of loss stimuli for coping. A modified flooding approach can help facilitate coming in contact with what has been avoided, allowing resolution of the loss. Clinical issues in this flooding process were discussed.
References
1. Hamilton-Oravetz, S. (1993). Patterns of attachment and grief in primary care medicine patients. Dissertation Abstracts International, 53,(n8-B), 43-72.
2. Stack, J.M. (1982). Grief reactions and depression in Family Practice - Differential diagnosis and treatment. Journal of Family Practice, 14, 271-275.
3. Brasted, W.S., & Callahan, E.J. (1984). A behavioral analysis of the grief process. Behavior Therapy, 15, 529-543.
4. Averil, J.R. (1968). Grief: Its nature and significance. Psychological Bulletin,70, 721-748.
5. Bowlby, J. (1988). A secure base. New York: Basic Books.
6. Hofer, M.A. (1975). Survival and recovery of physiological functions after early maternal separation in infant rats. Psychosomatic Medicine, 15, 475-480.
7. Miller, N.E. (1960). Learning resistance to pain and fear: Effects of overlearning, exposure, and rewarded exposure in context. Journal of Experimental Psychology, 60, 137-145.
8. Napalkov, A.V. (1963). Information process of the brain. In N. Weiner & J.C. Schade (Eds.), Progress in brain research: Nerve, brain and memory models (pp. 59-69).
9. Parkes, C.M. (1972). Bereavement. London: Tavistock.
10. Sanders, C.M. (1995). Grief of children and parents. In K.J. Doka (Ed.) Children mourning; mourning children. Washington, D.C.: Hospice Foundation of America, pp. 69-84.
11. Barsky, A.J. (1992). Amplification, somatization and the somatoform disorders. Psychosomatics, 33, 28-34.
12. Zisook, S., & Schucter, S.R. (1993). Major depression associated with widowhood. American Journal of Geriatric Psychiatry, 1, 316-326.
13. Ramsey, R.W. (1979). Bereavement: A behavioral treatment of pathological grief. In P.O. Sjoden, S. Bates, & W.S. Dockins (Eds.), Trends in behavior therapy, (pp. 214-248). New York: Academic Press.
14. Freud, S. (1994). Mourning and melancholia. In R.V. Frankiel (Ed.) New York: New York University Press, pp.38-51.
15. White, M. (1988). Saying hello again: The incorporation of the lost relationship in the resolution of grief. Dulwich Centre Newsletter, Adelaide: South Australia.
Edward J Callahan, Ph.D. is Professor and Director of Behavioral Medicine in the Department of Family Practice at the University of California at Davis.
|
