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CHAPTER

When Grief Goes Awry

Complicated Grief

■ Nature of the Beast

■ Traumatic Complicated Grief

■ Contemporary Thinking about Traumatic Complicated Grief

■ Treating Traumatic Complicated Grief

■ Chronic Complicated Grief

■ Risks and Risk Factors

■ Disenfranchised Grief

■ Coping

■ Emerging Models

All of us have or will experience significant loss. Profound grief is a normal reaction. As discussed in Chapter 10 , it is physically, emotionally, and psychologically challenging, but most of us get through it. The focus of this chapter is on what happens when grief goes awry—that is, when people for whatever reason can’t bounce back from their losses.

As you may recall from Chapter 10 , Colin Murray Parkes, one of the true pioneers in the field, coined the term complicated grief to describe reactions to loss that are experienced more severely or for a longer period of time than normal (Parkes, 1998a, 1998b). He suggested that experiencing a traumatic death, having had a conflicted relationship with the deceased, or having been overly dependent on the deceased puts bereaved people at higher risk for three forms of complicated grief he referred to as traumatic, conflicted, and chronic. Based largely on firsthand clinical experience, Parkes was the first modern grief expert to raise concerns about the possible health consequences of complicated grief, including early death, immune system impairment, posttraumatic distress, and feelings of profound depression.

A volunteer at the Vietnam Veterans Memorial comforts a Vietnam veteran who lost a comrade during the war.

In Chapter 10 we also discussed the new body of bereavement research, which challenged the old grief-work model—the stages, phases, and tasks of grief work—that has until recently been so influential in our thinking about the experience of normal grief (see Stroebe & Stroebe, 1987; Wortman & Silver, 1987, 1989; Bonanno & Kaltman, 1999, 2001). What does this emerging body of research have to say about complicated grief?

As discussed in Chapter 7 , we think that experiencing traumatic death, such as what happens as a result massive devastation, puts us at greater risk for experiencing the traumatic form of complicated grief.

NATURE OF THE BEAST

It seems quite clear that there is indeed a form of grief that is more troublesome than normal grief. Although most bereaved people get through the roller coaster of emotions associated with acute, or normal, grief bereavement experts now believe that between 10 and 15 percent of bereaved people experience complicated grief—grief so severe that it may require professional attention (Bonanno et al., 2002; Bonanno, Wortman, & Nesse, 2004; Ginzburg, Geron, & Solomon, 2002; Mancini, Prati, & Bonanno, 2011). The term complicated griefusually refers to reactions to loss that are significantly debilitating or that persist for a significant period of time.

The definitions and terminology associated with complicated grief continue to be in flux (Prigerson & Maciejewski, 2006; Neimeyer, 2006; Walter, 2006; Friedman, 2016; Lenferink & Eisma, 2018; Maciejewski et al., 2016; Heeke et al., 2017). The terms pathological, abnormal, morbid, neurotic, chronic, complicated, traumatic, prolonged, and several others have all been used to refer to similar phenomena. As you may recall, Parkes (1998a, 1998b) proposed three forms of complicated grief: chronic, conflicted, and traumatic. We have no evidence to support the existence of a conflicted form. However, there is evidence to support the existence of both chronic and traumatic experiences with grief sufficiently disturbing to justify diagnosis as mental disorders (see below).

Generally, persons with chronic complicated grief experience a persistent and disturbing disbelief about the loss and are resistant to accepting its painful realities (Byrne & Raphael, 1994; Middleton, Burnett, Raphael, & Martinek, 1996; American Psychiatric Association, 2011; Prigerson & Jacobs, 2001; Prigerson et al., 2009). The intense yearning and longing for the deceased often involves frequent waves of powerful, painful emotions, including anger and bitterness. The bereft tend to be preoccupied with thoughts of the deceased loved one, which are distressing and intrusive. As a result, people with complicated grief tend to avoid a range of situations and activities that remind them of their painful loss. As a result, their interest in, and engagement with, the usual activities of daily life are often limited or absent, making it hard for them to function in their usual roles. The reality of the death is not well integrated, and the powerful feelings people experience with normal grief are intensified and prolonged (Shear & Shair, 2005; Shear, 2015).

Persons experiencing traumatic complicated grief have been exposed to actual or threatened death, serious injury, or sexual violence (American Psychiatric Association, 2013). Although the DSM-5 includes “persistent complex bereavement disorder” for chronic grief, under the heading of “conditions for further study” the current edition does not include a specific diagnostic category for traumatic grief (American Psychiatric Association, 2013). Individuals who are experiencing traumatic grief are generally now diagnosed as having one of the “trauma- and stressor-related disorders,” like posttraumatic stress disorder, acute stress disorder, or dissociative disorder. In this chapter, we discuss both traumatic and chronic forms of complicated grief.

When mental health professionals assess people for suspected mental health problems, they often use the current edition of the Diagnostic and Statistical Manual, usually just called the DSM (and the suffix for whatever edition is current, e.g., DSM-5) (American Psychiatric Association, 2013). First, there was no diagnostic category in the previous edition of the manual used by the American Psychiatric Association (2000) specifically for complicated grief, yet the emerging research seemed clear in suggesting that a small but significant minority of bereaved people are plagued by intensely experienced and prolonged grief reactions. Second, there is also extremely strong evidence concerning the potential adverse health consequences of bereavement-related disturbance (Jacobs & Prigerson, 2000). Finally, interpersonal psychotherapy, which has been shown to be generally effective in treating a range of other mental health concerns, does not seem to be very effective in treating bereavement-related issues (Shear, Frank, Houck, & Reynolds, 2005). Holly Prigerson, for one, expressed the hope that a recognized diagnosis might lead to the development of more effective therapies (Prigerson et al., 2009), similar to what happened after posttraumatic stress disorder (PTSD) was recognized in the early 1980s.

FIGURE 11.1 Criteria for Proposed Bereavement Related Disorder in the DSM-5.

Source: This figure is based on APA, 2011.

Prigerson was a key figure in the fight for recognition. She and her team initially proposed the term traumatic grief for inclusion in DSM-5 because they thought it captured the essence of the phenomenon. Other investigators have grouped experiences of distressing separation and traumatic symptoms into a single syndrome they refer to as traumatic grief syndrome (Neria & Litz, 2004; Meagher, 2007). Prigerson and colleagues changed their proposed term from traumatic grief to complicated grief after the attacks on September 11 in order to avoid any possible confusion with posttraumatic stress disorder (Zhang, El-Jawahri, & Prigerson, 2006). Later, they changed it again to prolonged grief disorder (Prigerson et al., 2009).

The American Psychiatric Association was considering a new category, called something like bereavement-related disorder, for inclusion in the fifth edition of the Diagnostic and Statistical Manual (DSM-5), which addressed both traumatic and chronic experiences of complicated grief (American Psychiatric Association, 2011). Although a new “persistent complex bereavement disorder” has been included as an exploratory diagnostic category in DSM-5, there is no overarching category that encompasses both forms (Charney et al., 2018; Kaplow et al., 2012; Lenferink & Eisma, 2018). For an overview of a proposed “bereavement-related disorder” that was being considered, please see Figure 11.1 below.

TRAUMATIC COMPLICATED GRIEF

Pebbles in the Pond

In Chapter 7 , we looked at the experience of traumatic death. This exploration included several types of traumatic death: natural disasters, terrorism, suicide, and murder. In this light, When discussing murder, we briefly reviewed the case of Tariq Khamisa, a 20-year-old San Diego State University art student who was killed when delivering pizza (Dibsie, 1995; Hasemyer & Cantlupe, 1995). As you may recall, Tariq’s father later teamed up with the killer’s grandfather in an effort to do something about the problem of youth violence. So, in this sense, something good came of the murder. But some bad things also came of it. Let’s call these “pebbles in the pond” to signify the little ripples, or aftershocks, of the initial tragedy.

Tariq, called TK, was not an isolated individual. He had a family, friends, dreams, and no doubt problems, too. He met Jennifer at San Diego State and the two of them fell in love. They were engaged to be married. They decided to move out of the dorm and into their own apartment, but in order to do so they had to have money. So, they formed a pact. They would take turns working while the other went to school. Jennifer had just finished a stint working and TK had just started a job at DeMille’s Italian Restaurant, delivering pizzas. Jennifer, who was also a gifted artist and photographer, signed up for classes. Then tragedy struck. TK was murdered when delivering two large pizzas.

Jennifer wasn’t present when the shot was fired. The case got a lot of local media attention, including clips of the murder scene and TK’s lifeless body, lying bloody on the front seat of his “cool” tan-colored VW station wagon. And the case didn’t go away quickly. For months in San Diego, the media covered the hearings, trials, and finally the sentencing in adult court of a boy who was 14 years old when he pulled the trigger.

Jennifer came from a good family. Her father was a respected army dentist. She had two brothers. Her mother was a stay-at-home mom. We can’t know for sure exactly what she experienced after TK’s murder. What we do know is that her life unraveled. For a time, she was living on the streets of San Francisco, working at a club. She developed a heroin addiction. Her mother tracked her down through contacts at a church shelter and then helped her get into treatment. After she left treatment she moved to be with her family. She kicked the heroin habit and things improved a little, but she was still deeply troubled.

Jennifer went from therapist to therapist after she came home. One of these mental health professionals diagnosed her with schizo-affective disorder, a combination of mood disorder with psychotic symptoms. She was on and off her meds. She had sporadic conflicts at home, until her family moved her into her own little apartment. A girl with a history of eating disorders, she became isolated and reclusive after she lost her job at a local newspaper. Then, in late 2001, almost six years after TK was killed, she put a gun to her own head and pulled the trigger. When the body was found, her parents were called. More crime-scene yellow tape. More trauma. Ripples. After Jennifer’s death, her mother wrote a poem. It is shared here, with permission.

■ ■ ■

Surviving . . .

In my Rude Awakening I lost my compass, the earth turned to sand and the sky became hollow, colorless & non-existent.

A shade was pulled down upon the Window of my Life. I was as one in, “The Night of the Living Dead.” I slept the sleep of a drugged victim.

All nerve-endings pulled away from the wound.

I sought solace in solitude—or mindless activity.

I stared a lot—I slept a lot.

I prayed.

My prayers were like one—scratching . . .

on the interior surface of a blackboard coffin.

Pleas—scribbled in the scrawl, of a mad-woman mad with grief—insane with pain.

There is no Common Prayer for the newly bereft.

There are no words of comfort no pill, no treatment—to ease the troubling pain.

Only time & space & Sonshine can begin to soothe the cavity—we call sudden tragic loss.

C. PATCHEN

■ ■ ■

Early Research on Traumatic Complicated Grief

Among the first modern attempts to systematically study traumatic loss was the work done by Erich Lindemann (1944), who was then Chief of Psychiatry at Massachusetts General Hospital. Lindemann and other members of the staff at the hospital were called in to work with bereft families after a particularly tragic accident.

In the fall of 1942, there were two colleges in Boston that were renowned for the spirited nature of their football rivalry: Holy Cross and Boston College (Lindemann, 1944, cited in Worden, 2002). At the end of the game, many of the attendees went to a local nightclub, the Coconut Grove, to celebrate. A busboy accidentally set a decorative palm tree on fire. The fire spread rapidly, killing 492 revelers at the club, which was filled beyond its stated 460-person capacity with nearly 1,000 people. In working with over 100 bereaved family members, Lindemann and his colleagues were able to identify a pattern of six key traumatic grief reactions:

1. Somatic, or bodily distress.

2. Preoccupation with the image of the deceased.

3. Guilt about the circumstances of what happened.

4. Hostility.

5. Difficulty functioning as before.

6. Taking on characteristics of the deceased.

In addition to Lindemann’s early work with families and survivors, Alexandra Adler, the daughter of renowned psychoanalyst Alfred Adler, worked with more than 500 survivors of the Coconut Grove fire. Her work is now considered some of the earliest research on posttraumatic stress (Adler, 1943).

CONTEMPORARY THINKING ABOUT TRAUMATIC COMPLICATED GRIEF

As discussed in Chapter 7 , the experience of trauma conveys the idea of a shocking injury or to events outside the ordinary—for example, terrorism, murder, suicide, pandemic illness, or natural disaster. Traumatic deathcan contribute to problematic reactions among bereaved loved ones. Indeed, the criteria that were being considered for a new bereavement-related disorder (BRD) in the DSM-5 specified that evaluators should designate the loss as traumatic when this is the case (American Psychiatric Association, 2011). Although traumatic and prolonged forms of the proposed BRD have similarities and differences, there are similarities between a traumatically induced BRD and anxiety-based disorders such as posttraumatic stress disorder, acute stress disorder, and various dissociative disorders. Indeed, the DSM-5 criteria for posttraumatic stress disorder include exposure to situations involving threatened or actual death (American Psychiatric Association, 2013).

Currently, among the most commonly diagnosed anxiety-based reactions to psychological trauma is posttraumatic stress disorder. PTSD is a disorder that itself didn’t make it into the Diagnostic and Statistical Manual until the third edition, published in 1980. The designation PTSD was first officially used to describe a cluster of disturbing signs and symptoms experienced by a large number of Vietnam veterans suffering from the effects of their war-related experiences (Kemp, 1998, 2017).

Since then, the term has been applied to people who develop similar symptoms in response to other traumatic experiences, such as auto accidents, witnessing violence, being threatened, the aftermath of suicide or murder, or severe abuse (Kemp, 1998, 2017). In addition to exposure to a traumatic event sufficiently severe to produce such a reaction, the diagnosis of the disorder requires that several other criteria be met. In addition to a traumagenic event, symptoms include intrusive reexperiencing (through such things as flashbacks and nightmares); avoidance of people, events, or situations that “trigger” the reexperiencing; and hyperarousal(vigilant scanning the environment, sleep disturbance, jumpiness, etc.). The symptoms must last more than a month, and may be of short duration (fewer than three months), chronic (more than three months), or have a delayed onset.

According to the DSM-5 (American Psychiatric Association, 2013), acute stress disorder comes about as a result of exposure to actual or threatened death, serious injury, or sexual violation. It is a disorder in which the person develops anxiety, dissociative, or other symptoms that occur within a month of exposure (American Psychiatric Association, 2013). The factor that distinguishes it from PTSD is that it surfaces three days to a month after the event. Acute stress disorder occurs with or without the presence of dissociative symptoms.

Dissociative symptoms refer to the process whereby a person separates, or splits away, the experience from conscious awareness. It can be expressed as numbing, feeling personally detached, absence of emotional responsiveness, reduction of awareness, a feeling that the experience isn’t real, and amnesia to important aspects of the trauma. It should be noted that just because dissociative symptoms are not included within the criteria for PTSD does not mean that persons with PTSD don’t also have dissociative symptoms.

In addition, there is a class of disorder linked to dissociation, called dissociative disorders. Rather than catalog each separately, we survey them here as a group. According to the DSM-5 (American Psychiatric Association, 2013), “The essential feature of the dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment.”

Perhaps the most extreme, and famous, form of dissociative disorder is now called dissociative identity disorder (DID), a relatively rare condition caused by extreme psychic trauma that usually first occurs in very young children, before their personalities are fully established. The disorder was formerly called multiple personality disorder and involves the development of a number of distinct, autonomous, or semiautonomous personalities. As with other forms of dissociation, it develops as an attempt to cope with overpowering stress, and can be seen as a way to psychologically manage extreme levels of anxiety.

Other dissociative disorders include dissociative amnesia (loss of memory, usually about traumatic events, too extensive to be normal forgetfulness), depersonalization/derealization disorder (chronic feeling of being separated from one’s mind or body, but having normal awareness of reality), other specified dissociative disorder, and unspecified dissociative disorder.

TREATING TRAUMATIC COMPLICATED GRIEF

As previously discussed, the new science of bereavement research has begun to establish bereavement-related grief as a distinct condition (Prigerson et al., 2009; American Psychiatric Association, 2011). The previously proposed criteria for BRD have both differences and similarities to such other disorders as PTSD and major depressive disorder (MDD). Indeed, traumatic death is sometimes a factor in both BRD and PTSD, just as profound sadness occurs in both grief and MDD.

Treating trauma is a specialized field in itself. Attempting to address it thoroughly is beyond the scope of this chapter. Instead, we will briefly discuss some of the most important points. By way of introduction, we can say that any effort to treat trauma attempts to accomplish some basic goals: normalize the situation, shorten recovery time, reduce distress, restore functioning, and mobilize whatever resources may be available (Dyregrov, 2004; Marotta, 2000, cited in Meagher, 2007).

Posttraumatic Stress. The Veterans Administration is a major provider of care for patients with posttraumatic stress disorder in the U.S. (Rosen et al., 2004). It operates an extensive network of regional medical centers as well as a large number of community-based outreach clinics, called Vet Centers. In an effort to improve the quality of care for its patients, the VA system has begun to emphasize the use of evidence-based therapies and to disseminate knowledge about “best practices” in the treatment of posttraumatic stress disorder. It uses guidelines adopted by the International Society for Traumatic Stress Studies (ISTSS) (Foa et al., 2009; Foa, Keane, & Friedman, 2000).

Solid research points to the effectiveness of a range of cognitive-behavioral therapies (CBT), particularly exposure therapy (ET). Exposure therapy refers to a series of procedures that progressively help the person confront distressing thoughts and memories (Foa et al., 2009; Foa & McLean, 2016). This usually involves asking the individual to imagine as realistically as possible the distressing thought or memory along with real-life exposure to reminders. The military has been using virtual reality technology to enhance the process (McLay et al., 2010; McLay et al., 2017; Freedman et al., 2010).

Other effective CBT include systematic desensitization and stress inoculation training (SIT). Systematic desensitization involves pairing trauma-related memories and reminders with muscle relaxation (Asnaani, McLean, & Foa, 2016; Foa et al., 2009). SIT is an anxiety management program that includes education, muscle relaxation training, breathing, role playing, covert modeling, guided self-dialog, and thought stopping (Foa et al., 2009; Foa & McLean, 2016; Meichenbaum, 2017). There are also non-CBT therapies that have been shown to be effective in treating PTSD, including eye movement desensitization and reprocessing (EMDR), group therapy, and psychopharmacotherapy, or the use of medications to address distressing symptoms (Foa et al., 2009; Foa & McLean, 2016; Wilson et al., 2018). First developed by Francine Shapiro to help trauma victims, EMDR is an eight-phase psychotherapeutic process (Shapiro, 2001). It targets specific issues, events, feelings, and memories. Part of this process involves asking the patient to focus simultaneously on an image, negative thought, or disturbing feeling or body sensation, after which the patient is asked to follow a moving object. Group therapy provides a venue for efficiently delivering efficacious forms of treatment that also builds in social contact, social support, and modeling. The ISTSS believes that medications may play a role in targeting specific distressing symptoms of PTSD (Foa et al., 2009; Foa & McLean, 2016). There is good evidence that selective serotonin reuptake inhibitors (SSRIs) can be used to target anxiety, mood, and reexperiencing symptoms. And some evidence suggests that adrenergic agents, such as clonidine, may help with hyperarousal, impulsivity, nightmares, and sleep problems.

Dissociative Processes. The whole topic of dissociation and trauma is somewhat controversial in the mental health field. This having been said, we should acknowledge that the International Society for the Study of Dissociation (ISSD) has adopted a set of evidence-based criteria to guide treatment of dissociative disorders. These are intended to supplement generally accepted principles of psychotherapy and psychopharmacology (International Society for the Study of Dissociation, 2005).

Dissociation is defined by the DSM-5 as the “disruption in the usually integrated functions of consciousness, memory, identity, or perception” (American Psychiatric Association, 2013). In essence, it is a splitting or disintegration of consciousness, memory, identity, or perception in response to overwhelming trauma. It is the consensus of the ISSD community that the goal of treatment is to move the patient toward more integrated functioning.

Over the past three decades, a consensus has emerged in the ISSD that complex trauma-related disorders are most appropriately treated with a phase- or stage-oriented approach, as shown here (International Society for the Study of Dissociation, 2011):

1. Establishing safety, stabilization, and symptom reduction.

2. Confronting, working through, and integrating traumatic memories.

3. Identity integration and rehabilitation.

The ISSD suggests that the concept of complex PTSD may be an appropriate way to think of dissociative conditions, particularly DID, since its victims have usually had repeated traumas starting in early childhood (International Society for the Study of Dissociation, 2011). Dissociation, or “splitting,” becomes a learned way of coping with trauma, so mental health professionals who treat patients with dissociative disorders must help them confront their traumas but must also be somewhat tolerant of their use of dissociation until the person is able to manage without it.

During the initial stage of treatment, the focus is on managing the risk of suicide and a myriad of other safety concerns. During this phase, the ISSD recommends patient education on safety, identifying parts of the self that engage in unsafe behavior, entering into agreements about alternative strategies for managing problems, and developing strategies to deal with other symptoms (International Society for the Study of Dissociation, 2011). Efforts to help stabilize the individual may include use of skill building, soothing images, reaffirming statements, and calming imagery. The ISSD recommends that work with patients who have dissociative identity disorders requires interaction and communication with the “alters,” learning about their roles in dealing with life events, and outlining a map of the dissociative “system.”

During the second phase of work with dissociative patients, the ISSD (2011) recommends communicating directly with the patients about their traumatic memories and experiences. For patients with dissociative identity disorders, this involves interaction with alters that experience “themselves” as “holding” the traumatic memories. During this phase, efforts can be made to “detoxify” their experiences, framing them in a more understandable context, and looking for alternative meanings. The ISSD guidelines suggest that work during this phase may help the patient gain a sense of control.

In the third phase of treating dissociative patients, the goal is to help patients solidify the internal coordination and integration of the dissociative system (International Society for the Study of Dissociation, 2011). Patients are expected to function in a more integrated way. There is generally less discussion about past traumas and more attention on learning how to live better in the present. According to the ISSD, the experience of multiple losses, grief, and mourning is often experienced more profoundly during this stage. Finally, patients may need coaching about how to deal with the normal tribulations of life in a nondissociative manner.

The most common approach to treating dissociative disorders is individual psychodynamically oriented psychotherapy, sometimes supplemented with other therapies (International Society for the Study of Dissociation, 2011). These include behavior modification, CBT, systematic desensitization, SIT, dialectical behavioral therapy (DBT) (e.g., Dimeff & Linehan, 2001: Walsh & Eaton, 2014), and the appropriate use of hypnosis in cases where the therapist is qualified to use it. In addition, the ISSD suggests consulting the distinct body of literature that has been developed on treating complex PTSD.

CHRONIC COMPLICATED GRIEF

As discussed earlier in this chapter, the previously proposed diagnostic category of BRD focused on what used to be called chronic or prolonged grief, although it does admit the possibility of traumatically induced cases. Recent research suggests that the difference between the experience of separation distress (e.g., yearning and longing) and traumatic distress (e.g., numbness, anger, and bitterness) appears to lie in the cause of death (Holland & Neimeyer, 2011). Generally, this research confirms that traumatic distress is influenced by the traumatic nature of the death, whereas separation distress is influenced by having had a close relationship with the deceased. In a preceding section we the discussed the traumatic form of what Parkes would refer to as complicated grief. In this section we focus on the prolonged form of complicated grief, called “prolonged grief disorder” or “persistent complex bereavement disorder” depending on what diagnostic criteria are used (Charney et al., 2018; Lenferink & Eisma, 2018). In an exploratory chapter of the DSM-5 the term “persistent complex bereavement disorder” is used (American Psychiatric Association, 2013).

Individuals with chronic or prolonged grief are sometimes described as being stuck in their mourning (Bonanno et al., 2004; Zhang et al., 2006). As discussed in Chapter 10 , Colin Murray Parkes believed that the chronic form of complicated grief is largely caused by excessive dependency on the deceased (Parkes, 1998a, 1998b).

Indeed, George Bonanno, a leading contemporary bereavement researcher, whose work we discussed at length in Chapter 10 , believes that dependency is the glue that holds the yearning, isolation, and emptiness of chronic grief together (Bonanno, 2009). By dependency Bonanno generally means emotional dependency—the exaggerated need to be cared for, nurtured, and protected, even when capable of doing so for oneself. Sometimes excessively dependent individuals are described as clingy, submissive, and fearful of separation.

The yearning of chronic grief tends to be focused on one thing—finding the lost beloved—but the pining fails to bring the loved one back (Bonanno et al., 2007; Bonanno, 2009; Prigerson et al., 2009). Instead, it only brings deeper pain, cycling again and again in the futile quest for the deceased. For most bereaved people, the memories of their deceased loved one brings a sense of comfort. We can sometimes call on our memories of lost loved ones to bring us temporary relief at times of stress and turmoil. According to Bonanno, the bonds we form with our caregivers give us internal representations of them we can call on in times of trouble (Bonanno, 2009). For those unfortunate bereaved individuals who lack secure bonds, memories of their deceased loved ones don’t bring comfort. Instead, their lost loved ones haunt them in dreams, in faces in the crowd, or in the gait of a stranger who walks away. These experiences and the memories of their beloved remind them of their loss, not their connection, and tend to be experienced as disturbing.

RISKS AND RISK FACTORS

One of Colin Murray Parkes’s greatest contributions to the field was calling attention to the mental and physical health of people with complicated grief. The specific factors that seem to put people at somewhat increased risk for chronic grief include death of a parent during childhood, having been abused or neglected as a child; childhood separation anxiety; insecure attachment style (see discussion of Bowlby in Chapter 10 ); having had a very close kinship relationship with the deceased; marital closeness and support; and inadequate preparation for death (Zhang et al., 2006; Prigerson et al., 2009).

In a study of long-term adjustment, the authors laud the general resilience and adaptability of most people who grieve, but warn of the potential adverse effects of bereavement (Arbuckle & de Vries, 1995). Comparing 184 bereaved persons (41 parents and 143 spouses) to nonbereaved adults, they found significantly reduced life satisfaction as well as increased feelings of depression and the sense of hopelessness. However, survivors emerged with a heightened awareness of their own ability to cope, especially so for women. They found that the type of loss the person experiences, gender, and social context all influence the outcome.

Wolfgang Stroebe and Henk Schut (2001), two leading researchers, conducted a review of the literature on the effects of bereavement on the health of survivors. They focus on three primary categories:

1. The bereavement situation (how the person died).

2. The person (personality, religiosity, gender, age).

3. The interpersonal context (social support and kinship).

Stroebe and Schut qualify the findings of their review by noting its three key limitations: (1) It encompasses only one type of grief experience—partner loss; (2) it looks primarily at health outcomes (and does not address personal growth or relationship issues); and (3) it covers only the most common factors that have been studied.

The bereavement situation refers to the mode of death, or how the person died. Stroebe and Schut (2001) observe it is generally thought that sudden, traumatic loss creates more difficulty for the bereaved than slow, expected loss (although the experience of expected loss might also bring with it anticipatory grief). Using the concept of attachment, sudden loss would seem to have the potential to impair the survivor’s sense of safety and security. Stroebe and Schut report that the results of empirical studies are inconclusive on this point, even when the loss involves suicide. Some studies seem to indicate sudden loss leads to poor health outcomes, whereas other studies do not. Stroebe and Schut observe there may be other variables at play, such as the self-esteem of the survivor or the sense of personal control he or she has.

Personal Risk Factors

Personal risk factors include personality traits, religiosity, gender, and age. Stroebe and Schut (2001) count the survivor’s prebereavement adjustment and sense of personal control as being among the important personality elements. Indeed, Stroebe and Schut (2001) concluded from their review that prior adjustment did seem to play an important role in bereavement outcomes—those with poor adjustment before their loss seem to have much more difficulty after. This conclusion gets support from a longitudinal study that was done with a sample of 125 bereaved spouses (Henderson, Hayslip, & King, 2004).

Religiosity

Religiosity can be understood as the degree to which a person has a commitment to a religious faith tradition. Stroebe and Schut (2001) suggest two possible mechanisms to explain any beneficial effects that might be found: (1) the belief system is an internal source of support and (2) social support networks are inherent in faith communities.

The findings, however, were mixed. Some studies found a positive influence, others found none, and still others even found an unhealthy influence. More recent studies conclude there appear to be beneficial effects (Holen-Hoeksema & Larson, 1999; Levy et al., 1994; McIntosh et al., 1993, cited in Stroebe & Schut, 2001). Much of the effect seems to relate to the role of social support. Some evidence, however, supports the notion that religion itself may help people find meaning even in difficult experiences and achieve a better long-term adjustment. In a study of 135 people close to a patient with end-stage cancer, the investigators found that people with spiritual beliefs seem to resolve their grief more rapidly and completely after a death (Walsh, King, Jones, Tookman, & Blizard, 2002).

Gender

In their review of the literature, Stroebe and Schut (2001) note that the evidence has been fairly clear for some time that grief affects spouses significantly and differently. After the loss of a spouse, both men and women have more health problems than people who still have their spouses. The evidence seems fairly clear in suggesting that men tend to have more physical health problems and die more quickly than women. Women, in contrast, seem to have more difficulty with depression. This outcome is often attributed to differing amounts of social support men and women are able to accept in response the loss of a spouse (Stroebe & Stroebe, 1983). Margaret and Wolfgang Stroebe and their colleague, Henk Schut, use stress theory to develop an alternative explanation. Women seem better able to deal with the emotional, loss-oriented aspects of the loss, whereas men may be better at handling the more practical, restoration-oriented dimensions (Stroebe, Hansson, Stroebe, & Schut, 2001). This may make it easier for men get back to a normal routine more quickly but without the emotional aspects of their loss having been resolved. This presumably results in the emotional aspects of their loss being “internalized” in the body.

Age

It is paradoxical that, while age and health are normally inversely related (i.e., the older one gets, the less healthy), it seems that, when it comes to the impact of bereavement, the reverse is true. Older people seem to have an easier time adjusting to loss than younger people (Stroebe & Schut, 2001). There may be any number of variables that could contribute to this result, but it could result from older people having more experience with loss, better understanding the sudden nature of loss among those who are younger, or having more access to sources of help. In addition to the influence of age itself, it might be important to consider the generation the bereaved belongs to, since people experience different stressors depending on the era in which they live, as is especially seen during times when especially catastrophic events unfold, such as economic depression, natural disaster, war, or disease (e.g., polio and AIDS) (Folkman, 1997).

Interpersonal Risk Factors

Identified by Stroebe and Schut (2001) as being major factors bearing on the experience of bereavement are social support and kinship. In a very simple but elegant model, John Briere, a trauma psychologist of some notoriety, suggests that crisis can ensue in the face of severe stress when either the person’s internal strengths or external supports are not sufficient to face the situation at hand (Briere, 1992). In this model, either taking steps to support the individual’s own coping abilities or providing extra support are appropriate.

Attachment

Stroebe and Schut (2001) argue, however, that attachment theory may do a better job than stress theory in explaining grief associated with significant loss—a spouse, parent, child, or sibling. They observe that the literature is fairly clear. The loss of one’s child, especially an adult child, seems to have the most severe impact on bereavement. They puzzle at these results, which seems to show that, despite what they might expect on the basis of attachment theory, social support seems to benefit bereaved people. From their perspective, social support should not ameliorate a specific loss to a key attachment figure, yet it appears to do precisely this.

DISENFRANCHISED GRIEF

Grief is a normal response to loss. According to Kenneth Doka, who coined the term disenfranchised grief, this malady is grief is that is “not openly acknowledged, socially accepted, or publicly mourned” (Doka, 1989, p. 4). Examples of people who might be subject to disenfranchised grief include the illicit lover of a person who was married to someone else, the unmarried partners of gay men or lesbian women, women who have had a stillbirth or an abortion, mothers who have given up their babies for adoption, those who have lost a pet, or even the fan who had an idealized relationship with a celebrity who died.

Social acknowledgment, acceptance, recognition, or support for bereft individuals is withheld. Doka (1989, 2002) suggests there are five basic types of disenfranchised grief:

1. The relationship is not recognized (e.g., illicit lover, foster parent, or ex-spouse).

2. The significance of the loss is not acknowledged (e.g., the fan of the celebrity who has died).

3. The griever is excluded from public mourning (e.g., the very young, the very old, the demented, the mentally ill).

4. The circumstances of the death are stigmatized (e.g., death due to suicide, murder, AIDS, or the death penalty).

5. The way the individual grieves does not conform to social expectations (e.g., the person might appear “too cool” or, on the other hand, “too hysterical”).

According to Doka and his colleagues (Doka, 1989, 2002; Thompson & Doka, 2017), disenfranchised grief interferes with the process of achieving a resolution to loss. Bronna Romanoff and Marion Terenzio (1998) suggest that the reasons for this are that getting through bereavement is a process that involves an intrapsychic transformation of one’s sense of self, transition from predeath to postdeath social status, and continuation of one’s sense of connection to the deceased.

The lack of recognition makes it more difficult for bereft individuals to internalize the significance of their loss (Romanoff & Terenzio, 1998). They might wonder, “If my relationship is not recognized, could it really have been that important?” Funerals are public rituals that mediate the transition from one status to the next—for example, from alive to dead or from spouse to widow. If one is not allowed to attend the funeral or one’s status is not accepted, then negotiating the change can only be made without benefit of this activity. Bereavement experts now believe that maintaining a sense of connection to the deceased is important (Klass, 1993, 1997; Klass, Silverman, & Nickman, 1996; Klass & Walter, 2001). Being able to share helps keep a sense of relationship. Not being able to do so means that one cannot share one’s loss with others.

COPING

Coping with loss, or adaptation, is considered a multidimensional process whereby one restructures one’s self, one’s relationships, and one’s world to the reality of loss (Corr & Doka, 2001; Corr, 2015; Corr, Corr, & Doka, 2018; Doka, 2017). It can be thought of as an ever-changing approach to trying to manage specific external and/or internal demands that are experienced as stressful or that exceed the resources of the individual (Lazarus & Folkman, 1984). The person’s various efforts to cope or adapt can be directed to the problem itself or to the distressing feelings the person might be experiencing. While having to contend with the stresses that often surround the death of a beloved person is a clearly unpleasant prospect, it seems that human beings are far more resilient and adaptive than we may have realized.

Susan Folkman led a fascinating pioneering research effort that helps explain how people cope and adapt to extraordinarily stressful experiences (Folkman, 2001). Between 1990 and 1997, she and several of her colleagues conducted a longitudinal study of terminally ill gay men and their partners. In each case, death was expected. Anticipatory grief, coping, and adapting unfolded during a hugely challenging and poignant time in the lives of the affected individuals. It was not surprising that there were high levels of psychological stress.

One of the fascinating features of Folkman’s study of gay men dying of AIDS is that she and her colleagues were able to study how the men and their partners coped with the disease and how the bereft partners coped with loss over a five-year period of time (Folkman, 1997, 2001; Folkman, Moskowitz, Ozer, & Park, 1997). The research unearthed a paradoxical mix of both depressive symptoms and positive emotions, both when dealing with the disease process and after bereavement. Using both classical quantitative methods (to test for the effects of the stress) and qualitative methods (to explore the experiential dimensions), Folkman and colleagues found surprisingly positive psychological states throughout caregiving and the bereavement period. Folkman identifies three key elements that seemed to contribute to the positive states these men experienced:

1. Problem-focused coping with the practical tasks associated with managing the disease.

2. Positive reappraisal—redefining the situation in a more positive way.

3. Using religious and spiritual beliefs.

Despite the hardships, accomplishing such problem-focused tasks as changing bed linens, getting one’s partner to the clinic, or hammering out an issue with an insurance company, was associated with improvement in negative mood, which Folkman (1997, 2001) believes was connected to gaining a sense of control over an uncontrollable disease process. When successful with a task it seems to have led to at least a temporary feeling of mastery. The ability to positively reappraise the situation, to “reframe” it, seems to have literally made it possible to see their life in a new light. Five years after the death of their partners, these men said they had achieved enhanced feelings of self-worth, strength, and wisdom, which they credit to their bereavement experience. Nearly one in five said they no longer feared death. In Folkman’s study, the men claimed their religious and spiritual beliefs helped them find a sense of meaning and purpose in life that has stuck with them.

The work that Folkman and colleagues have done has led to some rethinking when it comes to our understanding of loss (Folkman, 1997, 2001; Folkman et al., 1997; Lazarus & Folkman, 1984). This and other recent work on bereavement has gone a long way to rouse the professionals, wake them, and stir them to question and reevaluate conventional ways of approaching bereavement, grief, and mourning (Stroebe & Stroebe, 1987; Wortman & Silver, 1987, 1989; Bonanno & Kaltman, 1999, 2001). In the next section, we consider other emerging models and directions.

EMERGING MODELS

As discussed earlier, traditional approaches to psychotherapy and the use of medication haven’t been very effective in treating people with chronic, or prolonged, grief. Indeed, one of the reasons why bereavement experts have been fighting so hard to gain recognition is in the hope that with it might come more effective approaches to treating it.

Treating Chronic Complicated Grief

One such approach to treatment has already been developed. Katherine Shear and colleagues at the Columbia University School of Social Work have developed an approach called complicated grief treatment (CGT)(Shear et al., 2005; Shear, 2015; Shear & Bloom, 2017). It uses an approach to CBT that targets specific symptoms of complicated grief. Much like the dual-process model discussed in Chapter 10 , the CGT model simultaneously guides patients in dealing with their loss and helps them take steps to rebuild their lives. Consistent with treatment shown effective in treating posttraumatic stress disorder, clients are increasingly exposed to imagery related to their loss from within the safety of a clinical environment. See Box 11.1 .

BOX 11.1

Treating Complicated Grief

As part of their research on complicated grief, Katherine Shear and colleagues (2005) developed a protocol for treating CGT. They have been able to empirically show that CGT is effective in treating complicated grief. It is a two-pronged approach in which the therapist simultaneously guides the patient to focus on the loss while at the same time helps the client take steps to rebuild his or her life.

• Introductory phase: The client is educated about normal and complicated grief and the dual-process model of adaptive coping that focuses on restoring a satisfying life and adjusting to the loss. Attention to personal life goals is included in this phase.

• Middle phase—revisiting: The patient is asked to close his or her eyes and tell the story of his or her loss. This is tape recorded and the patient is asked to listen to the recording at home. The patient is also asked to imagine situations related to the death he or she has been avoiding and gradually increase the exposure. A sense of ongoing connection with the deceased is also promoted by asking the patient to engage in a series of imagined conversations with the departed. The patient is also asked to complete a memories questionnaire, which primarily focuses on positive memories.

• Restoration focus: The patient is asked to articulate his or her personal life goals. The patient is also asked to consider what he or she would like for himself or herself if the grief was not so intense. The therapist assists the individual in working toward the identified goals.

• Termination phase: Review progress, discuss plans for the future, and talk about feelings regarding ending treatment.

Source: Shear, K. et al. (2005). Treatment of Complicated Grief: A Randomized Controlled Trial. Journal of the American Medical Association, 293 (21), 2601–2608. A copy of the protocol manual may be obtained from Katherine Shear, M.D., Department of Psychiatry, University of Pittsburgh, School of Medicine, 3811 O’Hara St., Room E-1116, Pittsburgh, PA 15213 ([email protected] ).

Meaning and Story

Robert Neimeyer and his colleagues have been working for some time to develop an approach based on the idea that grief and complicated grief is mediated by how we find meaning in our experiences (Neimeyer, 2000, 2001, 2006; Currier et al., 2015; Neimeyer, Fontana, & Gold, 1984). In an edited volume, Neimeyer and colleagues address such issues as how we can reestablish a relationship after a loss, transcend trauma, make use of story, and achieve a new sense of meaning (Neimeyer, 2001).

Long before the new breed of thanatologist began to challenge the grief-work hypothesis, ordinary people had already begun their own grassroots rebellion, clinging to the memories of their loved ones and refusing to establish “new” identities. What grief researchers really did was start asking the questions. In the renowned Tübingen Longitudinal Study (Stroebe & Stroebe, 1989, 1991, 1993; Stroebe, Stroebe, & Domittner, 1988; Stroebe, Gergen, Gergen, & Stroebe, 1992; Stroebe, Stroebe, & Hanson, 1993), we learn that over two-thirds of widows and widowers said they planned to continue their previous lifestyles as much as possible, a small number hoped for change, and a mere 17 percent reported seeking a new partner. Most said they planned to integrate their loss into their lives—not attempt to build a new identity. Nearly one-third claimed they could still sense the presence of their loved one over two years later, and over one-half said they “consulted” their deceased loved one when making important decisions. In a similar vein, Dennis Klass and colleagues have found in their work with bereft parents who have lost their children that these parents find it important to maintain a bond with their deceased children (see Chapter 3 ; Klass, 1993, 1997; Klass et al., 1996).

Margaret Stroebe and associates once suggested that three basic principles be used (Stroebe et al., 1992). The following brief summary attempts to capture the essence of these principles.

1. Conceptual integration: Rather than choosing from among apparently competing models of grief, it is beneficial to integrate or combine the best of each.

2. Invitation to culturally embedded practices: Instead of developing universal principles that attempt to apply in all situations, honoring the influence and rich textural variability of diverse cultures is advantageous in bereavement work. Intervention should be tailor-made for each situation.

3. Expansion of responsibility: Bereavement work should not be wedded to any particular theoretical “school” but should strive to honor and address the unique needs of each bereaved person.

As discussed in Chapter 10 , Stroebe and Schut (1999) proposed what they call a dual-process model of grief. In this model, healthy coping is seen as a process in which people deal with their grief by using a strategy in which they alternate between using avoiding and confronting strategies to deal with both their current pain and future-oriented issues, depending on individual needs and the current issues at hand.

Torill Christine Lindstrom (2002) comments that excessive rumination, frequent crying and talking about it, and intrusive thoughts of the painful events do not help, but that the bereaved person must still come to terms with the “incomprehensible, unbelievable, and unacceptable fact that a loss has happened” (Lindstrom, 2002, p. 15). She observes that we probably should not recommend traditional grief-work approaches that coerce the bereaved to endlessly ruminate on their loss. We should also not encourage them to forget their grief at all costs, advocate they sedate or divert themselves, or warn them about the possible adverse consequences of their loss-related thoughts or feelings. Rather, we should recommend that the bereaved recognize their emotional reactions as normal, accept their grief-related thoughts and feelings, and encourage them to allow their feelings to heal naturally with time, unless there are clear reasons to do otherwise.

In Chapter 10 , we also discussed the insights of Tony Walter about the importance of being able to “tell the tale,” or the story, about the deceased (Walter, 1996). As you may recall, he shared about the loss of his father and best friend. His point was, having the opportunity to tell the story with each other can help bereaved people heal from their loss. Walter observes that there are two second-best alternatives: professional counseling and self-help groups.

When Walter (1996) discussed the use of personal counseling as a second-best way to share one’s stories of a deceased love one, he was specifically referring to the client-centered therapy of Carl Rogers (Rogers, 1965). This approach focuses on creating an atmosphere of trust, which allows the client to share and be listened to empathically. It is a cornerstone of most present-day approaches to psychotherapy. Self-help groups provide the opportunity to share with and be supported by other people who have similar experiences. What therapists and groups lack is firsthand experience with the deceased himself or herself. Therefore, the sharing that does occur is less likely to be as personal or meaningful and perhaps less healing.

“Storying”

The simultaneous existence of many apparently conflicting “truths” has led to an uneasiness about the prospects for discovering some universal truth that could perhaps someday help explain human behavior (Corey, 2016). As a consequence, some argue that we have taken a postmodern turn (Best & Kellner, 1991, 1997, 2001; Corey, 2016; Kellner, 1999). Corey (2016) suggests that the postmodern turn in therapy involves a shift in which “truth” and “reality” have come to be understood as socially conditioned perspectives, shaped by history and social context.

In contrast to those who believe that there is an objective reality that can be systematically observed and measured, this new breed of theorists puts more emphasis on subjective realities, which are not thought to be wholly independent of human observation (Corey, 2016; also see Chapter 2 ). From this frame of reference, a key to understanding experience comes from the meaning that emerges out of the use of language and by the sharing of stories. Although there is no single postmodern approach developed to address grief, several general ones have emerged from this perspective (Corey, 2016). Two seem particularly well suited for clients coping with the loss of a loved one. These are narrative therapy and collaborative therapy (Corey, 2016).

Gerald Monk uses the metaphor of an archaeologist as a way to think about narrative therapy (Monk, 1997; Monk, Winslade, Crocket, & Eston, 1997; Semmler & Williams, 2000). As the archaeologist goes about the business of exploring a site, he or she carefully brushes way the accumulated debris of untold ages with a small brush, gradually exposing various shards, fragments, and artifacts. With an eye for what is exposed and the imagination to sense what might yet lie beneath the surface, the archaeologist gradually pieces the story of a people together. The therapeutic archaeologist, however, is working with a living, breathing person. As Monk explains, “Narrative approaches to counseling invite clients to begin a journey of coexploration in search of talents and abilities that are hidden or veiled by a life problem” (Monk, 1997, p. 3). Therapists strive to build a collaborative relationship with an emphasis on listening to the clients’ stories; searching for those times when they were skillful or successful; and using questions to engage with the client and facilitate the process (Corey, 2016). The approach assumes the stories we live by are socially created as a result of our interactions with others. A purpose of therapy is to uncover these stories, and transform their power in the lives of clients through a process of uncovering new meaning.

Corey (2016) describes the collaborative therapy approach (Anderson, 1993; Anderson & Goolishian, 1992; Beaudoin & Duvall, 2017; Carr, 1998) as a fairly unstructured style of counseling that emphasizes caring forand being with the client. Like the Rogerian person-centered approach, the collaborative language system approach asks the counselor to actively listen. Like narrative therapy, its parent, it starts with the premise that meaning is socially constructed. The client’s story has emerged from the interaction between the person and the significant people in their lives. The purpose of counseling is to help the client tell or retell his or her story—not confront or challenge it. As the story unfolds, the intent is that the dialog will turn into a therapeutic conversation and new meaning will emerge. With this new meaning, problems are dissolved rather than solved. But, in order for this to happen, the counselor must take the stance of being a listener, eager to hear and operate from a position of “not knowing.”

Chapter Summary

We began this chapter by noting that profound grief is a normal reaction to loss, but that the new science of bereavement research seems clear that a significant minority of grievers suffer from a more serious form of grief that probably requires professional attention. They suffer from intense yearning and longing; symptoms of traumatic distress; avoiding people or place associated with the deceased; disruption in social relations or personal identity; and significant impairment for an extended period of time (American Psychiatric Association, 2011).

Several terms have been applied to this phenomenon. The American Psychiatric Association considered a new category of mental disorder, which was tentatively called bereavement-related disorder, but ultimately declined to include it. For the chronic form of complicated grief, the APA did create an “exploratory” category called “persistent complex bereavement disorder.” The traumatic form was not specifically addressed in the DSM-5. We noted that Colin Murray Parkes had originally described three forms of complicated grief—traumatic, conflicted, and chronic—that he believed were caused by severe trauma, having had a conflicted relationship with the deceased, and dependency. The evidence suggests there is good evidence about the potential effects of trauma and dependency, but little about the impact of having had a conflicted relationship. So, we explored in some depth traumatic loss and prolonged grief.

We opened the discussion of traumatic loss by revisiting the murder of TK Khamisa, a 20-year-old San Diego State University student who was killed when trying to deliver two large pizzas, but we focused on the reactions of his fiancée, Jennifer, who had a great deal of difficulty coping after his death. Although TK’s death got a great deal of attention in San Diego, Jennifer’s difficulties got little attention, except from her family and friends, until she herself ended her own life.

Next we reviewed some of the earliest modern research on traumatic grief, done by Erich Lindemann and Alexandra Adler in response to the 1942 fire at the Coconut Grove nightclub, which ended in the death of 492 people. As a result of his work, Lindemann describes six traumatic grief reactions, which are quite consistent with the criteria being considered by the American Psychiatric Association for the new category of BRD(American Psychiatric Association, 2011).

According to Prigerson and colleagues, a key reason for considering a special category of BRD is in the hopes that doing so might result in more effective treatments, such as what happened when PTSD was recognized in the early 1980s (Prigerson et al., 2009). Then we turned to a discussion of how we assess and treat traumatic stress and posttraumatic stress disorder. We paid particular attention to the “best practices” that have evolved, especially several CBT (Foa et al., 2009).

We also looked at another trauma-related reaction, the development of dissociative disorders, including DID, which experts believe is often caused by the very severe abuse of young children. We reviewed the stage-oriented approach to treatment advocated by the ISSD.

We shifted our attention to a discussion of prolonged grief, which seems to be at the heart of much of the recent research on complicated grief. This new body of research appears to confirm Parkes’s early observations about a form of grief that seems to develop in people who were very dependent on the deceased prior to their deaths. Described as clingy, submissive, and fearful of separation, these individuals have a very hard time returning to normal life after their losses.

Briefly we explored disenfranchised grief—that is, grief that is not openly acknowledged, socially accepted, or publicly mourned (Doka, 1989, 2002). According to Doka, disenfranchised grief can interfere with a bereaved person’s ability to adjust to his or her loss. Doka (1989, 2002) discusses five types of disenfranchised grief, all of which relate to the refusal of society to acknowledge, recognize, and sanction certain types of loss.

We explored risks and risk factors associated with prolonged grief, including the influence of the bereavement situation, personal factors, and the interpersonal context: the role of how death occurred, personality characteristics, age, gender, religiosity, social support, and kinship. Then, we explored how people cope with, or adapt to, bereavement, drawing on the work of Susan Folkman, especially her study of gay men who cared for their terminally ill partners before they died. Despite the hardships, we learned how these men achieved an enhanced sense of life mastery by successfully using problem- focused coping strategies, “reframing” techniques, and their own religious or spiritual beliefs.

In the final section, we took a postmodern turn, considering a couple recent challenges to traditional approaches. These insights now seem to be influencing the direction of bereavement studies. These included narrative therapy and the collaborative therapy approach, which draw on what some people like to think of as the postmodern imagination.

Key Terms

avoidance

bereavement-related disorder (BRD)

cognitive-behavioral therapies (CBT)

collaborative therapy

complex PTSD

depersonalization disorder

dialectical behavioral therapy (DBT)

dissociation

dissociative amnesia

dissociative disorders

dissociative identity disorder (DID)

dissociative symptoms

exposure therapy (ET)

eye movement desensitization and reprocessing (EMDR)

hyperarousal

intrusive reexperiencing

narrative therapy

posttraumatic stress disorder (PTSD)

religiosity

traumagenic event

Suggested Activities

1. Conduct an Internet search on the key words complicated grief. How many different terms were you able to find? What kind of materials did the links take you to? Did you notice any differences between materials put together by laypersons and those developed by professionals?

2. Consider some of the recent natural disasters you have become aware of because of media attention. Based on your understanding of trauma and traumatic reactions, what sorts of things do you think we ought to be aware of when considering how we should respond?

3. Consider any recent media account of traumatic death in your community. Who do these accounts focus on? Are there others that get little or no attention? What kind of issues do you think they are facing?

4. Keep a media file on traumatic death in your community. After you have gathered a body of clippings, what patterns do you see?

5. Explore the topic of prolonged grief in the literature. Which authors have devoted their creative talents to addressing personal loss? What can we learn from it? What do you think happens as a result of telling their story?