[acb-hsp] Concepts and Controversies in Grief

[J.Rayl]

Concepts and Controversies in Grief

 and Loss.

by Robyn A. Howarth

Although grief

 is a universal experience, the ways in which it occurs are not universally agreed

upon. In fact, there is considerable controversy about the "normal" duration of

grief

 its expected outcome, and its course. Although most grieving adults will achieve

a sense of normalcy at some point, others seem not to do so. Continuing impairment

by

grief

 raises a question: Is the experience qualitatively different from normal

grief

 or is it different only in degree? This article discusses

grief conceptualizations, including that of complicated grief and approaches to grief

 counseling.

Loss is a universal human phenomenon, but people respond to it with varying degrees

of grief

 and mourning. Although the experience is common, its expression varies across individuals.

People grieve in different ways, for different durations, and with manifestations

that range from depression to rage to avoidance. Working with their clients and within

their communities mental health counselors are often faced with issues of

grief

. Although it has been widely studied, there is still disagreement about the definition

of grieving, as is clear from the diagnostic criteria issued by the American Psychiatric

Association in the Diagnostic and Statistical Manual of Mental Disorders ([DSM-IV-TR],

APA, 2000).

The loss of a loved one is one of the most distressing emotional experiences people

face, yet virtually everyone will deal with

grief

 at some point. Despite the emotional difficulty associated with loss, most people

experience a "normal" grieving process in which they endure a period of sorrow, numbness,

and even guilt or anger, followed by a gradual fading of these feelings as the griever

accepts the loss and moves forward.

In the literature many terms have been used to describe aspects of grief

 and loss. Bereavement is understood to be the experience of having lost a loved

one to death;

grief

 to be various emotional, physiological, cognitive, and behavioral reactions to the

loss; and mourning to be the cultural practices through which bereavement and

grief

 are expressed (Brown & Goodman, 2005). Finally, the term complicated (or

traumatic) grief (Prigerson & Jacobs, 2001) describes grief

 that appears to deviate from the norm in duration and symptom intensity. Some defining

aspects of both normal and complicated

grief presented here provide a context for the articles that follow.

Uncomplicated Bereavement

According to the DSM-IV-TR (APA, 2000), a bereavement v-code can be used when the

focus of treatment is a client's reaction to the death of a loved one. The normal

grieving process is considered to be characterized by feelings of great sadness and

anger, physical symptoms such as weight loss and insomnia, a preoccupation with the

death, and difficulty with concentration (Cohen, Mannarino, Greenberg, Padlo, & Shipley,

2002). The clinical presentation of bereavement responds to individual, family, environmental,

and cultural variables, although there are common tasks an individual likely goes

through to successfully navigate the grieving process (Lin, Sandler, Ayers, Wolchik,

& Luecken, 2004).

Uncomplicated bereavement involves reconciliation, which has been defined as "the

process that occurs as the bereaved individual works to integrate the new reality

of moving forward in life without the physical presence of the person who died" (Cohen

et al., 2002, p. 309).

Reconciliation is achieved through specific tasks that take place during bereavement.

Cohen, Mannarino, and Knudsen (2004) suggest that these tasks include (1) accepting

the reality of the death; (2) fully experiencing the pain associated with the loss;

(3) adjusting to life without the loved one; (4) integrating aspects of the loved

one into one's own self-identity; (5) converting the relationship from one of ongoing

interactions to one of memory; (6) finding meaning in the loved one's death; and

(7) recommitting to new relationships with other adults. Similarly, Worden (1991)

proposes that adaptation to loss involves navigating specific tasks that include

(1) acceptance of the reality of the loss; (2) working through and experiencing the

negative emotions associated with the loss; (3) adjusting to an environment in which

the deceased is no longer physically present; and (4) establishing continuing bonds

with the deceased.

Although most people are able to cope with and navigate the normative grieving process

without complication (Boelen, van den Hout, & de Keijser, 2003; Bonanno, 2004), some

are unable to do so successfully. When people are prevented from moving through the

tasks adequately, the normal bereavement process is interrupted,

grief

 reactions become much more painful and debilitating (Mayo Clinic, 2007), and complicated

grief may develop.

Complicated Grief

Among the terms that have been used in the bereavement literature to describe atypical

grief

 are complicated

grief (CG); traumatic bereavement; childhood traumatic grief; and prolonged grief

 disorder (PGD). In this article, for consistency we use the term complicated grief

. Although the specific definitions for these conditions may differ, the common defining

characteristic is that the bereavement process is interrupted and there is no resolution.

CG has been conceptualized as the development of trauma symptoms following a death

that interfere with the ability to grieve (Cohen et al., 2002). People may experience

trauma reminders, which remind them that death is

traumatic

; loss reminders--thoughts, memories, or people that are reminders of the deceased;

or change reminders, which remind the person of changes that have taken place as

a result of the death. All of these lead to intrusive and distressing thoughts, memories,

and images about the trauma (Cohen et al., 2002). These trauma-related thoughts then

prompt the person to experience physiological reactions and extreme psychological

distress similar to those experienced during the original loss (Cohen et al., 2002).

Individuals with CG may use avoidance and numbing strategies to protect themselves

against unpleasant feelings associated with the death. As a result, these individuals

are overwhelmed and cannot become reconciled to the loss (Brown & Goodman, 2005).

Essentially, complicated grievers get "stuck" in the course of their

grief, concentrating on the traumatic

 aspects of the death and unable to proceed through the normal bereavement process.

Symptoms. Although mental health experts continue to analyze how CG symptoms differ

from normal

grief

 reactions, signs and symptoms identified as characterizing CG include extreme focus

on the loss and reminders of the loved one; intense longing for the deceased; problems

accepting the death; numbness or detachment; preoccupation with feelings of sorrow;

bitterness about the loss; an inability to enjoy life; depression or deep sadness;

difficulty carrying out normal routines; withdrawing from social activities; irritability

or agitation; and a lack of trust in others (Mayo Clinic, 2007).

Symptoms associated with traumatic

 loss have been found to constitute a distinct form of bereavement-related emotional

distress independent of bereavement-related depression and anxiety (Boelen et al.,

2003). The onset and course of symptoms is important for differentiating CG from

the normal

grief

 process and other psychiatric disorders. Though it may be normative for symptoms

of posttraumatic stress disorder (PTSD) to arise immediately after a

traumatic

 death, they typically last no longer than a month (Cohen et al., 2002). However,

when the grieving individual has difficulty progressing through the normative tasks

and cannot positively reminisce or talk about the loved one, it becomes clear that

something more clinically significant is causing the interference (Cohen et al.,

2002). The presence of PTSD-like symptoms and their impingement on the ability to

fully grieve the loss of a loved one is what makes CG unique (Cohen et al., 2004).

Characteristic trauma symptoms present in CG resemble symptoms of acute stress disorder

and PTSD: intrusive and distressing thoughts, memories, and images about the trauma;

exaggerated avoidance symptoms; and

traumatic

 estrangement (Parkes, Relf, & Couldrick, 1996). The trauma-related thoughts then

prompt the person to experience physiological reactions and extreme psychological

distress (Cohen et al., 2002; Goodman, Cohen, Epstein, et al., 2004). For people

with CG, reminders of trauma, loss, and recent changes cause emotional numbing and

avoidance, whereas such reminders facilitate the healing process for those whose

bereavement is uncomplicated.

Complicated or pathological grief

 reactions are maladaptive extensions of normal bereavement. Maladaptive reactions

may overlap with symptoms of other psychiatric disorders and typically require more

complex, multimodal therapies than do uncomplicated

grief

 reactions (National Cancer Institute, 2008). Adjustment disorders (especially depressed

and anxious mood or disturbance of emotions and conduct); major depression; and substance

abuse are among the more common psychiatric sequelae of CG (Rando, 1993).

Diagnosis. In recent years CG has been the topic of several studies (Cohen et al.,

2002); the findings suggest that if not treated appropriately the condition may cause

negative long-term mental health consequences (Melhem, Day, Shear, Day, Reynolds,

& Brent, 2004). As a result, researchers are making attempts to define CG, understand

its relation to various adaptive responses and desired mental health outcomes, and

identify efficacious interventions (Brown & Goodman, 2005).

Although mental health providers do not yet recognize CG as an actual disorder, there

is a growing consensus that it should be included in the DSM, and some researchers

have proposed specific diagnostic criteria (Forstmaier & Maercker, 2007; Horowitz,

Siegel, Holen, Bonanno, Milbrath, & Stinson, 2003). Prigerson and Jacobs (2001) posit

that CG is distinguishable from other disorders currently covered by the DSM-IV-TR

by features of separation distress as well as

traumatic

 distress. Separation distress refers to a preoccupation with the deceased accompanied

by cognitions and behaviors such as longing and searching;

traumatic

 distress is a feeling of disbelief coupled with mistrust, anger, and other symptoms

resulting in clinically significant impairment.

Horowitz and colleagues (2003) contend that the symptoms of some CG reactions differ

from the DSM-IV-TR criteria for major depressive disorder. Hence, they suggest such

diagnostic criteria as experience of intense intrusive thoughts, pangs of severe

emotion, distressing yearnings, feelings of extreme emptiness and loneliness, excessive

avoidance of tasks reminiscent of the deceased, unusual sleep disturbances, and significant

loss of interest in activities more than a year after the loss. Symptoms must last

at least six months and disrupt daily functioning.

Most recently, Prigerson, Vanderwerker, and Maciejewski (2008) presented a case for

changing the terminology from CG to PGD. In addition to proposing specific diagnostic

criteria, the authors present descriptive features, risk factors, outcomes, and differential

diagnoses for PGD. Clearly, the development of specific diagnostic criteria for CG

is an important direction for future research.

Treatment. Given that as yet there are no consistent definition and specific diagnostic

criteria for CG, few randomized trials for treating it have been conducted. Studies

testing various types of treatment have had mixed results; additional research is

needed to help determine which treatment options may be best (Piper, Ogrodniczuk,

Joyce, & Weideman, 2009).

Shear, Frank, Houck, and Reynolds (2005) conducted a randomized controlled trial

with adults to compare the efficacy of a novel approach, complicated

grief

 treatment (CGT), with interpersonal therapy (IPT), a standard psychotherapy. CGT

specifically addresses trauma symptoms and combines loss-focused cognitive-behavioral

techniques with restoration-focused IPT strategies. Both treatments produced improvement

in CG symptoms, although CGT demonstrated higher response rates and faster time to

response.

Some studies have also examined the use of cognitive-behavioral therapy (CBT; Boelen,

de Keijser, van den Hout, & van den Bout, 2007; De Groot et al., 2007. CBT has been

used to treat a variety of psychiatric conditions, and recently treatment models

have also been extended to address aspects of adjustment to

grief

 and loss (Mathews & Marwit, 2004). CBT helps bereaved individuals identify and change

maladaptive cognitions and behavior patterns, which researchers suggest are at the

core of

traumatic grief.

Other forms of therapy, such as IPT, may also be effective (Klerman et al., 1984).

Although IPT was originally designed as a short-term therapy for depression, the

foci of

grief

 and role transitions seem particularly relevant for bereaved individuals with depressive

symptoms (Miller et al., 1994).

Grief

 is typically the most common problem area focused on when addressing the loss of

a loved one, although it may be necessary to examine other areas to determine how

they might be influencing management of the client's

grief

 reactions (Miller et al., 1994). As noted, researchers have demonstrated the usefulness

of incorporating IPT strategies into CG treatment (Shear et al., 2005).

Researchers have also examined effective treatments specifically for bereaved children.

According to Stubenbort and Cohen (2006), treating children who have CG requires

treatment of both trauma and

grief

 symptoms. Similarly, successful outcomes are associated with bringing surviving

family members into the treatment process. Additional studies are needed to examine

the appropriateness of current options for treating grieving individuals, including

children, who present with CG symptoms.

Bereavement and grieving are considered normal processes when an individual is coping

with a major loss (APA, 2000). As noted,

grief

 reactions may vary as a result of factors such as culture, age, and time since loss.

Although grieving individuals experience a period of significant emotional distress

after a loved one dies, usually the ability to engage in new interests, pleasurable

activities, and healthy relationships will eventually return (Tomita & Kitamura,

2002). In some cases, however,

grief

 reactions are more chronic and longstanding, resulting in clinically significant

impairment in social, occupational, or other major areas of functioning. Such CG

needs significantly more examination by clinicians and researchers if the nature

of this disorder and its treatment are to be fully understood.

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Robyn A. Howarth is affiliated with The University of Iowa. Correspondence concerning

this article should be directed to Robyn A. Howarth, Department of Psychological

and Quantitative Foundations, The University of Iowa College of Education, 361 Lindquist

Center, Iowa City, Iowa 52242-1529. E-mail: robyn.howarth at stjude.org.

Questia, a part of Gale, Cengage Learning. www.questia.com

Publication Information:

Article Title: Concepts and Controversies in Grief and Loss. Contributors: Robyn

A. Howarth - author. Journal Title: Journal of Mental Health Counseling. Volume:

33. Issue: 1. Publication Year: 2011. Page Number: 4+. COPYRIGHT 2011 American Mental

Health Counselors Association; COPYRIGHT 2011 Gale, Cengage Learning

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