Psychotherapy of traumatic grief: a review of evidence for psychotherapeutic treatments

Are youth suicide memorial sites on Facebook different from those for other sudden deaths?

To explore possible distinctive features of online memorials for youth suicides, amid concerns about glorification, we compared public Facebook memorials for suicides and road traffic accident deaths, using Linguistic Inquiry and Word Count software. People who posted on memorial sites wrote at greater length about suicides, using longer words and more quotation marks. Words suggesting causation and achievement were more prevalent in suicide memorials. Thematic content for the two types of death was more similar than different. Suicide memorial posts had more tentative words, non-fluencies, and question marks, suggesting that people were struggling to make sense of these deaths.

The Usage of Digital Resources by Swedish Suicide Bereaved in Their Grief Work: A Survey Study

This study examined Swedish suicide bereaved individuals’ use of different resources in their grief work and how they value these resources. The material consisted of a web-based survey, which was analyzed with quantitative methods. The results showed that the psychosocial ill-health was severe among the suicide bereaved participants and that a majority used digital resources in their grief work. The propensity to engage in online support groups or memorial websites was not predicted by the severity of psychosocial consequences following the suicide. However, multiple regressions showed that higher online support group activity predicted more satisfaction with current psychosocial health, while memorial websites seemed to have the opposite effect. This study not only indicates that some digital resources, for example, online support groups, may be an effective way of coping with grief related to suicide loss, but also suggests that memorial websites may increase rumination and in this way cause emotional distress.

Disaster Management: Mental Health Perspective

Disaster mental health is based on the principles of 'preventive medicine' This principle has necessitated a paradigm shift from relief centered post-disaster management to a holistic, multi-dimensional integrated community approach of health promotion, disaster prevention, preparedness and mitigation. This has ignited the paradigm shift from curative to preventive aspects of disaster management. This can be understood on the basis of six 'R's such as Readiness (Preparedness), Response (Immediate action), Relief (Sustained rescue work), Rehabilitation (Long term remedial measures using community resources), Recovery (Returning to normalcy) and Resilience (Fostering). Prevalence of mental health problems in disaster affected population is found to be higher by two to three times than that of the general population. Along with the diagnosable mental disorders, affected community also harbours large number of sub-syndromal symptoms. Majority of the acute phase reactions and disorders are self-limiting, whereas long-term phase disorders require assistance from mental health professionals. Role of psychotropic medication is very limited in preventing mental health morbidity. The role of cognitive behaviour therapy (CBT) in mitigating the mental health morbidity appears to be promising. Role of Psychological First Aid (PFA) and debriefing is not well-established. Disaster management is a continuous and integrated cyclical process of planning, organising, coordinating and implementing measures to prevent and to manage disaster effectively. Thus, now it is time to integrate public health principles into disaster mental health.

From suicide survivor to peer counselor: breaking the silence of suicide bereavement

This study sought to explore the phenomenon of peer counseling in suicide bereavement by addressing the question, what are the lived experiences of suicide survivors who become peer counselors? Participants were 15 individuals bereaved through suicide who had been volunteering with others bereaved in the same manner. This research employed the interpretative phenomenological analysis (IPA) approach to provide a detailed description of participants' journeys that went from experiencing the suicide of a loved one, to the decision to become a peer counselor, to, finally, providing support to other survivors. The findings suggest that participants understand the provision of peer counseling as a transformative process. Being a peer counselor means actively challenging the silence around suicide by speaking out about suicide-related issues and offering other survivors a safe space to share their stories. The broader implications of these findings for suicide postvention research and clinical practice are addressed.

The Impact of Contact With Suicide-Related Behavior in Prison on Young Offenders

Background: Prison suicide rates are high, and suicide-related behaviors (SRBs) higher, but effects of contact with such behaviors in prison have not previously been examined. Aims: To compare the mental state of young men witnessing a peer’s suicide-related behavior in prison with that of men without such experience, and to test for factors associated with morbidity. Method: Forty-six male prisoners (age 16–21 years) reporting contact with another’s suicide-related behavior in prison were interviewed 6 months after the incident, with validated questionnaires, as were 44 without such contact at least 6 months into their imprisonment. Results: Significantly higher levels of psychiatric morbidity and own suicide-related behaviors were found in the witness group, even after controlling for their higher levels of family mental illness and pre-exposure experience of in-prison bullying. Some personal factors were associated with higher morbidity; incident and institutional factors were not. Conclusions: Findings of heightened vulnerabilities among young men exposed to suicide-related behaviors in prison suggest a need for longitudinal study to clarify temporal relationships and inform strategies to prevent or limit development of morbidity and further harm.

After the death of a friend: young men's grief and masculine identities

Young men can have an uncomfortable relationship with grief. Socially constructed masculine ideals dictate that men be stoic in the aftermath of loss, most often expressing their sadness and despair as anger. Perhaps because of alignment to such masculine ideals little research has been done to explore young men’s grief – and chronicle the ways they think about loss, their responses and how they go about describing their identities after a tragic event. Using qualitative individual interviews and photo elicitation methods, we investigated the ways in which 25 men aged 19–25 grieved the accidental death of a male friend. The study was conducted from April 2010–December 2011. Causes of death were diverse, and included motor vehicle accidents, adventure sports, drug overdose and fights. The findings revealed men’s predominant grief responses as emptiness, anger, stoicism and sentimentality. Participants’ description of their grief responses illustrated the ways in which they struggled to reconcile feelings of vulnerability and manly ideals of strength and stoicism. We gained insight into men’s grief practices by looking at the ways in which they aligned themselves with a post-loss masculine identity. These identities, which included the adventurer, father-figure and the lamplighter, revealed gender-specific processes through which men understood and actively dealt with their tragic loss. The results offer novel insights to men’s grief and identity work that may serve to affirm other men’s experiences as well as guide counselling services targeted to young men.

Complicated grief therapy as a new treatment approach

Complicated grief therapy (CGT) is a relatively new psychotherapy model designed to address symptoms of complicated grief. Drawn from attachment theory and with roots in both interpersonal therapy (IPT) and cognitive-behavioral therapy, CGT includes techniques similar to prolonged exposure (repeatedly telling the story of the death and in vivo exposure activities). The treatment also involves focusing on personal goals and relationships. CGT has been demonstrated to be effective in a trial in which participants with complicated grief were randomly assigned to CGT or IPT; individuals receiving CGT responded more quickly and were more likely to respond overall (51% vs 28%). This article briefly summarizes the conceptual underpinnings of CGT, discusses the empirical evidence for its efficacy, describes its techniques, and presents a case example of a client treated in a 16-session manualized CGT protocol. The article concludes with a description of future research directions for CGT.

A traumatic death support group program: applying an integrated conceptual framework

This article describes an 8-week, curriculum-based traumatic death support group program that is offered at Bo's Place, a grief and bereavement center in Houston, Texas. The program was implemented in 2006 in an effort to help family members who had experienced a death in the family by suicide, murder, accident, or sudden medical problem. The program provides the opportunity for families to come to the center and engage in selected activities as a unit, while also providing adults and children the opportunity to participate in separate support groups with curricula adapted to different age levels. The program uses an integrated conceptual framework that draws upon elements from a variety of theoretical and conceptual models related to grief. The purpose of the program is to provide multiple paths for progress in the grief journey for the bereaved. In 2008, Bo's Place incorporated a brief questionnaire into the weekly meetings, in an effort to gain a better understanding of the perceptions of adult participants of the program and their own progress in their grief. The questionnaire asked adults to provide self-ratings of their perceptions of support from the program and of their progress in their grief journey. The positive results from this pilot study have encouraged Bo's Place to develop plans for more rigorous research into the mechanisms that contribute to progress in the grief journey for bereaved adults and children.

Identifying bereaved subjects at risk of complicated grief: Predictive value of questionnaire items in a cohort study

Background

Bereavement is a condition which most people experience several times during their lives. A small but noteworthy proportion of bereaved individuals experience a syndrome of prolonged psychological distress in relation to bereavement. The aim of the study was to develop a clinical tool to identify bereaved individuals who had a prognosis of complicated grief and to propose a model for a screening tool to identify those at risk of complicated grief applicable among bereaved patients in general practice and palliative care.

Methods

We examined the responses of 276 newly bereaved individuals to a variety of standardised and ad hoc questionnaire items eight weeks post loss. Inventory of Complicated Grief (ICG-R) was used as a gold standard of distress at six months after bereavement. Receiver operating characteristic (ROC) curves analysis was performed for all scales and items regarding ICG-R score. Sensitivity, specificity and area under curve (AUC) were calculated for scales and items with the most promising ROC curve analyses.

Results

Beck's Depression Inventory (BDI) was the scale with the highest AUC (0.83) and adding a single item question ('Even while my relative was dying, I felt a sense of purpose in my life') gave a sensitivity of 80% and specificity of 75%. The positive/negative predictive values for this combination of questions were 70% and 85%, respectively. With this screening tool bereaved people could be categorized into three groups where group 1 had 7%, group 2 had 23% and group 3 had 64% propensity of suffering from complicated grief six months post loss.

Conclusions

This study shows that the BDI in combination with a single item question eight weeks post loss may be used for clinical screening for risk of developing complicated grief after six months. The feasibility and clinical implications of the screening tool has to be tested in a clinical setting.

How the Internet is changing the experience of bereavement by suicide: A qualitative study in the UK

The aim of this qualitative study was to explore how Internet support may be changing the experiences of people who have been bereaved by suicide. Forty narrative interviews about the (whole) experience of being bereaved by suicide were conducted with a maximum variation sample of people living in the UK. Interviews were transcribed for thematic analysis. The analysis explores several ways in which the Internet has made a difference to the aftermath of the death. These include the use of e-mail and social networking sites to inform others about the death, making sense of the events and gaining support from an Internet community of others who had been similarly bereaved and setting up website memorials. A few people preferred not to use the Internet for this purpose or had no access to a computer. Few adverse consequences of Internet communities were mentioned. In conclusion we found evidence that the Internet is transforming the experience of bereavement by suicide, most dramatically through providing access to other people’s experiences.

Bereavement in families with relatives dying of cancer

PURPOSE OF REVIEW

The aim of this review is to examine the new conceptualization on bereavement and, more specifically, on grief and bereavement in family members of patients who have died of cancer

RECENT FINDINGS

Current research findings in palliative care clearly suggest that grief and bereavement should be approached as a continuum, in order to provide optimal care for the family both before and after the death of their loved one. A growing body of evidence indicates the need for screening of dysfunctional patterns during anticipatory grief (preparatory grief) to prevent complications during bereavement and set up proper intervention. The concept of pathological grief and its risk factors has also been the subject of research. New phenomenological dimensions of pathological grief, such as complicated grief and traumatic grief, have been explored. Complicated grief has been proposed as a possible category in DSM-V.

SUMMARY

It is important to understand the suffering endured by family members of patients dying of cancer and the consequences of bereavement. A careful and systematic exploration of the risk factors for pathological bereavement is important for optimal psychosocial care of family members in palliative medicine programs and community medicine.

Grief and its complications in individuals with intellectual disability

Bereavement and loss have significant impact on the lives of individuals with intellectual disability (ID). Although there is a growing impetus to define the symptoms of grief that predict long-term functional impairment, little is known about maladaptive grieving among individuals with ID. We examine the literature concerning the phenomenology of traumatic grief (TG) in the general population, along with what is known about the manifestations of grief in individuals with ID. We then apply modern theories of grief and grief resolution to individuals with ID in order to highlight potential areas of vulnerability in this population and to lay the groundwork for interventions that will facilitate their adaptation to loss. We provide a theoretical framework for the proposition that individuals (including children and adults) with ID are more susceptible to TG, based on an increased risk of secondary loss, barriers to communicating about the loss, and difficulty finding meaning in the loss. We conclude that individuals with ID should be considered as potential candidates for targeted bereavement interventions. Further research is required, however, in order to develop population-appropriate measurement scales for testing these hypotheses.

Interventions to Enhance Adaptation to Bereavement

This paper reviews quantitative evaluations of the efficacy of intervention programs designed to reduce the pain and suffering associated with bereavement. After identifying the psychological and physical health impacts of bereavement and outlining the prevalence of detrimental outcomes, we conclude that a minority of bereaved persons experience severe and sometimes lasting consequences, whereas the majority manage to overcome their grief across the course of time. We detail criteria for establishing the efficacy of bereavement intervention and examine the impact of intervention according to these stringent criteria. We critically examine previous reviews and summarize their conclusions. Using a narrative review approach, we apply a public health framework to organize intervention programs into primary, secondary, and tertiary prevention strategies. A comprehensive, updated review of empirical studies in these categories leads to the following conclusions: Routine intervention for bereavement has not received support from quantitative evaluations of its effectiveness and is therefore not empirically based. Outreach strategies are not advised, and even provision of intervention for those who believe that they need it and who request it should be carefully evaluated. Intervention soon after bereavement may interfere with "natural" grieving processes. Intervention is more effective for those with more complicated forms of grief. Finally, a research agenda is outlined that includes the use of rigorous design and methodological principles in both intervention programs themselves and in studies evaluating their efficacy; systematic investigation of "risk factors"; and comparison of relative effectiveness of different intervention programs (i.e., what works for whom).

A case for establishing complicated grief as a distinct mental disorder in DSM-V

In this paper, we contend that complicated grief (CG) constitutes a distinct psychopathological diagnostic entity and thus warrants a place in standardized psychiatric diagnostic taxonomies. CG is characterized by a unique pattern of symptoms following bereavement that are typically slow to resolve and can persist for years if left untreated. This paper will demonstrate that existing diagnoses are not sufficient, as the phenomenology, risk factors, clinical correlates, course, and outcomes for CG are distinct from those of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and adjustment disorder (AD). It is argued that the establishment of CG as a diagnostic entity is essential because its symptoms are associated with enduring mental and physical health morbidity and require specifically designed clinical interventions. We conduct a critical review of all published evidence on this topic to date, demonstrating that the advantages of standardizing the diagnostic criteria of CG outweigh the disadvantages. In addition, recommendations for future lines of research are made. This paper concludes that CG must be established in the current nosology to address the needs of individuals who are significantly suffering and impaired by this disorder.

Social work competencies in palliative and end-of-life care

Social workers from clinical, academic, and research settings met in 2002 for a national Social Work Leadership Summit on Palliative and End-of-Life Care. Participants placed the highest priority on the development and broad dissemination of a summary document of the state-of-the-art practice of social work in palliative and end-of-life care. Nine Summit participants reviewed the literature and constructed this detailed description of the knowledge, skills, and values that are requisite for the unique, essential, and appropriate role of social work. This comprehensive statement delineates individual, family, group, team, community, and organizational interventions that extend across settings, cultures, and populations and encompasses advocacy, education, training, clinical practice, community organization, administration, supervision, policy, and research. This document is intended to guide preparation and credentialing of professional social workers, to assist interdisciplinary colleagues in their collaboration with social workers, and to provide the background for the testing of quality indicators and "best practice" social work interventions.

Complicated Grief in Survivors of Suicide

Summary: Complicated grief is a newly defined and distinctive psychiatric disorder that occurs in response to a significant loss through death. New findings suggest that survivors who were close to the deceased are at heightened risk for complicated grief. Little is known about whether close kinship (spouses, parents, children, siblings, vs. in-laws, aunts/uncles, nieces/nephews, friends, or coworkers) to a suicide victim also represents a heightened risk for complicated grief. Assessing for complicated grief is important, especially with survivors of suicide, because of the potential for associated health risks. This report contains preliminary data from an exploratory, descriptive pilot study examining complicated grief in adult survivors of suicide. Sixty bereaved subjects, within one month after the suicide of a family member or significant other, were assessed for complicated grief symptoms. Statistically significant differences, as measured with the Inventory of Complicated Grief, were noted between closely related and distantly related survivors of the suicide victim. These preliminary results indicate that health care professional's assessments and interventions for complicated grief should take into consideration the bereaved's familial and/or social relationship to the deceased. The closely related survivors of suicide had higher levels of complicated grief and could be at risk of developing physical and/or mental health problems, including suicidal ideation, in the future.

Does grief counseling work?

Most bereavement caregivers accept as a truism that their interventions are helpful. However, an examination of the bereavement intervention literature suggests that the scientific basis for accepting the efficacy of grief counseling may be quite weak. This article summarizes the findings of four recent qualitative and quantitative reviews of the bereavement intervention literature. It then discusses three possible explanations for these surprising findings and concludes with recommendations for both researchers and clinicians in thanatology that could help to focus efforts to answer the questions of when and for whom grief counseling is helpful.