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Experiences of Grief - Coggle Diagram
Experiences of Grief
Processing Grief
Roles of Death in Life
- Death of self
- Death of others
Death of Self
- Defensive avoidance
- Reflective acceptance
-
Grief
- Permanent reality
- Price pay for love
Types of Grief (Shear, 2012)
- Acute
- Integrated
- Complicated
Acute Grief
- Immediate & intense emotional response to loss
- Typically lasts few weeks/months
- Healthy processing moves to integrated grief
- Unhealthy/insufficient processing moves to complicated grief
Integrated Grief
- Permanent grief but no longer disruptive/intense
- Acceptance of loss but place for loss in ongoing life
- Life seems purposeful
- Capacity for joy restored
Complicated Grief
- Form of prolonged acute grief
- Individual remains stuck in state of intense pain
- Unable to move toward integration
Disenfranchised Grief (Doka, 2008)
- Resultant grief not openly acknowledged/socially validated/publically mourned
- When person experiences significant loss
- Grief legitimised only when lives of victims considered beyond reproach
- No right to grieve/no claim for social sympathy/no claim for support
Meaning Reconstruction (Neimeyer, 2019)
- Central process in grieving is attempt to reaffirm/reconstruct world of meaning that has been challenged by loss
- Death challenge life story & require reconstructing meaningful narrative
- Prolonged grief symptoms vs meaning-making
Example: Questions Asking Self
- Who am I w/out. them
- Why did this happen
- Is it okay to feel joy again
- Was there something I missed/could have done
Why Necessary
- Story tellers in search for meaning & impose meaning on life
- Constructivism (Frankl, 1959)
- Events like loss disrupt meaning & shatter assumptions of world (Janoff-Bulman, 1989)
Reconstructing Meaningful Narrative (Neimeyer & Anderson, 2002)
- Sense-making of loss
- Way to understand loss, not that make the loss okay
- Benefit-finding in experience
- Find benefit in pain & healing
- Identity reconstruction in aftermath
Measure: Integration of Stressful Life Experience Scale (Holland et al., 2014)
- Extent agree/disagree w. statements w. regard to loss of loved one
- 5-point Likert scale
- 1 = Strongly agree
- 5 = Strongly disagree
- Less grief related symptoms the more meaning-making symptoms
- Importance of meaning-making in grief
Statements
- I have difficulty integrating event into my understanding about world
- This event is incomprehensible to me
- I am perplexed by what happened
- Since this event happened I don't know where to go next in my life
- I don't understand myself anymore since this event
- This event has made me feel less purposeful
Theories of Grief
Theories
- Stage theories
- Task theory
- Dual-process model
- Two track model
Stage Theories
- 5 stages (Kübler-Ross, 1969)
- 4 stages (Bowlby, 1982)
5 Stages (Kübler-Ross, 1969)
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Design
- Designed to explain anticipatory grief when hearing about terminal illness
- Extended to include experiences of loss & change
Explanation
- Linear progression
- Failure to progress between stages leads to complicated grief
4 Stage Theory (Bowlby, 1982)
- Shock & numbness
- Yearning & searching
- Disorganisation & despair
- Acceptance that person gone & loss of attachment to other person
- Reorganisation & recovery
Design
- Embedded in attachment theory
- Focus on disruption to close emotional bond
Explanation
- Linear progression
- Failure to progress leads to complicated grief
- Final stage is re-engagement w. self through maintain symbolic connection
- Do things that preserve memory
- Act in way that makes lost one proud
Task Theory (Worden, 2008)
- Is active process w. tasks to address
- Not necessarily in specific order
- Tasks not prescriptive
- Diff & individualised ways to process pain
Tasks to Address
- Accept reality of loss
- Process pain of grief
- Adjust to world w/out. deceased
- Find enduring connection w. deceased while embarking on new life
Accept Reality of Loss
- Often loss hard to process
- Intellectually gone
- Moments where still think they will be there
- Can be to extreme end w. denial
- Work through mindset that person truly gone
Process Pain of Grief
- Confront & work through emotions that make them realise person gone
Adjust to World
- Diff levels
- External changes
- Internal changes
External Changes
- Adoption of new roles & responsibilities
Internal Changes
- Shift identity
- Cosmic confrontation w. reality & asking spiritual q's
Enduring Connection
- Find way to maintain new bond
- Physical attachment gone
- Spiritual attachment can endure
- Connection must allow to continue aspects of own life
Example: Enduring Connection
- Share memories
- Share stories
- Live life in way think they would approve of
Development
- Developed from bereavement lit & clin practice
Dual-Process Model (Stroebe & Schut, 1999)
- Cope w. loss through two types of coping
- Confrontation & avoidance of diff stressors associated w. bereavement
- 'Optimal' grief is oscillating & that productive in processing grief
- Need to process loss, emotions, & accept reality
- Need relief from intense loss experience
Types of Coping
- Loss orientated
- Restoration-orientated
Loss-Orientated Coping
- Focus on loss
- Who person was
- Emotions arise from loss
- Experiencing grief, & processing associated pain
- Known as grief work
- Too much is too intense & debilitating
Restoration-Orientated Coping
- Adapting to life
- Engage in daily activities
- Focusing on future, & engage in daily activities
- Known as rest breaks from grief
- Too much means not process grief properly
Measure
- Measures oscillation balance
- Score of 0 indicates perfect oscillation balance
Oscillation
- Can be voluntary
- Feel down so distract self from grief
- Can be imposed
- Responsibilities mean have to focus on element other than grief
Two Track Model (Rubin, 1999)
- Healthy adaptation to loss proceed along 2 tracks simultaneously
- Challenges/impediments arise on either/both tracks
Tracks
- Biopsychosocial functioning
- Relationship to deceased
Biopsychosocial Functioning
- Response to loss
- Symptomology of grieving
Strengths & Difficulties
- Anxiety
- Depression
- Somatic concerns
- Traumatic responses
- Familial relationships
- Interpersonal relationships
- Self-esteem
- Meaning structure
- Work
Anxiety
- Thoughts & feelings
- Degree & frequency
- Triggers & mitigates
Depression
- Thoughts & feelings
- Degree & frequency
- Triggers & mitigates
Somatic Concerns
- Current state of physical processes
- Appetite
- Sleep
- Sexual drive
- General health concerns
Traumatic Responses
- Degree & duration of trauma symptoms
- Other psychopathological diagnoses
Negative
- Helpless
- Unimportant
- Worthless
- Alone
Positive
- Competent
- Unshaken
- Stimulated to grow
Meaning Structure
- Change in values/worldview/spirituality/religion/existential understanding
Work
- Meeting demands at work
- Inadequate
- Adequate
- More than adequate
Investment in Life Tasks
- Energy/motivation for tasks beyond existing
Relationship to Deceased
- Continuing bond
- Ongoing relationship to complex of memories, feelings, thoughts
- Assess bereaved response to loss
Adaptive Strengths & Weaknesses
- Reconnection
- Imagery & memory
- Emotional closeness
- Positive perceptions/affect
- Preoccupation w. loss
- Negative perceptions/affect
- Conflict
- Loss trajectory
- Upsetting impact on self-esteem
Reconnection
- Wish to reconnect w. deceased
- Nature
- Character
- Strength
Imagery & Memory
- What remembered of & relationship w. deceased
Emotional Closeness
- Degree of emotional closeness involvement w. deceased
- Relationship w. deceased
Positive Perceptions/Affect
- Positive perceptions/affect present when thinking about deceased
Negative Perceptions/Affect
- Negative perceptions/affect present when thinking about deceased
Conflict
- Degree deceased is remembered as someone w. whom was problematic relationship
Loss Trajectory
- Reconfiguring understanding of 'stages' of lass as dimensions of response to loss
Upsetting Impact on Self-Esteem
- Feelings of lower self-esteem
Memorialisation & Transformation
- Meaningful ways found to memorialise deceased
Development
- Developed from attachment/trauma literature
Critical Evaluation
- Stage theories
- Task theory
Critical Evaluation of Stage Theories
- Appealing framework
- Deeply ingrained & accepted by society & medical professionals
- Is routinely taught as way to feel okay about emotions
- Phases implies grief is passive process
- But no evidence
Variability of Grief (Genevro et al., 2004)
- Responses widely variable
- Experience emotions at different intensities
- Oscillate between emotions
- No clearly defined course/process of bereavement/grieving
Critical Evaluation of Task Theory
- Is about active element of grieving
- Overall validity of model not empirically examined
- Little evidence for model & often from clin practice not empirical
Critical Evaluation of Dual-Process Model
Study: Oscillation Balance (Caserta & Lund, 2007)
- A: Loss of spouse & engagement in coping style
- P: Widows
- R: Adjustment outcomes related to coping style
- LO coping reported less favourable adjustment outcomes
Engagement in Coping
- Primarily LO
- Balanced
- Primarily RO
Outcomes
- Grief
- Depression
- Loneliness
- Coping self-efficacy
- Perceived active coping skill
- Health care participation skill
- Household management skill
- Home safety skill
- Nutritional self-care
- Personal growth
Implication
- Those oscillating engage in healthier coping
Culture & Grief
- Diff cultures & religions promote diff grief
- Ways to grieve
- Acceptable expressions of grief
- Issue whether it should impact
Grief Disorders
Grief Needing Therapy
- Therapy straight after not necessary (Schut & Stroebe, 2005)
- Intervention can interfere w. bereavement
- For most part & to acceptable level can grieve & adjust to life w/out. loved one (Zisook & Share, 2009)
- But if struggling & look for help should give them it
Disorder Associated w. Grief
- Prolonged grief disorder
- Secondary disorders to berevament
Mental Disorders Secondary to Bereavement
- Major depressive disorder
- Post-traumatic stress disorder
Major Depressive Disorder
- Feelings of sadness/guilt/worthlessness
- Social withdrawal & isolation
Differentiation to PGD in Presentation (Szuhany et al., 2021)
- Symptoms of sadness/social isolation more generalised
- Generalised anhedonia
Post-Traumatic Stress Disorder
- Intrusive thoughts/images of death
- Avoidant behaviours related to death
- Emotional numbness
Differentiation to PGD in Presentation (Szuhany et al., 2021)
- Fear
- Intrusive thoughts of traumatic event
- Threat reduction/safety motivation
- Hyperarousal/hypervigilance
Prolonged Grief Disorder
- Condition character
- Combination of symptoms of MDD & PTSD
Differentiation to PTSD in Presentation (Szuhany et al., 2021)
- Yearning/sadness
- Intrusive thought of loss itself
- Avoidance of painful reminders
- Re-engagement in life
Diagnostic Criteria (PGD; ICD-11)
- Disturbance following death of person close to bereaved
- Persistent & pervasive grief response characterised by 1+ symptoms
- Accompanied by intense emotional pain characterised by 1+ symptoms
- Pervasive grief response persisted for atypically long time (>6 months) following loss, markedly exceeding social/cultural/religious norms
- Disturbance causes sig impairments in personal/family/ social/educational/occupational/ other important area of functioning
Persistent & Pervasive Grief
- Longing for deceased
- Persistent preoccupation w. deceased
Intense Emotional Pain
- Sadness
- Guilt
- Anger
- Denial
- Blame
- Difficulty accepting death
- Feeling have lost part of self
- Inability to experience positive mood
- Emotional numbness
- Difficulty engaging w. social/other activities
Study: Prevalence (Lundorff et al., 2017)
- P: N=8035
- M: Meta-analysis
- R: Prevalence of 9.8%
Differentiation to MDD in Presentation (Szuhany et al., 2021)
Integrative Risk Factor Model (Stroebe et al., 2006)
- Bereavement situation
- Mediated by interpersonal & intrapersonal risk factors
- Appraisal & coping
- PGD symptoms
Study: Protective & Risk Factors (Buur et al., 2024)
- P: 120 studies w. N = 61,580
- M: Meta-analysis & systematic review
- R: Identified protective & risk factors that align w. model
Risk Factors
- Nature of death
- Death of individual
- Attachment anxiety
- No. losses
- Mental health difficulties
- Demographic
Explanation
- Closeness & strength of interpersonal bond
- Question of identity in wake of loss
- Undermine natural order
- Disrupt fundamental assumption of meaning framework
Mental Health Difficulties
- Pre-loss grief symptoms
- Pre-loss depressive symptoms
Explanation
- Already experience intense difficulty w. loss before it occurs
Demographics
- Marital status
- Gender
- Income & education
Explanation
- More isolated
- Restoration coping & social support important
Explanation
- May be men under-reporting
- Socialised to be less reporting of emotions & expected to deal w. less experiencing of emotions
Explanation
- Less access to psychosocial support
- More life stresses on background & chronic level
- Extra burdened may make it difficult to process loss
Explanation
- Undermine predictability of life
- Disrupts meaning system & assumptions of life
Explanation
- Struggle w. separation w. other
- Difficulty processing absence
Explanation
- Bereavement overload
- Being bereaved once an emotional experience
- Processing more in quick succession v. difficult
- New loss can bring back difficulties of old loss
Grief Therapies
CBT
- About symptom reduction
- Target maladaptive behaviour
Study: Cognitive Behavioural Therapy (Konnerup et al., 2024)
- A: Effect of CBT components on PGD symptoms
- M: Meta-analysis of 22 studies (N = 2,602)
- R: Medium effect on PGD symptoms
CBT Components
- Exposure
- Cognitive restructuring
- Behavioural activation
Exposure
- Gradual confrontation w. avoided grief-related thoughts, feelings, & reminders
Impact on PGD
- Reduce anxious avoidance
- Support integration of loss into autobiographical memory
Cognitive Restructuring
- Identify, challenge, & replace maladaptive grief-related beliefs
Impact on PGD
- Reduce distress
- Shift unhelpful thoughts to more balanced, adaptive thoughts
Behavioural Activation
- Re-engagement w. meaningful & enjoyable activities
Behavioural Activation
- Counter depressive avoidance
- Restore mood, functioning, & connection to valued activities
Meaning-Making Therapies
- How make sense & process loss
- Indirect reduction of symptoms
Meaning-Based Constructivist Approach Therapies
- Complicated grief therapy
- Meaning-centred grief therapy
- Meta-cognitive therapy for prolonged grief
- Meaning re-construction therapy
Meaning-Centred Grief Therapy (Lichenthal & Breitbart, 2015)
Meta-Cognitive Therapy for Prolonged Grief (Wenn et al., 2019)
Meaning Re-Construction Therapy (Neimeyer et al., 2017)
- Integrate loss into ongoing self-narrative
- Focus on two dimensions
Dimensions
- Event story of death
- Backstory to relationship
Approach (Neimeyer, 2019)
- Process & make sense of event story
- Chapters of lives w. big moments in life to show have seen challenges & can use resilience again
- Draft table of contents into life to organise loss into larger framework
Narrative Story
- External narrative
- Internal narrative
- Reflexive narrative
Access Backstory
- Imaginal conversation
- Techniques superior to generic forms of counselling (Shear et al., 2005)
Imaginal Conversation Mechanisms
- Chair work
- Letter writing
Complicated Grief Therapy (Shear & Bloom, 2017)