INTERVENTIONS FOR PROLONGED GRIEF
Solution-focused therapists do not usually offer direct advice. However, in some circumstances they may choose to offer strategies or ideas which others have found to be of value. In common events such as grief there are a number of recognised options which can be tried. Some are drawn from my practice while others have been developed by different disciplines.
Losing a loved one by death or separation is followed by grief. Prolonged grief is defined as grief which is not moving through the expected stages at the expected pace or where grieving is continuing beyond the expected time period. This must be distinguished from a formal depressive illness arising from the stress of bereavement, which has identifiable symptoms and may require treatment in addition to any intervention required for the bereavement process. According to The Compassionate Friends organisation for bereaved parents (TCF; http://www.tcf.org.uk/) grief for a lost child is never wholly completed. This can apply to parents who lose children through adoption or separation as well as loss through death.
Normal grief after the death of a pet is a maximum of three months (Keddie 1977). But if we die, our pet will not grieve for three months. We grieve according to our kind, not according to the nature of the relationship. So there is a time of grieving which we cannot shorten, although some of the techniques described may reduce our pain. Equally, we can know that one day our pain will be less. When we receive a physical injury, often that first moment is the worst that it will ever be; thereafter, even in small ways, healing and recovery are reducing the pain. Mourning follows a similar pattern.
Prigerson et al (1997) propose that ‘traumatic grief’ predicts prolonged distress. Shear et al (2005) rename this concept ‘complicated grief’, identifiable within six months of the loss by ‘a sense of disbelief regarding the death; anger and bitterness over the death; recurrent pangs of painful emotions, with intense yearning and longing for the deceased; and preoccupation with thoughts of the loved one, often including distressing intrusive thoughts related to the death’. (They devised ‘complicated grief therapy’ (CGT): see below.)
However, Breen and O’Connor (2011) suggest that grief is not a fixed process with recognisable stages. Instead they conclude that grief comes and goes for a variable length of time, with recurrences that may be just as painful as the first time, although perhaps less prolonged. They suggest that support from others is important and helpful. The best support takes the form of listening and asking for details (‘what else?’) about the loss. Offering explanations and saying ‘pull yourself together’ is not helpful.
Prolonged grief may benefit from intervention. Also, certain individuals may benefit from earlier intervention in the grieving process. For example, a young mother who has lost her partner may not be able to care for her children adequately unless her own distress can be reduced. Similarly, personal distress can make it difficult for counsellors to practise their profession.
Some of the techniques below have proved useful in both prolonged and acute grief and are offered as possibilities for appropriate situations. The list is deliberately short and to the point. In acute grief many people do not find it easy to follow complex strategies or instructions. However, a single brief response or action may allow the pain to diminish for the time being.
The first session will often include future-focused questions such as the miracle question. With some clients who have experienced a recent loss or bereavement, their miracle will be a restoration of the loss such as ‘My girlfriend will come back’, ‘My gran will not be dead’. This is evidence that they are still in the ‘numbness’ stage of bereavement and have not yet accepted their loss. They will not be able to develop new visions of the future until they accept the loss, so further future-oriented questions are unlikely to be useful at this stage. Possible responses are: ‘Is there any chance that you will get together with your girlfriend again? or ‘It would be good if your grandmother could come back to life but I guess that this is not very likely to happen?’ Then the worker can move to crisis intervention questions.
Focused crisis intervention questions:
John Sharry and his colleagues (2002) have suggested creative uses for rating scales from 1-10: ‘How confident are you that you can get through the day / the weekend? What would increase that by one point?’. They also use the interview to take stock of the effect of the event itself. ‘Has this event made you stronger or weaker? Are there things that you are thinking now that had not occurred to you before? Is it possible that some good might come of this? If you look back in six months and see that this turned out for the best, what will you be doing then?’.
It can be important to face and perhaps remove painful cues concerning the lost person (Shear et al 2005; Mawson, Marks and Ramm 1981). Some may be objects with a practical use and therefore worth keeping. It is usually advisable to retain one photograph of the person, preferably out of sight or put away for safe keeping. In the future, a single photograph can be useful for family memories or life history techniques. If some of the reminders are large items, consider a car boot sale or an auction house.
Modern means of communication have added to the variety of reminders of the lost person that may be retained inappropriately.
Delete all emails with painful contents, but be careful not to delete email sequences until you have made sure that there are no useful facts further down in the sequence. Consider if you wish to block emails from the person and if they should remain in your ‘Contacts’ list.
Shared life experiences
The object of these exercises is to begin the creation of new memories which do not include the lost person.
Restrict talk about your loss to one or two people. These may be personal friends or professionals. Otherwise you will constantly be asked ‘how are things?’ and so be reminded again. Once your feelings have moved on, you may not wish people to know how distressed you were.
Change all documents such as bank statements which include the lost person.
Go out and meet people and have many brief conversations. This will also help you to identify aspects of the lost person for the exercises below.
If possible, do not move home until the grieving process has diminished. It is easy to make mistakes while distressed and the additional stress of removals will not help. It is usually wise not to form a new relationship until you have moved some way through the grieving process, as your distress means that you are likely to make mistakes and experience additional pain.
To reduce intrusive or negative thoughts
Dreams of the lost person
During sleep, dreams of the lost person can be distressing reminders, which may also disturb sleep. Jungian practitioners have studied the psychotherapeutic aspects of the dreaming process for many years. They have found that dream material becomes less painful and less frequent if it is attended to in waking life. They advise writing down as much as you can remember of the dream and any thoughts and associations that come to mind about it while you are doing this (Martin 1955). This can form part of the ‘write, read and burn’ task described above. Dream content takes some months to catch up with changed appearances and relationships (Macdonald 1984).
Some like to write these materials, reread them and then burn or shred them.
Complicated Grief Therapy (CGT)
A combination of imaginal exposure (from cognitive behavioural therapy) and restoration of effective functioning (from interpersonal therapy). Therapists record patients recalling stories of their loved one's death and patients listen to the tape between sessions. They try to reduce distress levels during each session by "promoting a sense of connection" to the loved one, for example through imagined conversations with the deceased and a discussion of positive and negative memories about him or her. They ask patients to discuss what their plans and goals would be if their grief was not so intense.
Eye Movement Desensitisation and Reprocessing (EMDR)
This has been used in pathological grief with benefit. It cannot help in the initial ‘numbness’ stage. However, in subsequent phases it can remove specific blocks and can ease the grieving process. It cannot accelerate the adjustment process, which will remain painful. (See Solomon and Rando 2007.)
FURTHER READING AND REFERENCES
Breen LJ, O’Connor M (2011) Family and social networks after bereavement: experiences of support, change and isolation. Journal of Family Therapy 33: 98-120.