Bereavement and End of Life Issues > Chapter 4 - General Treatment Approaches and Case Studies

Chapter 4: General Treatment Approaches and Case Studies

IV. General Treatment Approaches

The initial treatment approach to be explored is that of Kubler-Ross (1969).This approach was developed through working with dying patients, in addition to their families before and after the death.The primary treatment strategy in this approach is to be available and empathetic.The healthcare practitioner should be willing to listen to the expression of anger and despair and help the person explore these as they would like.Part of this plan is to assess the individual's support system.The presence of a person who is open to listening as the bereft talks about the deceased individual helps them over the initial shock to gradual acceptance.

Since a person may have fantasies or hallucinations of the deceased they will often isolate themselves.The strategy here is not to attack the fantasy but to gradually take the person out of isolation so that energy can be transferred from one relationship to others.So the overall purpose of treatment is to assist the client through the stages of grief back to their previous level of functioning.

One weakness of this treatment is it has not been tested cross-culturally.Whether going through these stages of grief is necessary for all cultures or even all individuals in our culture should be questioned.Other weaknesses would reside in the model itself, whether or not individuals generally go through the designed stages. It also does not rule out developmental or psychological factors of the individuals.

The strengths of this treatment is that it would appear to be congruent with the whole idea of normal bereavement. It is not a mental disorder in which one needs in-depth intervention.Treatment is more of a supportive type to help reduce the pain and work through some of it. Basically, the purpose is to help bear a burden.

Another method of treatment is used by Hodgkinson (1982).This treatment is divided into three stages.In the assessment the focus is on highlighting the area of emotional pain or avoidance.The initial phase of the treatment is concentrated toward the releasing of emotions; convincing the client that the death is real.This is done by bringing in significant objects linked to the deceased, like a picture.Confrontations with these objects are for the purpose of stimulating cathartic outbursts.

In the second stage of the treatment is the third chair exercise.This helps to externalize the conflict by talking to the deceased.In the third stage the client begins to say good-bye to the deceased individual.If not used carefully, this approach may force a natural process.It sounds impatient and whether it works could be questioned.This treatment breaks down helpful defenses which allow the person to cope.The very fact that there are defenses working suggests that the individual is not able to handle the situation at that moment. A strength to this treatment is that some individuals respond better to directness, but this approach should be used cautiously.

The third and final approach that will be explored is crisis intervention.In this approach assessment is done through focusing techniques that will help understand the precipitating event and the effect it has had on the client.After the initial assessment a plan is formed to help bring the person back to their previous level of functioning. Some of the steps in intervention encompass helping the individual bring out feelings that were not previously accessible. This includes anger, grief, or guilt.In addition, an exploration of coping skills can be done. In this stage the person can see what they have already tried and then examine alternative ways of coping.Finally, reopening the social world, or reintegration, can be accomplished by exposure to others who can fill the void of the loss.In the last phase the therapist helps the client review the new found coping skills and see hope in the future through planning.

This approach fits in nicely with bereavement.It is a short term crisis that is difficult to deal with. A strength of this approach is that it assesses and even strengthens coping skills, taking into account the current functioning of the client.Since this treatment is only to be done in crisis situations, the only possible weakness would be in the poor assessment or intervention of the therapist.

All of the approaches above are of a preventive nature, which is appropriate for uncomplicated or normal bereavement. The main goal is to allow the client to grieve as normally as possible and prevent any long term dysfunction or disorder. The prognosis for such prevention oriented treatment is very good, considering the nature of the diagnosis.The expectations of all of these treatments are that the person is able to return to their previous level of functioning with the integration of the loss into their life.

V. Case Studies: Assessments and Treatment Interventions

A. Psychosocial Assessment and Treatment of Bereavement

The next part of this course is a case study in bereavement.The setting is a public outpatient clinic and at this stage the client had been in therapy two months.This case study shows the initial assessment and interventions of treatment, future planning of sessions with the client and considerations for the scope of treatment.

I. Presenting Problem

The client is a forty year-old Hispanic female who comes to the agency complaining of depression, nervousness, and difficulty sleeping.The precipitating factor of these symptoms appears to be the death of her 18 year-old son. He was shot and killed while attempting to steal a car (not a car jacking). In addition, the client reports her family to be struggling with the grieving process.Most notably are her long-term live-in boyfriend who has resorted to heavy drinking, and her fourteen year-old son who has withdrawn, but also acts out in anger. This son is currently on probation for riding in a stolen car.

II. The Client Characterologically

The client comes to the sessions clean and well groomed.She is very verbal and cooperative.Her speech content is very tangential, almost like free-associating or in a dumping style. The client displays some traits of a dependent personality disorder manifested in session by her need of therapist approval and permission.Further, the client expresses fears of abandonment and allows others to do a lot of her thinking and decision making for her.

In addition to the dependent traits, the client exhibits some passive aggressive traits.For example, the client will forget or procrastinate completing her boyfriend’s requests instead of directly refusing to do them.She also becomes irritable whenever he requests anything.This is as a result of her disappointment and anger toward the boyfriend for drinking and telling her not to cry over her son's death.

The client is also very favorable to her eight year-old son compared to her fourteen year old.She reported to the therapist while both were present how wonderful her eight year old is and hugged him. At the same time she explained to the therapist what a quiet boy, and bad boy her other son is. This seemed to show some narcissistic qualities, caring for he who fulfills her needs and showing a lack of empathy for the suffering the fourteen year old son is experiencing.

III. Psychosocial Issues

There are many psychosocial issues which currently impact on the client.In regards to the family constellation, the patient has been living with her current partner for sixteen years, resulting in two children: the fourteen and eight year- old sons already mentioned.A previous marriage produced two other children: the recently deceased son and a daughter who is sixteen and currently pregnant.The client receives AFDC and both she and her boyfriend are presently unemployed.

Neither she nor her boyfriend is able to speak English, and neither have a driver's license, although both drive.This resulted in the client receiving a $400 ticket.Other debts include $5500 for funeral and burial expenses.

Other psychosocial issues within the family affecting the client include the conflictual relationship of her two sons who fight an average of five times per day.The client's boyfriend puts her in a double bind telling her to let Cesar, her deceased son, rest in peace and not to cry, and on the other hand telling her that she does not care that Cesar died when she does something for fun.

Issues from sources external to the family include the investigation of the crime itself.The client has a great deal of anger because in her perception her son was killed and the police do nothing about it, while they give her a ticket that she can hardly pay.The client is also trying to work through Victims of Crime to pay for the burial costs, but the case is still under investigation.

The Client has been seeing a medical doctor who referred her to the agency.He was prescribing Florexepan to help her sleep, and Diazepan to combat her nerves.She complains of the side effects of these medications from being very sleepy and having difficulty pronunciating correctly.Client denies any abuse of drugs or alcohol on her part.

Educationally the client went up to the third grade while in Mexico and she confesses to have low reading and writing skills in Spanish and, as mentioned, does not speak English. This limits her attempts to work within her environment to get her needs met.

Regarding religion the client belongs to the Catholic faith.She has had troubles in this area as her priest, in her perception, is avoiding her.Religion also influences her attitudes toward mourning her son's death, wearing black, and not allowing certain previously enjoyable activities in her home out of respect for the dead.

IV. Life Experiences and Ego Development

The client has a history that factors in many experiences that put her at risk for the characterological traits mentioned earlier. The client's mother left for the United States when the client was one year-old.This appears to have been the primary attachment figure for the client since her father abandoned the family prior to her birth.The client was left with the grandmother to live.

At the age of one year the client would have already formed an attachment with the mother and begun to explore the environment, looking back to make sure the mother is still there (Bowlby, 1977 and Mahler, 1975).Finding the mother not there could cause confusion, unhealthy anxiety, and destroy the trust and experimentation with autonomy the infant is attempting to establish during this time period (Erikson, 1964).Such experiences may be contributors to her intense feeling of abandonment by her son, in addition to that continuing fear as part of dependent personality.

This experience validates the mention of the possibility for avoidant personality traits, also.Having had the attachment interrupted the client would be at risk to fear involvement in other relationships, especially those outside of the family. These symptoms, or personality disorders, are an outward manifestation of an underdeveloped ego. Because so much of the client's identity and development were tied into the mother as an attachment figure, the loss of that figure causes a halting and a possible regression of the ego's development.The results of this lower ego functioning are manifested by her poor boundary and limit setting for her boyfriend in relation to his poor treatment toward her.In addition, she appears to be detached from some of her children, yet smothering to others.

The client’s underdeveloped ego boundary developed an overly enmeshed relationship with her deceased son, resulting in the adjustment disorder she is now experiencing.This is manifested currently by her seemingly loss of self at the loss of her son. Her life is not perceived as valuable to her now, and many things she does are tied into Cesar's life and events surrounding his death. An example of this is her unwillingness to eat well because Cesar did not eat dinner the night he was shot; since he was hungry, she must also be hungry.

So the rupturing of the bond at infancy has had a great effect on the client’s reaction to her son's death.Many of these disorders or problems have also been reinforced by some childhood and adolescent events.At nine years of age the client moved north to Tijuana with her siblings and grandmother to live with her mother.The client's mother opened a restaurant there. This situation lasted only a few years.The mother and grandmother began arguing a lot until the grandmother decided to move back south.The client and her siblings were left with the decision to live with their mother or their grandmother. They all chose to move back to their grandmother's.

Obviously a strong attachment had formed with the grandmother which probably saved the client from more embedded dysfunctions. However, the choice to leave her mother may have contributed to her abandonment issues.At sixteen another loss was experienced. This time her mother got papers to bring the client and her siblings up to the United States and did so.This, and the subsequent death of her grandmother three years later, added to her loss and abandonment.

In her adulthood the client married a man who was very abusive to her.They lived together for five years and broke it off after counseling. Since that time the client has lived with her current partner for sixteen years.

V. Ecological Pressures

In examining the client's environment it is important to assess the “energy” exchanges taking place (Anderson and Carter, 1984). Referring to ecological pressures means that there is negative energy directed toward the client, or an unequal exchange of positive energy. One of the primary ecological pressures on the client is her indebtedness.This pressure comes from the mortuary, cemetery, and the court. The client is attempting to pay some of these debts, lessening the negative energy toward her with positive energy.

In regard to family, there appears to be mostly negative energy flowing, although with her extended family members the client is receiving a good amount of support.This is one of the greatest factors guarding the client from progressing toward entropy.

Other interactive forces in the client's environment are the children's schools and church that provide positive energy, while others such as the juvenile probation department, and the police which in the perceptions of the client add pressures.

VI. Treatment

The main goal of treatment is to bring the client to at least her previous level of functioning that existed prior to the death of her son.The client's symptoms of her problems and goals of treatment are as follows:

Presenting Problems Treatment Goals
1. Dysphoric mood as evidenced by patient's statement,
”I am depressed over my son's death."

Baseline=16 hrs. of dysphoric mood per day.
1. Decrease dysphoric mood to 8 hrs. per day per client report
2. Insomnia evidenced by ct. sleeping 4 hrs. per night per client report.

Baseline=4 hrs per night.
2. Client to sleep 8 uninterrupted hours per night per client report.
3. Low energy evidenced by inability to do housework per week per ct. report.

Baseline=0 hrs. of house cleaning activity per week.
3. Client will clean house 1 time per week per client report.
4. Client isolating from family.

Baseline=l0 hrs. per day per client report.
4. Client to begin communicating with family surrounding issue of son's death.
5. Lack of appetite as report by client.

Baseline=1 meal per day
5. Client to eat at least 3 meals per day as reported by the client.

The treatment model that is being used with this client is individual psychotherapy with monthly collaborative visits with her two sons (The client's boyfriend refuses to come). The approach in treatment is brief therapy focusing on bereavement.The schedule of treatment is to have weekly visits for the first four months and afterward having bi-monthly visits during the last two months of treatment to help with termination of the treatment.

The primary interventions to be used are conative therapy to allow the individual through the initial stages of grief (Kubler-Ross, 1969) including denial, anger, bargaining and depression. In addressing the depressive symptoms cognitive theory will be used and will receive greater emphasis as the client accepts the loss and what it entails.

This treatment was chosen on the basis of previous literature and studies on bereavement counseling. In a study of sixty one women Marmar and others (1988) found that brief psychotherapy helped to significantly reduce key symptoms of grief. Alexy (1982) compared client preference to treatment approaches between conative and cognitive theories. He found that clients preferred the conative approach throughout therapy, but cognitive therapy became more preferred as treatment continued. In addition to these studies, others have also found that support for grief and encouragement of mourning are beneficial to prevent pathological grief and assist the client to reach previous levels of functioning.

As already listed, the goals in treatment for the client are to return to previous levels of functioning prior to the death of her son. The first two months of treatment consisted of working with the client where she was at emotionally. Sessions began with her talking a lot about her emotions that day and the therapist worked with her in exploring these feelings with a lot of empathic responses.

The client has been able to verbalize quite well her feelings and the therapist/client relationship was well established and helpful to the process. The client would discuss the events ofthe week and report on her progress in goals without prompting. The client reported to be eating two meals per day, and in a dysphoric mood about six hours per day. Sleeping continued to be difficult and, as a result, the client requested to see the psychiatrist and was prescribed medication to assist with her sleeping. In session the client's affect is happier and she appears more stable. There have been two collaborative visits with the client's remaining sons. They have continued to fight with each other which was a problem previous to the incident. The client's boyfriend is still somewhat unstable though he does not attack her grieving as much. The client has begun to mix in some colors with her primarily black-mourning clothing. In addition, the client has begun to attend a religious Bible-study group which she reports to be helping her a great deal.

At his point treatment consisted of continued empathic responses and exploration. In addition, it appeared the client may have been on the tip of acceptance, kind of vacillating in and out of this step. Some lower level cognitive interventions could be implemented at this point, but it was still important not to push them as the hurt may have caused the client to regress to some denial. The therpist will follow the client's lead as she talks about the acceptance of the death herself. Then exploration of what that death meant to her, and letting go could be processed.

As the client is able to accept the loss of her son as evidenced by her return to the previous level of functioning, then the therapist will discuss with the client reducing the sessions to every other week. After two sessions then they can begin reviewing in more depth her original purpose for coming to treatment and the progress she has made since that time. They can then use this as a foundation for talking about ending her treatment which would now project as being at least a month earlier than the previous estimate. At termination the therapist will assure the client that he will be available to her for a few more months.

There is more work to be done for this client and her family so there can be a possible referral. However, as far as the current therapist’s treatment with the client, she came in for help with her grieving process and that is the main focus of treatment. Although the other pressures may not be part of an ideal lifestyle, the client was able to cope with these difficulties before coming to treatment.

If it is decided the client and the therapist will continue to work together they will concentrate on helping her work more in depth on the ecological and abandonment issues. Because there are a lot of ecological issues involved, empowering the client to use her environment to work through these are important. At his point goals include interpreting for her in communication with “Victims of Crime” and referring her to parenting classes to help her discipline her sons. In addition, collateral visits with the family can be planned to discuss each other's grieving and work on relationship building, and refer/encourage her to join a support group, possibly within her church, to increase her social activity and for a source of energy.

In working with her issues of loss and abandonment the client may need to have provided the opportunity to mourn these losses. Such a process may bring up issues of transference as the fear of being abandoned by the therapist will probably come into play. After the realizations of all the anger and hurt from the loss has been realized, then some ego functioning can be repaired through the setting of boundaries and the greater sense of self as a more independent personality. Finally, some cognitive restructuring can be utilized to assist the client in viewing her world differently, helping her understand cause and effect, and use this to empower her. Added to this is the importance, especially in the early stages, of encouragement, expression of caring, and validation of her grief. Helping her work through stages of grief are fundamental in this process.

B. Case Study: Multiple Losses and Treatment Approaches

Beder (2002) cites the following case study and treatment interventions: After the death, Laura (48 years old) continuously questioned why she had been singled out to be so tortured. Her life had been going along fairly well: she had had a serious, committed, loving relationship with a man, Sid (53 years old), for the past 7 years; her three children were grown, one living nearby, the other living upstate, and her oldest son, David (24 years old), living at home and working. She was healthy and had a steady job, and although she was not rich, she lived comfortably. She had limited contact with the husband from whom she had been divorced when the children were very young; she spent weekends with Sid and during the week she would see friends and “do her thing.”

Sid was a magazine editor and had never married; when he had met Laura 7 years prior they just seemed right for each other and a deep and abiding love developed between them. They were each other's best friend; the separate living arrangement seemed to suit both of them, allowing each some freedom while being deeply committed to time together. Sid had not been feeling just right for a short time before consulting his doctor. Tests showed some type of malignant mass in his pancreas, and he was to begin chemotherapy as soon as it could be scheduled. This weighed heavily on Laura and Sid, despite the optimistic prognosis offered by Sid's doctors.

In Laura's life, the routine of the household was that she woke David up in the morning, as he was notorious for sleeping through his alarm clock and arriving late for work. One morning, she went down the steps to his room and bent over to shake David awake, but this morning he could not be awakened; he had died during the night. Laura ran through the house screaming, called 911, and within minutes the medics and police were there but he had been dead for several hours. The final determination was that he had died from an embolism that probably began in his leg and traveled to his heart. No explanation was forthcoming from the doctors about why a clot had formed. David had been treated for recurring allergic reactions over the years and the doctors speculated that perhaps an explanation resided there. An autopsy was ordered; to this day, Laura has not looked at it.

The next days were a total blank as Laura went through the motions of all that had to be done. The family gathered, the funeral took place, and Laura blocked most of it out.

Essentially, she was unable to function. Her grief and depression were crippling and overwhelmed everything. For the first few weeks, she could not eat or sleep; she was unable even to consider returning to work, as she was immersed in her grief. Sid and others suggested that she should get some help, so Laura went for group counseling at a local mental health agency. The group proved somewhat helpful; it enabled Laura to return to work about 5 weeks after David's death. At work, she found herself short tempered, snapping at those who worked with and for her; she was preoccupied and could not focus; and she was frequently late. Somehow she was able to get through most days, only to come home and cry.

David died in April, and Sid died in November. Sid began to spiral downhill about 3 months after David's death. He was losing weight and strength and was forced to leave his job. The doctor began to use words such as “hospice” and “care facility, ” which was the signal that Sid was not going to improve. During the last months of Sid's life, Laura was very involved in his care, and to the end she believed that he would get better. Even on the last day in the hospital when Sid died, she remained hopeful. Again, the family gathered, hers and Sid's, the funeral took place, and Laura blocked out most of it.

It was her anger that finally propelled her into individual counseling; she was unable to be civil to those at work “who were idiots.” The few friends that she still had, her mother, and even the people in the grocery store “who push ahead as though I am not standing there” were objects of her wrath. She found herself irrationally lashing out at anyone who even slightly annoyed her, and she began to feel isolated and frightened by her own actions. She began bereavement counseling in December, 8 months after David had died.

Three months after Laura had entered counseling, in March, she got word that her former husband had died suddenly from unknown causes. Within 11 months, there had been three deaths: her son, her partner and life mate, and her ex-husband. “How much can a person take?” Laura lamented.

Treatment Interventions

Two approaches to bereavement work for those with multiple losses will be suggested: Worden's model of grief therapy and guided mourning.

1. Grief Therapy-Worden

Worden (2002) outlined nine procedures to follow for those struggling with complicated mourning, for those suffering multiple losses, or both. These procedures are listed here numerically, but it should not be assumed that they must be followed chronologically. When dealing with multiple losses, Worden suggested that generally it is best to explore the loss believed to have the fewest complicating factors first and then apply the same schema to the subsequent losses.

  • Rule out physical disease. If the mourner presents with physical complaints, it is important to assess the mourner for any physical problems to be certain that the complaints are not emotionally based.

  • Set up a contract for the focus of the work and establish an alliance. Setting up a contract may be difficult for the mourner but it is wise to adhere to Worden's procedures. Within this step, the multiply bereaved agrees to reexplore his or her relationship with one of the deceased persons (as noted, the client should decide which is the least complicated loss, which would be the first addressed). The counselor reinforces the beneficial aspect of this part of the work despite the pain that it might provoke in the survivor. The focus is specifically on the loss and what is directly related to it. Within this procedure, the counselor temporarily becomes a substitute for the lost person, offering hope and comfort. Establishing an alliance may be difficult, as those who have been faced with multiple loss do not easily connect for fear of losing yet another person.

  • Revive memories of the deceased person. Talk about the person who died, his or her respective qualities, what he or she was like, what is best remembered about him or her, what he or she enjoyed doing, and how he or she related to the bereaved. Once some of these positive memories have been discussed, a slight turn is needed to help the mourner look at some aspects of the deceased person that have a negative quality such as anger, hurt, and disappointment. By looking at the deceased in a more balanced way-as possessing good qualities and bad-the griever is helped to see the deceased as less idealized. This balance can help in integrating the loss by seeing that much will be missed and some aspects of the deceased will not.

  • Assess which of the four mourning tasks are not complete and make an effort to address the gaps. The four tasks of mourning as detailed by Worden are to accept the reality of the loss, experience the pain of grief, adjust to the environment in which the deceased is missing, and withdraw emotional energy and reinvest it in another relationship. If the mourner has not accepted the reality of the loss, the survivor has to begin the letting go of the deceased; if the difficulty is in experiencing the pain, the counselor has to help the mourner feel safe enough to feel both the positive and negative aspects of his or her grief. The safety is built up through the accepting relationship established between counselor and griever. If adjusting to the environment seems to be the hurdle, then problem solving becomes the focus to help the bereaved to make the needed accommodations to get back to living. If the bereaved is unable to engage in a new relationship and withdraw his or her emotional energy from the deceased, the counselor has to work with the mourner to help release him or her from a binding attachment to the deceased and to be free to develop a new relationship. Often mourners are afraid to let go of the deceased for fear that the deceased will be forgotten. It may be constructive to counsel the griever to build new connections to the deceased, new ways to think about him or her in a more spiritual or ethereal manner. The counselor who urges social connectedness with others and by encouraging and supporting efforts in that direction can facilitate this. Often membership in a bereavement group can be the first step in that part of the healing process.

  • Deal with effect or lack of effect stimulated by memories. There is a tendency for the bereaved to speak of the deceased in overly glowing terms. Early on in the counseling this is encouraged but it is suspect later on in the work as this hyperbole often covers angry, unexpressed feelings. The counselor must urge the survivor to feel the anger and hurt, which facilitates the verbal expression of these emotions. Guilt, as well as anger, is often not directly expressed. The feelings of guilt are to be reality tested by the counselor, as often these feelings are irrational.

  • Explore and diffuse linking objects. Linking objects are symbolic yet concrete objects-such as a watch, camera, or clothing-that the survivor retains that keep the deceased's memory alive. Counselors are urged to discuss these objects with the survivor and encourage the survivor to bring them into the counseling session. The problem with linked objects is that the survivor often becomes compulsively attached to the object and may experience anguish if the item is misplaced. In addition, the retention of the object(s) can restrict the grieving process. The letting go of the linked object is seen as a step toward letting go of the deceased.

  • Acknowledge the finality of the loss. Some survivors harbor the belief that the deceased will return, holding on to a chronic hope for reunion. The counseling effort is to help the bereaved accept the loss and understand why he or she is holding on to this belief.

  • Deal with the fantasy of ending grieving. Help the bereaved to explore the fantasy of what it would be like to complete grieving, what would be lost and what would be gained. Does he or she want to relinquish the role of mourner?

  • Help the mourner say a final good-bye. Survivors need to be reassured that saying good-bye to the deceased does not mean that the deceased will be forgotten. In addition, the process of saying goodbye to the grief counselor has to be handled well, with the counselor initiating and discussing the ending of the relationship with the bereaved, giving the bereaved a lot of notice and time to adjust to the loss of their relationship. For those who suffer multiple losses, leaving the bereavement counselor might activate some of the previous losses (Worden, 2002). Worden suggested that a scheduled recheck with the counselor be agreed upon, especially if new issues arise.

2. Guided Mourning

As described by Mawson, Marks, Ramm, and Stern (1981, p. 185), guided mourning “…likens unresolved grief, to other forms of phobic avoidance which have been treated successfully by exposure to the avoided situation.” Multiple losses usually create unresolved grief, and patients are amenable to this approach. Guided mourning involves intensive exposure to reliving of avoided painful memories and feelings associated with bereavement. It entails repeated deblockedion of difficult situations pertaining to the loss, encouragement to visit places that have been avoided since the loss, encouragement to verbally and behaviorally say good-bye to the deceased, assignments consisting of forced writing and thinking about the deceased, facing the grief, and daily viewing of the deceased’s photograph (Rando, 1993).

In their investigation on the effectiveness of guided mourning, Maw-son and colleagues compared two groups of 6 patients each. The patients in the control group were encouraged to avoid thinking of the deceased, to not give much attention to painful memories, and to employ distraction whenever possible. The guided mourning group was directed to immerse themselves, in imagination and real life, in their loss. All

patients were assessed as having morbid grief reactions and had been on a clinic waiting list for bereavement counseling. Each group had six sessions with a grief counselor over a 2-week period. After 2 weeks, the guided mourning group showed significantly greater improvement on three measures and a trend toward improvement on four measures on a grief measurement inventory. In contrast, the control group showed no significant improvement or trend on any measure. These findings have led the researchers to state, “Results suggest that guided mourning is a useful ingredient in the management of morbid grief” (Mawson et al., 1981, p. 191) despite the limited sample.

As an approach, guided mourning appears most useful in survivors where mourning has been avoided, repressed, or delayed. For the mourner with multiple losses, because of the potential for numbing based on repeated losses, it would be advisable to look at each loss separately and experience the loss as an entity unto itself.

In summary, the individual who sustains multiple losses can be helped using various intervention approaches. Guided mourning and Worden's procedures for helping those with complicated mourning are suggested because they address the aspects of multiple losses that keep the mourner from experiencing grief and moving through it.


 
Bereavement and End of Life Issues > Chapter 4 - General Treatment Approaches and Case Studies
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