UNIT 4: TRAUMA & GRIEF COUNSELLING

4.1: Trauma Related Conditions - Acute stress

and Post traumatic stress Disorder
Generalized Anxiety Disorder

Anxiety involves a general feeling of apprehension about possible future

danger & sometimes we cannot clearly specify the danger, and fear is an alarm
reaction that occurs in response to immediate danger & source of danger is
clear.

● Anxiety disorders include those disorders that share features of excessive

fear, anxiety and related disturbances.

● Fear: An emotional response to real or perceived imminent threat

● Anxiety disorders differ from each other in the types of objects or situations
that induce anxiety. Therefore, even though anxiety disorders can be comorbid
in nature, they can be differentiated on the basis of their triggering
objects/situations.

 GENERALISED ANXIETY DISORDER:

1. Live in a relatively constant future-oriented mood state of anxious
apprehension, chronic tension, worry, and diffuse uneasiness that they
cannot control.
2. Show marked vigilance for possible signs of threat in the environment
3. Frequently engage in subtle avoidance activities such as procrastination,
checking, or calling a loved one.
4. Have difficulty making decisions, worry constantly after making a decision.
5. Generalized anxiety disorder is a relatively common condition
6. Current estimates from the National Comorbidity Survey-Replication are
that approximately 3 percent of the population suffers from it in any 1-year
period and 5.7 percent at some point in their lives
7. If it disappears, it may have been replaced by a somatic symptom disorder.
8. It also tends to be chronic.
9. Twice as common in Women than in Men.
10.Age of onset is often difficult to determine because 60 to 80 percent of
people with GAD remember having been anxious nearly all their lives, and
many others report a slow and insidious onset.
11.Co-morbidity with other anxiety and mood disorders such as panic disorder,
social phobia, specific phobia, PTSD, and major depressive disorder
12.Usually don’t seek psychological help but frequently go to physicians with
medical complaints.
 CAUSES : PSYCHOLOGICAL

 PERCEPTIONS OF UNCONTROLLABILITY AND UNPREDICTABILITY-

1. People with GAD may have a history of experiencing many important

events in their lives as unpredictable or uncontrollable.
2. They have less tolerance for uncertainty than non-anxious controls and
than people with panic disorder. This low tolerance for uncertainty in
people with GAD suggests that they are especially disturbed by not being
able to predict the future.
3. In addition, perhaps some of these people’s intolerance for uncertainty, as
well as their tension and hypervigilance (the sense of always looking for
signs of threat), stems from their lacking safety signals in their environment.
4. For e.g. Not knowing when a stressor may occur can lead to lacking safety
signals.

 A SENSE OF MASTERY: THE POSSIBILITY OF IMMUNIZING AGAINST

ANXIETY-

1. A person’s history of control over important aspects of his or her

environment is another important experiential variable strongly affecting
reactions to anxiety-provoking situations.
2. In human children, experiences with control and mastery often also occur in
the context of the parent–child relationship and so parents’ responsiveness
to their children’s needs directly influences their children’s developing
sense of mastery.
3. Parents of anxious children often have an intrusive, over controlling
parenting style, which may serve only to promote their children’s anxious
behaviors by making them think of the world as an uns afe place in which they
require protection and have little control themselves
 THE CENTRAL ROLE OF WORRY AND ITS POSITIVE FUNCTIONS

Several of the benefits that people with GAD most commonly think derive from
worrying are:

1. Superstitious avoidance of catastrophe (Less likely for feared event to

occur)
2. Avoidance of deeper emotional topics
3. Coping and preparation

When people with GAD worry, their emotional and physiological responses to
aversive imagery are actually suppressed. So it reinforces process of worry.

 THE NEGATIVE CONSEQUENCES OF WORRY

1. Worry itself is certainly not an enjoyable activity and can actually lead to a
greater sense of danger and anxiety (and lower positive mood) because of
all the possible catastrophic outcomes that the worrier envisions
2. People who worry about something tend subsequently to have more
negative intrusive thoughts than people who do not worry.
3. Finally, there is now considerable evidence that attempts to control
thoughts and worry may paradoxically lead to increased experience of
intrusive thoughts and enhanced perception of being unable to control
them

 COGNITIVE BIASES FOR THREATENING INFORMATION

1. Not only do people with GAD have frequent frightening thoughts, they also
process threatening information in a biased way, perhaps because they
have prominent danger schemas.
2. Generally allocate attention to threatening cues.
3. Heightened sensitivity to threatening cues
4. They have a much stronger tendency to interpret ambiguous information in
a threatening way.
 CAUSES: BIOLOGICAL

 GENETIC FACTORS- Modest Heritability

1. Neurotransmitter abnormalities- Functional deficiency in GABA. GABA helps

in the way our brain inhibits anxiety in stressful situations.
2. An anxiety-producing hormone called corticotropin releasing hormone
(CRH) has also been strongly implicated as playing an important role in
generalized anxiety. When activated by stress or perceived threat, CRH
stimulates the release of ACTH (adrenocorticotropic hormone) from the
pituitary gland, which in turn causes release of the stress hormone cortisol
from the adrenal gland
3. Cortisol helps the body deal with stress. The CRH hormone may play an
important role in generalized anxiety.
4. Recently, people with GAD have been found to have a smaller left
hippocampal region

TREATMENT: Medical

1. Many clients with generalized anxiety disorder consult family physicians,

seeking relief from their “nerves” or anxieties or their various functional
(psychogenic) physical problems.
2. Most often in such cases, medications from the benzodiazepine category
such as Xanax or Klonopin are used—and misused—for tension relief,
reduction of other somatic symptoms, and relaxation. Their effects on
worry and other psychological symptoms are not as great; can create
physiological and psychological dependence and withdrawal.
3. A newer medication called buspirone (from a different medication
category) is also effective, and it neither is sedating nor leads to
 physiological dependence. It has greater effects on psychic anxiety than do
the benzodiazepines. However, it may take 2 to 4 weeks to show results.
4. Several categories of antidepressant medications like those used in the
treatment of panic disorder are also useful in the treatment of GAD, and
they also seem to have a greater effect on the psychological symptoms of
GAD than do the benzodiazepines. However, they also take several weeks
before their effects are realized.

TREATMENT: Cognitive Behavioural Therapy

1. CBT for generalized anxiety disorder has become increasingly effective as

clinical researchers have refined the techniques used.
2. It usually involves a combination of behavioral techniques, such as training
in applied muscle relaxation, and cognitive restructuring techniques aimed
at reducing distorted cognitions and information-processing biases
associated with GAD as well as reducing catastrophizing about minor
events.
3. Finally, CBT has also been found to be useful in helping people who have
used benzodiazepines for over a year to successfully taper their
medications.

 Post Traumatic Stress Disorder

DIAGNOSIS

Note: The following criteria apply to adults, adolescents, and children older
than 6 years.

A. Exposure to actual or threatened death, serious injury, or sexual violence

in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or

close friend. In cases of actual or threatened death of a family member or
friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the

traumatic event(s) (e.g., first responders collecting human remains; police
officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media,

television, movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated

with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic

event(s).

Note: In children older than 6 years, repetitive play may occur in which themes
or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the

dream are related to the traumatic event(s). Note: In children, there may be
frightening dreams without recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts

as if the traumatic event(s) were recurring. (Such reactions may occur on a
continuum, with the most extreme expression being a complete loss of
awareness of present surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or

external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or

resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s),

beginning after the traumatic event(s) occurred, as evidenced by one or both
of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings

about or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places,

conversations, activities, objects, situations) that arouse distressing memories,
thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic

event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s)

(typically due to dissociative amnesia and not to other factors such as head
injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself,
others, or the world (e.g., “I ambad,” “No one can be trusted,” “The world is
completely dangerous,” “My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the

traumatic event(s) that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or

shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to

experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic

event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically

expressed as verbal or physical aggression toward people or objects.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a

substance (e.g., medication, alcohol) or another medical condition.

 Acute Stress Disorder

1. The diagnosis of PTSD requires that symptoms must last for at least 1
month. Instead, the diagnosis would be acute stress disorder.
2. Acute stress disorder is a diagnostic category that can be used when
symptoms develop shortly after experiencing a traumatic event and last for
at least 2 days.
3. The existence of this diagnosis means that people with symptoms do not
have to wait a whole month to be diagnosed with PTSD. Instead they can
receive treatment as soon as they experience symptoms.
4. Moreover, if symptoms persist beyond 4 weeks, the diagnosis can be
changed from acute stress disorder to posttraumatic stress disorder.
Studies show that people who develop an acute stress disorder shortly after
traumatic event are indeed at increased risk of developing PTSD. This
highlights the importance of early intervention

 TREATMENT

Stress Inoculation Training: This preventive strategy prepares people to

tolerate an anticipated threat by changing the things they say to themselves
before or during a stressful event. As helpful as these approaches are,
however, it is almost impossible to be prepared psychologically for most
disasters or traumatic situations, which by their nature are often unpredictable
and uncontrollable.

Telephone Hotlines

 CRISIS INTERVENTION:

1. Short-term crisis therapy is of brief duration and focuses on the immediate

problem with which an individual or family is having difficulty.
2. In crisis situations, a therapist is usually very active, helping to clarify the
problem, suggesting plans of action, providing reassurance, and otherwise
providing needed information and support. A single-session behavioral
treatment has been shown to lower fears and provide an increased sense of
control among earthquake trauma victims (Başoğlu et al.,2007). Although
people are far from better after this single session, they receive knowledge
and learn skills that will help them gain better control over their lives in the
ensuing weeks and months.
3. A central assumption in crisis-oriented therapy is that the individual was
functioning well psychologically before the trauma. Thus therapy is focused
only on helping the person through the immediate crisis, not on “remaking”
her or his personality.

 PROLONGED EXPOSURE THERAPY: The patient is asked to vividly recount

the traumatic event over and over until there is a decrease in his or her
emotional responses. This procedure also involves repeated or extended
exposure, either in vivo or in the imagination, to feared (but objectively
harmless) stimuli that the patient is avoiding because of trauma-related
fear.
Prolonged exposure can also be supplemented by other behavioral techniques.
For example, relaxation training might also be used to help the person manage
anxiety following a traumatic event. Because prolonged exposure therapy
involves persuading clients to confront the traumatic memories they fear, the
therapeutic relationship may be of great importance in this kind of clinical
intervention. The client has to trust in the therapist enough to engage in the
exposure treatment.

4.2 Bereavement –The Mourning

Process, Abnormal Grief Reactions

 BEREAVEMENT
1. Root of the word means ‘to be robbed’
2. It is the losing of someone to whom one has been closely attached.
3. Feelings that arise are loneliness, emptiness, frustration, deprivation,
yearning and longing, and often abandonment and rejection.

 GRIEF
1. Normal grief, also referred to as uncomplicated grief, encompasses a broad
range of feelings and behaviors that are common after a loss.
2. It is the subjective experience of the loss (Lindemann 1944;Worden, 1982)
3. Gestalt’s holistic perspective helps us see how grief can affect us on all
levels of experience
4. In the body it is experienced as tears, crying, tightness in the throat,
heaviness in the chest, emptiness or churning in the stomach, fatigue,
weakness, restlessness, insomnia, or physical pain.
5. Emotionally , grief can bring sadness, anger , fear, anxiety , mood swings,
shame or guilt, and often relief. On the cognitive level there is first disbelief,
an inability to assimilate the reality of the loss.
6. Preoccupation with thoughts about the deceased is common.

Mental functioning can be disrupted, a kind of temporary attention deficit

disorder , with difficulty concentrating or focusing; being easily distracted,
forgetful, or disorganized; having trouble finishing things begun; and
hyperactivity.

There are major individual differences in how people grieve.

 MOURNING

Mourning is an Old English word meaning “remembering with care and

sorrow . ” Grief is the internal subjective side of mourning, but mourning also
involves the field around us.

At best, it is a public process involving recognition by others of the loss, family

and community presence and support, and social, cultural, and religious
customs and rituals.

 MEDIATOR 1: WHO THE PERSON WHO DIED WAS

1. To begin with the most obvious: if you want to understand how someone
will respond to a loss, you need to know something about the deceased.
2. Kinship identifies the dead person’s relationship to the survivor. Such a
relationship could be that of a spouse, child, parent, sibling, other relative,
friend, or lover.
 MEDIATOR 2: THE NATURE OF THE ATTACHMENT

1. The strength of the attachment- It is almost axiomatic that the intensity of

grief is determined by the intensity of love.

2. The security of the attachment- How necessary was the deceased to the
sense of well-being or self-esteem of the survivor?

3. The ambivalence in the relationship- In any close relationship there is always

a certain degree of ambivalence. Greater ambivalence-> Greater guilt

4. Conflicts with the deceased- Not just to conflicts around the time of death,
but also to a history of conflicts, especially stemming from earlier physical
and/or sexual abuse; possibility of unfi nished business that never gets
resolved

5. Dependent relationships- can affect the person’s adaptation to the death,

especially task III issues. External adjustments will be greater for a person who
was dependent on the deceased for the fulfillment of various daily activities.

 MEDIATOR 3: HOW THE PERSON DIED

1. How the person died has an impact on how the survivor deals with the
various tasks of mourning.
2. Traditionally, deaths are cataloged under the NASH categories: natural,
accidental, suicidal, and homicidal.
3. The accidental death of a child may be grieved differently than the natural
death of an older person, whose death would be seen as occurring at a
more appropriate time.
4. The suicidal death of a father may be grieved differently than the expected
death of a young mother leaving small children.
OTHER DIMENSIONS ASSOCIATED WITH THE DEATH THAT CAN AFFECT
BEREAVEMENT:

PROXIMITY- Where did the death occur geographically—did it happen near

the survivors or far away? (Occured at a distance → Sense of unreality)

SUDDENNESS OR UNEXPECTEDNESS- Was there some advance warning or was

the death unexpected?

VIOLENT/TRAUMATIC DEATHS- The impact of violent and traumatic deaths

can be long lasting and often leads to complicated mourning. Challenges self-
efficacy & internal adjustments, shatter the worldview, difficult to express
anger, guilt (homicide), PTSD

MULTIPLE LOSSES-Some people lose a number of loved ones in a single tragic

event or in a relatively short period of time→ Bereavement overload

Explore each loss individually, starting with least complicated

PREVENTABLE DEATHS- When the death is seen as preventable, issues of guilt,

blame, and culpability come to the surface.

AMBIGUOUS DEATHS-There are some situations when the survivors are not
sure whether their loved one is alive or dead.

Stigmatized Deaths- Doka and others have written about disenfranchised grief
(Attig, 2004; Doka, 1989, 2002). Deaths such as suicide and death by AIDS are
often seen as stigmatized deaths.
 MEDIATOR 4: HISTORICAL ANTECEDENTS
1. In order to understand how someone is going to grieve, you need to know if
he or she has had previous losses and how these were grieved.
2. Were they grieved adequately, or does the person bring to the new loss a
lack of resolution from a previous one?
3. A person’s mental health history may be important here.
 MEDIATOR 5: PERSONALITY VARIABLES

Bowlby (1980) makes a strong plea for therapists and other counselors to take
the mourner’s personality structure into account.

 AGE AND GENDER

Men responded better to affect-stimulating interventions, and women to

problem-solving interventions.

Looking at men who had lost spouses, Lund (2001) found men in their 50s
were the most effective in coping with their grief

 COPING STYLES

Distress is mediated by one’s coping choices—how inhibited one is with

feelings, how well one handles anxiety, and how one copes with stressful
situations. Lazarus and Folkman (1984) define coping as the changing thoughts
and acts that an individual uses to manage the external or internal demands of
stressful situations. There are three main groups of coping functions.

1. Problem Solving Coping

2. Active Emotional Coping: Redefinition, Humor, Venting (+ve & ve
emotions) &Accepting support
3. Avoidant Emotional Coping: Denial, Distraction, Substance or alcohol
abuse, Social withdrawal, associated with development of PTSD or
complicated grief.
 ATTACHMENT STYLE

Another important mediator that affects how one handles the various tasks of
mourning is one’s attachment style. Attachment styles are set up early in life as
the result of early parent-child bonding. The goal of these behaviors is to
maintain or reestablish proximity to an attachment figure usually the mother.

1. Secure Attachment Style

2. Insecure Attachment Styles

a) Anxious / Preoccupied Attachment.

b) Anxious / Ambivalent Attachment.

c) Avoidant / Dismissing Attachment.

d) Avoidant / Fearful Attachment.

 COGNITIVE STYLE
1. Different people have different cognitive styles. Some are more optimistic
than others. Associated with such an optimistic style is the ability to find
something positive or redemptive in a bad situation.
2. People who ruminate persistently and repetitively focus on their negative
emotions without taking action to relieve these emotions
3. How to help those who ruminate a lot? → teach skills for problem solving,
increase social contacts & find more ways of dealing with task IV
 EGO STRENGTH : SELF ESTEEM AND SELF EFFICACY
1. All people come to a death event with attitudes about their own worth and
attitudes about their ability to affect what happens to them in life.
2. Some deaths can challenge a person’s self-esteem and self-efficacy, thus
making the internal adjustments of task more of a challenge (Reich &
Zautra, 1991).
3. This is especially true when ego strength depended on the deceased.
 ASSUMPTIVE WORLD: BELIEFS AND VALUES
1. Each of us carries assumptions about the benevolence and the
meaningfulness of the world (Schwartzberg & Janoff-Bulman, 1991).
2. Some deaths can challenge a person’s assumptive world more than others,
causing a spiritual crisis for the individual who is uncertain of what is true
and what is good.
3. However, certain worldviews can serve a protective function by allowing
individuals to incorporate a major tragedy into their belief system.
 MEDIATOR 6: SOCIAL VARIABLES

Grieving is a social phenomenon

The degree of perceived emotional and social support from others, both inside
and outside the family, is significant in the mourning process.

Several studies have shown that perceived social support alleviates the
adverse effects of stress, including the stress of bereavement (Schwartzberg &
Janoff-Bulman, 1991; Sherkat & Reed, 1992; Stroebe et al., 1999).

Following are the important social mediators:

1. Support satisfaction- More important than the mere availability of support

is the mourner’s perception of social support and satisfaction with it.
2. Social role involvements- Involvement in multiple roles has been found to
affect adjustment to a loss by death. Persons who participate in more and
varied social roles seem to adjust better to loss than those who don’t.

3. Religious resources and ethnic expectations- Each of us belongs to various

social subcultures including both ethnic and religious subcultures. They provide
us with guidelines and rituals for behavior.

 MEDIATOR 7: CONCURRENT STRESSES

Other factors that affect bereavement are the concurrent changes and crises
that arise following a death.

Some change is inevitable, but there are those individuals and families who
experience high levels of disruption (secondary losses) following a death,
including serious economic reversals.

WHEN IS MOURNING FINISHED?

1. There is no ready answer. Bowlby (1980) and Parkes (1972) both say that
mourning is finished when a person completes the final mourning phase of
restitution.
2. Another view= mourning is finished when the tasks of mourning have been
accomplished. It is impossible to set a definitive date for this.
3. One benchmark of mourning moving to completion is when the person is
able to think of the deceased without pain. There is always a sense of
sadness when you think of someone you have loved and lost, but it is a
different kind of sadness—it lacks the wrenching quality it previously had.
4. When people regain an interest in life, feel more hopeful, experience gratifi
cation again, and adapt to new roles.
ABNORMAL GRIEF REACTIONS: COMPLICATED MOURNING

 WHY PEOPLE FAIL TO GRIEVE:

1. RELATIONAL FACTORS
 The type of relationship that most frequently hinder people from
adequately grieving is the highly ambivalent one with unexpressed
hostility.
 Inability to face up to and deal with a high ambivalence in one’s relationship
with the deceased inhibits grief and usually portends excessive amounts of
anger and guilt that cause the survivor difficulty.
 Narcissistic Relationship- To admit to the loss would necessitate
confronting loss of part of oneself, so the loss is denied. In some cases, the
death may reopen old wounds (e.g. abuse) Highly dependent relationships
are also difficult to grieve because feelings of helplessness and the self-
concept of oneself as a helpless person tend to overwhelm any other
feelings or any ability to modulate this negative self-concept with a more
positive one.
2. CIRCUMSTANTIAL FACTORS
 Important mediator of the strength and outcome of grief reaction.
 Certain specific circumstances that preclude a person from grieving or
make it difficult for him or her to bring grief to a satisfactory conclusion.
 Eg. When loss is uncertain, multiple losses.
3. HISTORICAL FACTORS
 People who have had abnormal grief reactions in the past have a higher
probability of having an abnormal reaction in the present
 People who have had a history of depressive illness also run a higher risk
of developing a complicated reaction
 Early parental loss as well as early parenting has an influence on grief
reactions.
4. PERSONALITY FACTORS

Personality factors affects his or her ability to cope with emotional distress.

Some people are unable to tolerate extremes of emotional distress, so they

withdraw to defend themselves against such strong feelings and this often
develops into a complicated grief reaction.

Inability to tolerate dependency feelings.

Self-concept (eg. I am the strong one in the family)

5. SOCIAL FACTORS
 Lazare (1979) outlines three social conditions that may give rise to
complicated grief reactions.
 Socially unspeakable loss (Suicidal death)
 Loss is negated by others around us (Abortion)
 Leads to disenfranched grief- mourner’s grief is not recognized or
sanctioned by society
 Absence of a social support network
 Complicated mourning manifests in several forms and has been given
differentlabels.
It is sometimes called
 Pathological grief
 Unresolved grief
 Complicated grief
 Chronic grief
 Delayed grief
 Exaggerated grief.

Definition

The intensification of grief to the level where the person is overwhelmed,

resorts to maladaptive behavior, or remains interminably in the state of grief
without progression of the mourning process towards completion.

It involves processes that do not move progressively toward assimilation or

accommodation but, instead, lead to stereotyped repetitions or extensive
interruptions of healing

AN EMERGING DIAGNOSIS OF COMPLICATED GRIEF

1. Two factors at work in complicated grief; one was traumatic distress and
the other separation distress.
2. Although this is interesting theoretically, these two types of distress tended
to overlap and correlated highly so this idea received less attention along
the way.
3. The other idea that emerged is that this phenomenon of complicated grief
was distinctly separate from anxiety and depression.
4. They posited that there are three distinct entities: complicated grief,
anxiety, and depression with minimal overlap (Prigerson, Bierhals, Kasl, &
Reynolds, 1996).
  AN EXISTING MODEL OF COMPLICATED MOURNING

This paradigm describes complicated mourning under four headings:

(3) exaggerated grief reactions

(4) masked grief reactions.

 CHRONIC GRIEF REACTION:

1. Excessive in duration and never comes to a satisfactory conclusion
2. Fairly easy to diagnose because the person experiencing it is very much
aware that he or she is not getting through the period of mourning.
3. This awareness is particularly strong when the grieving has gone on for
several years and the person is feeling unfinished.
4. It is common for people to come 2 to 5 years after the death
“I’m not getting back to living,” “I need help to be myself again.”
Even though the person is aware of the condition, chronic grief does not
necessarily resolve on its own.
5. Treatment would require assisting them to deal with any of the 4 tasks of
mourning.
 DELAYED GRIEF REACTIONS
1. Delayed grief reactions are sometimes called inhibited, suppressed, or
postponed grief reactions. In this case the person may have had
anemotional reaction at the time of the loss, but it is not sufficient to the
loss.
2. At a future date the person may experience the symptoms of grief over
some subsequent and immediate loss, and the intensity of his orher
grieving will seem excessive
3. Multiple losses can also cause grieving to be postponed due to the
magnitude of the loss and bereavement overload.
4. Such delayed reactions can occur not only after a subsequent loss, but also
when one is watching someone else go through a loss, or a media event in
which loss is the main theme
 EXAGGERATED GRIEF REACTIONS
1. Feels overwhelmed or resorts to maladaptive behaviour
2. People with an exaggerated grief response are aware that the symptoms
and behaviors they are experiencing are related to the loss, and they seek
therapy because their experience is excessive and disabling.
3. Exaggerated grief responses include major psychiatric disorders that
develop following a loss and often receive a DSM diagnosis..
4. Anxiety, Depression, Phobia, Alcohol & Substance Abuse, PTSD, Mania
 MASKED GRIEF REACTIONS
1. Patients experience symptoms and behaviors that cause them difficulty, but
they do not recognize
2. These symptoms or behaviors are related to the loss.
3. They develop non-affective symptoms.
4. Masked or repressed grief generally turns up in one of two ways: either it is
masked as a physical symptom or it is masked by some type of aberrant or
maladaptive behavior.
5. Physical or psychiatric symptoms

Distinction between exaggerated grief and masked grief-

Both may give rise to a formal psychiatric and/or medical diagnosis. However,
in exaggerated grief, the patient knows that the symptoms began around the
time of the death and are the result of the experience of the loss. On the other
hand, those with masked grief do not associate their symptoms with a death
 CLUES TO DIAGNOSE COMPLICATED MOURNING
1. The person being interviewed cannot speak of the deceased without
experiencing intense and fresh grief.
2. Some relatively minor event triggers an intense grief reaction.
3. Themes of loss come up in a clinical interview.
4. The person who has sustained the loss is unwilling to move material
possessions belonging to the deceased. (Factor in cultural & religious
differences)
5. An examination of a person’s medical record reveals that he or she has
developed physical symptoms like those the deceased experienced before
death (around anniversaries or similar age)
6. Make radical changes to their lifestyle following a death presents a long
history of subclinical depression, often marked by persistent guilt and
lowered self-esteem or the opposite
7. A compulsion to imitate the dead person self-destructive impulses
8. Unaccountable sadness occurring at a certain time each year
9. A phobia about illness or about death is often related to the specific illness
that took the deceased.
10.Knowledge of the circumstances surrounding the death can help the
therapist determine the possibility of unresolved grief
 4.3: grieving special types of losses:

1. Sudden death:

Sudden deaths are those that occur without warning and require special
understanding and intervention. Although suicidal deaths fall into this
category, there are other types of sudden deaths, such as accidental deaths,
heart attacks, and homicides that need to be discussed.

There are certain special features that should be considered in work with the
survivors of those who die a sudden death.

 Unreality about the loss: A sudden death usually leaves survivors with a
sense of unreality about the loss. Whenever the phone rings and one learns
that a loved one has died unexpectedly, it creates a sense of unreality,
which may last a long time. It is not unusual for the survivor to feel numb
and to walk around in a daze following such a loss. It is common for the
survivor to experience nightmares and intrusive images after a sudden loss,
even though they were not present at the time of the death. Appropriate
counseling intervention can help the survivor deal with this manifestation
of sudden death, reality test the event, and deal with the intrusive images
from the trauma.
 Feelings of guilt: Feelings of guilt are common following any type of death.
However, in the case of a sudden death, there is often a strong sense of
guilt expressed in “if only” statements such as “If only I hadn’t let them go
to the party,” or “If only I had been with him.” One of the main issues of
counseling intervention is to focus on this sense of culpability and help the
survivor reality test the issues of responsibility. A common phenomenon
found in children after a sudden death is that of guilt associated with the
 fulfillment of a hostile wish. It is not uncommon for children to wish that
their parents were dead or that their siblings were dead, and the sudden
death of that person or people toward whom the hostile wish was directed
can leave the child with a very difficult load of guilt
 Need to blame: In the case of a sudden death, the need to blame someone
for what happened can be extremely strong. Because of this, it is not
unusual for someone within the family to become the scapegoat and,
unfortunately, children often become easy targets for such reactions.
 Involvement of medical and legal authorities: For those whose loved one
was the victim of homicide, getting on with the tasks of mourning is diffcult,
if not impossible, until the legal aspects of the case are resolved. As
everyone knows, the judicial system moves slowly, and these procedures
often take a long time to reach completion. The delays can serve one of two
functions. They can delay the grieving process; that is, people who are
grieving may be so distracted by the details of the trial that they are kept
from dealing with their own grief on a fi rsthand basis. However, there are
times when these legal interruptions can play a positive role. When there is
some adjudication of a case and the case is closed, this can help people
move forward with their grieving.
 The sense of helplessness: This type of death is an assault on our sense of
power and on our sense of orderliness. Often this helplessness is linked
with an incredible sense of rage, and it is not unusual for the survivor to
want to vent his or her anger at someone. Occasionally, hospital personnel
become the targets of violence or the survivor expresses a wish to kill
certain people for having been involved in the death of a loved one. It is not
uncommon to hear litigious accusations coming from survivors of those
who die a sudden death. This expression of their rage may help counter the
 feelings of helplessness they are experiencing. A survivor can also exhibit
manifest agitation. The stress of sudden death can trigger a flight-or-fight
response in a person and lead to a very agitated depression. A sudden
increase in levels of adrenalin usually is associated with this agitation.
 Unfinished business: The death leaves them with many regrets for thing
they did not say and things they never got around to doing with the
deceased. Counseling intervention can help the survivor to focus on this
unfinished business and find some way to closure. Meaning making is a
large part of mourning task III. In the case of sudden death, there seems to
be an especially strong need to fi nd meaning. This search for meaning can
be related to the need for mastery when a death has been traumatic. Along
with this, of course, is the need not only to determine the cause but to
assign blame. At this point, some people fi nd that God is the only available
target for their recriminations, and it is not uncommon to hear people say,
“I hate God,” when they are trying to put together the pieces following the
death.
 SOME INTERVENTIONS:
1. Reinforcing self-efficacy to minimize regression as soon as possible.
2. Giving them a choice to see the body of the deceased to facilitate grief and
actualization.
3. Help the person come to the reality of the loss is to use the word “dead,”
for example, “Jenny is dead. Whom do you want to notify about her
death?” Using this word helps bring home the reality of death as well as
giving assistance with regard to arrangements that need to be made.
4. Offer follow-up care, either from yourself or community or religious
resources.
In any discussion of sudden death, one should consider the issue of trauma.
Certain deaths such as homicide can evoke trauma responses as well as grief
responses. The central features of trauma are intrusive images; avoidant
thinking; and hyperarousal, such as hearing a car backfire and thinking that it is
a gunshot.

2. Miscarriage:

 A miscarriage is often treated as a socially negated loss. Often the

pregnancy is not common knowledge and the woman may be embarrassed
to mention that she has lost a baby.
 Self-blame is another major issue among woman who has experienced a
miscarriage. The woman generally needs to blame someone and often the
first focus of her recrimination is inward in self-directed anger. Losing a
pregnancy under these circumstances can add to the degree of self-blame
and the impact of the loss. Women also focus some of their blame on their
husbands.
 Studies show that both men and women grieve in the case of a miscarriage.
In general, the longer the pregnancy, the more intense is the grief,
especially for the father. Attachment is also an important mediator of grief
with this type of loss.
 There are few established rituals for a miscarriage to help make the loss
more tangible and facilitate the expression of grief. There are some things
that the counselor can encourage, such as naming the fetus, having a
memorial service in which a candle is lit or a tree is planted, and fi nding
ways to put the hopes and dreams for the infant into words, such as writing
a poem or letter to the baby.
3. Suicide:

Nearly 750,000 people a year are left to grieve the completed suicide of a
family member or loved one, and they are left not only with a sense of loss, but
with a legacy of shame, fear, rejection, anger, and guilt.

 SHAME: Of all the specific feelings the survivors of those who die by suicide
experience, one of the predominant feelings is shame. The survivors are the
ones who have to suffer the shame after a family member takes his or her
own life, and their sense of shame can be influenced by the reactions of
others. “No one will talk to me,” said one woman whose son killed himself.
 GUILT: Guilt is another common feeling among survivors of suicide victims.
They often take responsibility for the action of the deceased and have a
gnawing feeling that there was something they should or could have done
to prevent the death. This feeling of guilt is particularly difficult when the
suicide happened in the context of some interpersonal conflict between the
deceased and the survivor. Survivors of suicide victims experience guilt
more often than do those who survive those who have died from other
causes Because of the intensity of the guilt, people may feel the need to be
punished, and they may interact with society in such a way that society, in
turn, punishes them.

Guilt can sometimes be manifested as blame. Some people handle their own
sense of culpability by projecting their guilt onto others and blaming them for
the death. Finding someone to blame can be an attempt to affirm control and
to find a sense of meaning in a difficult to understand situation.

 ANGER & LOW SELF ESTEEM- People who survive those who die by suicide
usually experience intense feelings of anger. They perceive the death as a
rejection; when they ask, “Why, why, why?” they usually mean, “Why did
 he do this to me?” The intensity of their rage often makes them feel guilty.
Survivors often speculate that the deceased did not think enough of them
or they would not have committed suicide. This “rejection” can be an
indictment of the survivor’s self-worth, leading to low self-esteem and
intense grief reactions
 FEAR: Fear is a common response after a suicide. Farberow and colleagues
(1992) found higher levels of anxiety among survivors of those who die by
suicide than among survivors of those who died natural deaths. A common
primary fear among survivors is their own self destructive impulses. Many
seem to carry with them a sense of fate or doom.
 Distorted thinking- is another feature found among survivors of suicide
victims. Very often survivors, especially children, need to see the victim’s
behavior not as a suicide but as an accidental death. What develops is a
type of distorted communication in families. The family creates a myth
about what really happened to the victim, and anyone who challenges this
myth by calling the death by its real name reaps the anger of the others,
who need to see it as an accidental death or some other type of more
natural phenomenon. This kind of distorted thinking may prove helpful on a
short-term basis, but it is definitely not productive in the long run.
 INTERVENTIONS:

COUNSELING SURVIVORS OF SUICIDE VICTIMS

 Reality Test the Guilt and Blame - Again, much of the guilt may be
unrealistic and will yield itself to reality testing, giving the person some
sense of relief. There are some instances, however, in which the person
really is culpable, and the counselor is challenged to help the person deal
with these valid feelings of guilt. When blame is the predominant feature,
 the counselor can also promote reality testing. If the blame takes the form
of scapegoating, family meetings can be an effective way to resolve this. A
few survivors feel guilty because of their sense of relief.
 Correct Denial and Distortions- Survivors need to face the reality of the
suicide in order to be able to work through it. Using tough words with them
such as “killed himself” or “hanged himself” can facilitate this. People who
witnessed the suicide are sometimes plagued by intrusive images of the
scene and show this and other signs of PTSD (Callahan, 2000). For people
who were not present, the imagined scene can sometimes be worse than
the actual one. Exploring graphic images can be difficult, but discussing
them can help with reality testing. These images usually fade with time, but
if not, special intervention may be required.

Another task is correcting distortions and redefining the image of the

deceased, bringing it closer to reality. Many survivors tend to see the victim as
either all good or all bad, an illusion that needs to be challenged.

 Explore Fantasies of the Future- Use reality testing to explore the fantasies
survivors have as to how the death will affect them in the future. If there is
a reality involved explore ways to cope with that reality by addressing
questions the survivor may have, such as “When I have children, how can I
tell them that their uncle killed himself?”
 Work With Anger- Working with the anger and rage such a death can
engender allows for its expression while reinforcing personal controls the
survivor has over these feelings.
 Reality Test the Sense of Abandonment- Feeling abandoned is perhaps one
of the most devastating results of a suicide. People who lose loved ones
through a natural death feel abandoned, even though the death was
 neither desired nor caused by the deceased. However, in the case of death
by choice, the sense of abandonment is extreme. There may be some
reality in this feeling, but the level of reality can be assessed through
counseling.
 Help Them in Their Quest to Find Meaning in the Death- Survivors of those
who take their own lives are confronted additionally by a death that is
sudden, unexpected, and sometimes violent. There is a need to search for
an answer to why the loved one has taken his or her life and, in particular,
to determine the state of mind of the deceased before the death. Survivors
frequently feel obliged to explain the suicide to others when such an
explanation is typically beyond their own understanding

4.4 preparing for long term illness: hiv, cancer & palliative
counselling