Complicated Grief Treatment From Both Sides Now

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M. Katherine Shear M.D. Professor of Psychiatry Columbia University Columbia School of Social Work Center for Complicated Grief www.complicatedgrief.org COMPLICATED GRIEF TREATMENT FROM BOTH SIDES NOW ADEC APRIL 2014

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Complicated Grief Treatment From Both Sides Now

Transcript of Complicated Grief Treatment From Both Sides Now

Page 1: Complicated Grief Treatment From Both Sides Now

M. Katherine Shear M.D.Professor of Psychiatry

Columbia UniversityColumbia School of Social Work

Center for Complicated Griefwww.complicatedgrief.org

COMPLICATED GRIEF TREATMENT FROM BOTH

SIDES NOW

ADECAPRIL 2014

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What we feel for someone who…

…is rewarding to be with

…we don’t want to be separated from

…provides comfort and solace when we are feeling bad

…is our cheerleader and coach when we are out there on our own doing new things

M. Katherine ShearCenter for Complicated Grief

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grief is a form of love(the form love takes

when someone we love dies)

M. Katherine ShearCenter for Complicated Grief

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ACUTE GRIEF

The initial response to bereavement• Frequent strong feelings of

yearning and sorrow• A mixture of other feelings

(positive and negative)• Thinking focused frequently on the

deceased• A sense of disbelief• Feelings of insecurity• Loss of interest in ongoing life

Acute grief is usually time-limitedM. Katherine ShearCenter for Complicated Grief

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INTEGRATED GRIEF

A lasting form of grief • Feelings of yearning and sorrow,

mostly muted, in the background• A mixture of other feelings (positive

and negative)• Thoughts of the deceased accessible

and bittersweet• Renewed sense of the potential

for joy and satisfaction in life

Integrated grief is permanent

To be yourself in a world that is

constantly trying to make you

something else is the greatest

accomplishmentRalph Waldo Emerson

M. Katherine ShearCenter for Complicated Grief

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MOURNING IS THE WAY ACUTE GRIEF IS TRANSFORMED AND

INTEGRATED

MOURNING IS A LEARNING PROCESSM. Katherine ShearCenter for Complicated Grief

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WHAT WE NEED TO LEARN

WHAT IT MEANS THAT OUR LOVED

ONE IS REALLY GONE

WHAT OUR RELATIONSHIP

WITH OUR LOVED ONE WILL BE LIKE WHO WE ARE

WITHOUT OUR LOVED ONE

M. Katherine ShearCenter for Complicated Grief

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WHAT WE NEED TO MOURN SUCCESSFULLY

1. Support from friends (we don’t grieve well all alone)

2. Self-compassion

3. To honor and attend to basic human needs

• A sense of belonging• Connection to our authentic selves• Competence to meet meaningful challenges

M. Katherine ShearCenter for Complicated Grief

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COMPLICATED GRIEF

Acute grief persists without a feeling of meaningful progression• Frequent strong feelings of yearning and

sorrow• A mixture of other feelings (positive and

negative)• Thinking focused frequently on the

deceased• A sense of disbelief• Feelings of insecurity and loss of interest in

ongoing life

Grief complications (thoughts, feelings and behaviors) interfere with successful mourning

M. Katherine ShearCenter for Complicated Grief

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COMPLICATED GRIEF

COMPLICATED GRIEF

1. Persistence of acute grief symptoms

2. Complicating cognitive, emotional and behavioral symptoms

COMPLICATIONS Second guessing, “if only” Trying to protect oneself from

the painful reality by avoidance Managing intense emotions

ineffectively

THE TERM “COMPLICATED” used in the medical sense of a superimposed problem that interferes with healing

BEREAVEMENT

MOURNING

blockACUTE GRIEF

INTEGRATED GRIEF

M. Katherine ShearCenter for Complicated Grief

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BEREAVEMENT

Acute grief symptoms

Integrated grief

CGT Targets

Grief complicationsInterfere with

healingNatural healing

Resolving complicating problems

Facilitating natural healing

CONSTRUCTING COMPLICATED GRIEF TREATMENT (CGT)

M. Katherine ShearCenter for Complicated Grief

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CORE PRINCIPLES

1. People have a natural inborn capacity to adjust to loss that utilizes the adaptive unconscious

Successful mourning is facilitated by

2. Receiving meaningful support

3. Self-compassion

4. Addressing self-determination needs 1. A sense of belonging and mattering to others

2. Authenticity

3. Meeting meaningful challenges

M. Katherine ShearCenter for Complicated Grief

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COMPONENTS OF CGT

Grief monitoring

Imaginal revisiting

Situational revisiting

Memories and pictures

Imaginal conversation

Grief monitoring

Building support

Personal aspirations and plans

Self care and positive emotions

Situational revisiting

Loss focus: reshaping grief

Restoration focus: remaking life

• 16-session treatment with elements from CBT, IPT, MI

• Manualized and tested in 2 NIMH-funded studies

M. Katherine ShearCenter for Complicated Grief

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END SESSION

Summary and feedback Plans for the week

RESTORATION FOCUSRewards and self-care Personal

aspirations/goals

LOSS FOCUSImaginal exercise Memories/pictures/

situational revisiting

BEGIN SESSIONREVIEW diary and other

plans Set agenda

STRUCTURE OF A TYPICAL CGT SESSION

M. Katherine ShearCenter for Complicated Grief

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OVERVIEW OF THE 16-SESSION FORMAT

Getting started (Sessions 1-3)• Creating companionship• Getting to know grief (e.g.

introduce GMD)• Orientation to treatment• Introducing aspirational

goals workRevisiting Sequence (Sessions 4-9)• Imaginal revisiting exercise• Situational revisiting• Memories and pictures

work• Aspirational goals work

Midcourse review (Session 10) Closing Sequence (Sessions 11-16) • Imaginal conversation• Finishing revisiting and

memories• Continuing goals work• Possible work on second

loss• Work on termination

M. Katherine ShearCenter for Complicated Grief

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REVISITING

1re·vis·ittransitive verb \(ˌ)rē-ˈvi-zət\ : to go to (a place) again especially after a long period of time: to think about or look at (something) again

Full Definition of REVISIT:  to visit again :  return to; also :  to consider or take up again

http://www.merriam-webster.com/dictionary/revisit

Revisiting in CGT• Imaginal revisitingA procedure in which we ask the person to close her eyes and visualize herself back at the time when she first learned of the death • Situational revisitingA graded exposure-like procedure for revisiting the people, places and things that contain painful reminders of the loss

M. Katherine ShearCenter for Complicated Grief

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IMAGINAL REVISITING: DESCRIPTION

Revisiting is a repetitive imaginal exercise focused on returning to the time of learning of the death to visualize, verbalize and reflect on the reality of the loss

Conducted in 4 steps

STEP ONE: Visualize the time of learning of the death and describe the experience out loud

STEP TWO: Reflect on the death and the experience of visualizing and telling the story, with the help of a trusted companion

STEP THREE: Put away or set aside the revisiting image, thoughts and feelings

STEP FOUR: Shift focus to planning a rewarding activityM. Katherine ShearCenter for Complicated Grief

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IMAGINAL REVISITING (CONT.)

• Revisiting is usually done weekly over a 4-6 week period and possibly a little longer.

• The exercise is recorded so the person can listen to the recording during the week at home.

• We make a new recording each session.

• The process goes faster and is more powerful if the person listens every day.

M. Katherine ShearCenter for Complicated Grief

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SITUATIONAL REVISITING

• Bereaved people cannot avoid reminders of the deceased

• For people with CG these reminders are often very painful

• CGT encourages confrontation with reminders as a natural part of the healing process; facing these situations

• Provides an opportunity for reflecting on the loss

• Releases a bereaved person to resume full engagement in ongoing life

• Work with daily life reminders includes

• Difficult times

• Planned revisiting of avoided activities, places and people

• In-office work with pictures and other momentos

M. Katherine ShearCenter for Complicated Grief