Bereavement
54
Alex Iglesias and Adam Iglesias
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The loss of a loved one is a ubiquitous and devastat-
ing experience. While in many cases, the bereaved
is able to reach a resolution of the loss without the
presence of disabling and/or prolonged characteris-
tics, there are many instances when such loss engen-
ders prolonged and/or debilitating grief. This chapter
will review the burgeoning body of information on
prolonged grief disorder (PGD), a construct that has
been heretofore titled complicated grief, traumatic
grief, and pathological grief with subcategories
including interrupted, delayed, and absence of grief
(Averill, 1968). The literature on the treatment of
PGD with hypnosis also will be reviewed and a case
example of hypnosis-aided behavioral treatment in
a case of spousal bereavement will be presented.
Included is the treatment protocol with a transcript
of hypnotic suggestions, which was employed.
UNCOMPLICATED BEREAVEMENT REACTIONS
Healthy adjustment to bereavement has been
described by several theoretical models (Bonanno
& Kaltman, 1999; Neimeyer, 1998, 2005; Shuchter
& Zisook, 1993; Stroebe & Schut, 1999; Stroebe,
Schut, & Stroebe, 2005a, 2005b). These models
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share several features including (a) focus on resil-
ience and adaptation, (b) premise that adaptation
requires strategies in a multitude of situations, (c)
the importance of developing and operationalizing
coping strategies, and (d) the role that the sociocul-
tural context plays in the adaptation process.
One model relevant to hypnotherapy for
bereavement is the model of adaptation developed
by Bonanno and Kaltman (1999). This theoretical
model places significant importance on behavioral
coping strategies, which act as emotion regulation
strategies as well. It lends credence to the therapeu-
tic value of mastering behavioral tasks considered
C H A P T E R
by the bereaved as too difficult or even impossible
to achieve. Moreover, this model considers the
acquisition of new behavioral skills, in graduated
successive approximations, the key toward a sense
of mastery and independence in the bereaved. This
premise was supported by Bauer and Bonanno
(2001), who found that bereaved individuals who
felt self-efficacious were less likely over time to
experience intense grief. Chentsova, Dutton and
Zisook (2005) also supported this theoretical
premise and emphasized that when conducting
assessments of the functioning of widows and wid-
owers it becomes imperative to define coping more
comprehensively and to take the acquisition of new
skills and improved physical, social, and occupa-
tional functioning into account. Caserta, Lund,
and Obray (2004) also supported this theoretical
position and posited that offering bereavement
counseling services that focus on behavioral strat-
egies, self-care behavioral methods, daily living
skills, and assuming tasks that were the province
of the deceased is a beneficial direction to promote
the personal mastery among the bereaved.
Pursuant to this orientation, Lieberman (1978)
and Ramsey (1978) developed therapeutic pro-
grams for the bereaved that focused on the behav-
ioral therapy methods of systematic desensitization
and flooding. Their aim was for the bereaved to
focus their attention and confront activities asso-
ciated with their loss that they were avoiding.
Theoretically, this approach allows the bereaved
to be exposed to the seemingly intolerable stim-
uli, at a gradual pace, and to achieve successive
approximations of the desired goal at a rate that
is tolerable to the individual. The behavior ther-
apy orientation maintains that changed behaviors
lead to a shift in feelings and thoughts (Barbato &
Irwin, 1992). Controlled exposure to bereavement
cues was based on the Kavanagh (1990) principle
that bereaved individuals need to confront grief
 486 ■ III: PSYCHOLOGICAL APPLICATIONS
by deliberate exposure to bereavement cues. This
principle indicates that only by deliberate expo-
sure to bereavement cues can the bereaved develop
skills for confronting and coping with the distress-
ing signals.
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PROLONGED GRIEF DISORDER
The essence of PGD is the magnification of bereave-
ment traits rather than the diminution of the same
over time. Precursors of the disorder include a his-
tory of prior trauma or loss, a history of mood
and anxiety disorders, insecure attachment style,
a violent cause of death, and lack of social sup-
port subsequent to the loss (Jordan & Litz,
2014). The Diagnostic and Statistical Manual of
Mental Disorders, fifth edition (DSM-5; American
Psychiatric Association, 2013) includes nomen-
clature, which references prolonged grief-related
problems. These include other specified trauma and
stressor-related disorder, and persistent complex
bereavement disorder (PCBD). PGD is a condition
that has been found to be a disorder distinct from
bereavement depression and anxiety (Prigerson et
al., 1996).
RESEARCH ON HYPNOSIS FOR THE TREATMENT
OF GRIEF REACTIONS
The literature on hypnosis for bereavement is
scarce. Perhaps the most ambitious effort of treat-
ing inordinate grief with hypnosis was provided by
Gravitz (2001). A single-session hypnosis-based,
imagery strategy was designed to focus and address
the patient’s tormenting images of her mother as
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she agonized during her final days. These recurrent
intrusive images were hypnotically replaced with
images of her loved one during happy and healthy
times. It was concluded that creating hypnoti-
cally reconstructed memories is a viable approach
for treating inordinate grief. Gravitz (2001) also
contributed a thorough review of the hypnosis lit-
erature for bereavement. This review referenced
an 1813 report wherein the hypnotic techniques
of uncovering and revivification were employed
to assist a young woman to cope with grief.
Additional contributions to the hypnosis literature
on the applications of hypnosis for the treatment
of complicated grief included the work of Fromm
and Eisin (1982), wherein the authors treated a
female patient with self-hypnosis to work through
feelings of loss following the death of her husband.
Furthermore, there were documented case reports
by Turco (1981) as well as Savage (1993) in which
complicated grief reactions in female patients
were successfully treated with hypnosis. In addi-
tion, Gravitz (1994) reported on several cases of
traumatic grief in which hypnotic strategies were
employed first to bring to conscious memory the
previously repressed memories of traumatic inci-
dents. These memories were subsequently restruc-
tured, including the memory of the original event
as well as the psychological meaning to the patient.
In pediatric populations, Iglesias and Iglesias
(2005) developed an approach to reduce obses-
sive focusing on morbid and horrific details of the
accidental death of a parent. The gruesome nature
of the parental death complicated the children’s
grief reaction, interrupted their grief, and led to
a PTSD reaction. The authors designed the hyp-
notic trauma narrative, an instrument designed to
provide therapeutic elements by means of two age-
progression methods. The first is a telescope meta-
phor/strategy created in order to allow the child
to view images of the catastrophic loss through
a distant vantage point (i.e., child looks through
the wide end of a telescope) and facilitate the nar-
rowing, constricting, and blurring of horrific and
painful details. Second, the hypnotic trauma narra-
tive also provides a more unstructured indirect age
progression technique aimed to allow the child to
orient to future possibilities (Phillips & Frederick,
1992).
CASE EXAMPLE
The patient, a 72-year-old Caucasian male who
was 13 months postspousal bereavement, was
referred by a local hospice. He had received 10
bereavement support group sessions with mini-
mal results. The focus of the support group was
emotion-based, which resulted in iatrogenic
effects for this patient (e.g., exacerbated his sense
of despair). He was deeply grieved and met the
criteria for PGD. He exhibited behaviors that con-
tributed to perpetuate the bereavement reaction.
He was also not engaging in behaviors conducive
 54: BEREAVEMENT ■ 487

TABLE 54.1 on behaviors as the unit of attention is consonant

with the orientation of behavioral therapy (Gray &
SELF-DEFEATING BEHAVIORS AND RESOLUTION OF GRIEF Litz, 2005). In behavior therapy, the therapist adopts
EXAMPLES a problem-solving focus and assists patients to opera-
tionalize the presenting problems, set goals, and learn
Self-Defeating Behaviors Facilitators of the new skills to replace self-defeating behaviors (Barbato
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(SDB) Resolution of Grief (FRG) & Irwin, 1992). Theoretically, this approach is based
Refuses invitations from Accept invitations on the notion that behavior is learned and through
friends a systematic training program, the patient can be
helped to replace self-defeating behaviors with more
Discontinues attendance to Resumes attendance to
health club health club
health-promoting behaviors (Corey, 1986).

Eats meals on a tray/does not Uses dining table First Phase

use dining table

Stays in night clothes during
the day
Does not return phone calls
Does not answer the phone
Cancels grocery shopping
trips
Ignores mail received
Ignores personal hygiene
Obsessive reminiscing of final Reminiscing a host of
moments
Maintains a museum-like
environment
Exclusive display of pictures
of the deceased
Ambulates aimlessly around
house
Sleeps for large segments of
the day
Overeating or
undernourishment
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Out of night clothes in the
morning
Returns phone calls
Answers the phone
Makes grocery shopping trips
Attends to mail received
Pays close attention to
hygiene
memories
Maintains a lived-in
environment
Displays an assortment of
pictures
Maintains an agenda and
avoids aimlessness
Avoids sleeping during the
day
Adheres to proper diet
The initial meetings involved the task of developing
two lists of behaviors targeted for attention. First,
the patient was instructed to identify specific behav-
iors associated with the present circumstance that
were self-defeating (i.e., self-defeating behaviors)
These behaviors were acknowledged by the patient
as necessary to be reduced and even eliminated in
order to resolve the grief. Stated differently, as the
self-defeating behaviors diminished, resolution of
the grief would be facilitated. The goal became to
extinguish those self-defeating behaviors that were
interfering with the resolution of grief. Second, the
patient was instructed to identify behaviors that
needed to be established and increased in frequency.
These behaviors were designated as facilitators of the
resolution of grief; establishing them and increasing
their frequency became a pivotal goal. These items
in essence became the antidotes to the self-defeating
behaviors (SDB) shown in Table 54.1.
Second Phase
A protocol consisting of items from the facilitators
of the resolution of grief (FRG) list was prepared.

After inducing hypnosis using an eye fixation induc-

tion (Hammond, 1990) and relaxation (Elkins,
to reconnect socially. The recalcitrance of his
2014), the items from this list were presented and
grief picture and the debilitating impact that an
repeated to the patient in hypnosis. Ideomotor sig-
emotion-based treatment modality exacted on
naling was employed to allow for patient responses
the patient were criteria used to select a behav-
(Hammond, 1998). The following protocol was
ioral treatment approach.
employed in the case in question.
Technique
TRANSCRIPT
The treatment consisted of a hypnotically aided
behavioral orientation that, rather than focus on the
grief itself, addressed specific behaviors that were hin- “Now that you are in a comfortable hypnotic state
dering the resolution of grief (Sobel, 1981). The focus you will be provided suggestions of behaviors we
 488 ■ III: PSYCHOLOGICAL APPLICATIONS
have deemed need to be enhanced and their fre-
quency increased. Understand that the increased
frequency of these behaviors will by definition
bring about a normalization of your emotions.
I will ask you to visualize yourself engaging in
these behaviors. See yourself performing each of
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the items as if you were watching a movie. The
movie is played out with a minimum of feeling.
This will make the process bland and maybe bor-
ing. It is expected that images that are accepted
during hypnotic treatment will become accepted
to be incorporated into daily use. You will keep
your eyes closed to be able to see yourself clearly
engaging in the behaviors that I will suggest. The
activities in question may be carried out without
much desire or pleasure. The important factor
is that you see yourself carrying them out. Now
begin by seeing yourself engaging in [item from
the facilitators of the resolution of grief (FRG)
list]. Even if you do not feel like engaging in the
behaviors, you can perform or carry out the same
in your mind. Remember, these suggestions are
medically necessary and were designed by your
doctor expressly for you and with your circum-
stances in mind. Those tasks performed in hyp-
nosis will be able to be carried out in daily life.”
The patient was instructed to incorporate into
his agenda and carry out those items successfully
rehearsed in hypnosis.
The patient was seen for six visits of individual
attention on a biweekly basis. The patient was able
to perform in vivo the tasks rehearsed in hypnosis.
Deceased levels of emotional reactivity from the
PGD reaction were recognized as an indirect result of
the reconnecting and restoration efforts. The patient
was able to diminish the morbid and self-defeating
elements of his reaction to the loss. He was seen for
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follow up two months after treatment concluded.
He had retained the reconnecting and restoration
activities that were targeted in therapy. He was also
observed to be devoid of the morbidity and melan-
cholic elements present before treatment started.
CONCLUSION
Millions of people are bereaved every year and a
proportion of them go on to develop PGD. If left
untreated or improperly treated, the consequences
can be significant from a point of view of functional
impairment, reduced quality of life, and increased
mortality and morbidity (Jordan & Litz, 2014).
Hypnotherapy is a valuable approach to treat
bereavement. A hypnotic-mediated approach is
presented here that emphasizes reconnecting and
restoration aspects. Clinicians using this approach
are encouraged to:
1. identify specific behaviors that are self-defeating
in regard to resolving grief;
2. identify facilitators for the resolution of grief;
3. utilize hypnotic inductions with relaxation sug-
gestions and control;
4. employ ideomotor signaling to confirm
responses;
5. present positive suggestions to decrease self-
defeating behavior and to facilitate grief
resolution; and
6. consider biweekly sessions with in vivo rehearsal
of grief resolution in hypnosis.
Hypnotic-mediated approaches that emphasize
reconnecting and restoration aspects of PGD treat-
ment should be considered as an invaluable part
of therapy in cases (Jordan & Litz, 2014; Schut &
Strobe, 2005; Stroebe & Shut, 1999) of prolonged
grief.
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