Grief and Loss

U d
Understanding
t di Complicated
C li t d Grief
Gi f

Joan Haliburn
Child Adolescent & Family Psychiatrist,
Child, Psychiatrist
Psychotherapist
Senior clinical lecturer, University of Sydney

Definitions

• Grief: A normal response to loss of a loved one

one,
Often felt acutely in the early stages
It is an adaptive response
• Complicated grief: Is the continuation of acute grief
It continues longer than would be expected
• Mourning: Is the psychological process of
acknowledging the finality of
Loss
The coming to terms with its inevitability
and irreversibility

1
 Differences Between ordinary
Grief and Major Depression
Ordinary Grief Major Depression
Mixture of sadness and Inability to experience
pleasant pleasure
Emotions
Experienced as waves/pangs Almost continuously
depressed
Maintains hope of feeling Despairing and hopeless all
better day
Strong emotional connections Self-focussed and cut off
Normal response Pathological response

Bereavement Versus Major

Depression
“B
“Bereavement
tddoes nott immunize
i i against
i t Major
M j
Depression”

“We must not medicalize normal grief, but

neither must we normalize major depression,
simply because it occurs in the context of
bereavement”
Ronald W. Pies, MD J. Affective Disord. 2009; 116: 1-3

2
 Attachment Relationships –
Key to Understanding Grief
• Proximity seeking towards certain persons
• Source of security, comfort, support &
reassurance
• Resist separation from these persons
• A two-way process
• A source of pleasure in life – a source of loss
in separation
• A bio-behavioural motivational system - from
life to death
• Recorded in Internal Working Models

Memory and Attachment

Models
• Recorded in specific brain circuits – implicit
memory - develops early
• Contains emotional, cognitive and behavioural
memories- explicit later

Implicit – Brain locations Explicit – Brain locations

Subcortical Cortical
Right hemisphere Left hemisphere
Amygdala Hippocampus
Orbital-medial prefrontal Dorsal lateral prefrontal
cortex (OMPFC) Cortex (DLPC)

3
 Normal Grief

• Occurs after a loss

• Recurrent feelings of sadness and longing for
the lost person
• Emotional confusion – positive and negative
emotions
• Intrusive thoughts
g and memories of the lost
person
• Avoidance of reminders/urges to seek
proximity
• Feelings of isolation and helplessness

Factors Affecting Grief

• Circumstances
Ci t off th
the loss
l

• Relationship between the bereaved and the

deceased person

• Characteristics of deceased person

• Consequences of the loss

• Characteristics of the bereaved

• Context of the bereavement

4
 Basic Assumptions About
Grief and Loss i
• Is
I universally
i ll experienced
i d

• Characterized by a set of symptoms

• Occurs in stages

• Necessary for coming to terms with

• Requires supportive environment

Basic Assumptions About

Grief and Loss ii
• Understanding
U d t di off close
l relationships
l ti hi

• Grief is associated with loss of attachment

figure

• Grief must end because loss is irreversible

• Acceptance and moving on must follow

• Re-engaging with life is to be expected

5
 Complicated Grief – Is
Unprocessed Grief
• Persistent rumination about the loss, including
self-blame
• Dysfunctional behaviours – avoidance, proximity-
seeking, other
• Persistent emotional dysregulation – anxiety,
depression, sleep
• Persistent neglect of self and others – self & other
– blame
• Intense grief symptoms persist with longing,
searching
• Meaningless, joyless, dissatisfied feelings –
increased reactivity

Some Facts About

Complicated Grief
• It occurs in
i all
ll cultures
lt

• Occurs in less than 10% of those bereaved

• More frequent in parents who have lost

children

• In sudden violent death

• After suicide

• In all settings

6
 Complicated Grief and
Impairment
• Chronic
Ch i Sleep
Sl disturbance
di t b

• Suicidal ideation

• Impaired social relations – isolation/erratic

socializing

• Increasing health problems

• Erratic use of alcohol/drugs

• Interference in social and relational functioning

Traumatic Bereavement

• Triggered
Ti dbby lloss

• Yearning for lost one and sadness predominate

• Intrusive thoughts related to the person

• Avoidance due to loss

• Reminders of the person lost

• Longing and proximity seeking

• Persistent and intense grief

7
Unresolved Grief in Long Term
Psychotherapy
• Obstacle
Ob t l tot progress

• Loss often in early years

• Compounded by later losses

• Environment not conducive to grieving

• Found in avoidant personalities

• Difficulties in ending

Approach to C.G. in Short

Term Psychotherapy (i)
• Development of therapeutic relationship and
provision of information
• Have an idea of the person’s relationship with
the deceased
• Assess the context of the loss
• Try
y to establish what the death means to the
bereaved person
• Allow the patient to talk about the deceased
person
• Validate and acknowledge loss and reaction to
loss

8
 Approach to C.G. in Short
Term Psychotherapy (ii)
• Help
H l come tto tterms with
ith loss
l and
d look
l k ahead
h d

• Dealing with reminders – allow to reflect

• Visiting avoided places or looking through

avoided photos

• Helping to put away constant reminders

• Look at new ways of living without the

deceased person

Screening for Complicated Grief

1. Preoccupation with deceased 11. Avoidance of reminders of
deceased
2 Remembering
2. R b i iis upsetting
tti 12 Pain
12. P i as in
i ddeceasedd person
3. Inability to accept death 13. Feeling that life is empty
4. Longing for reunion with deceased 14. Hearing voice of deceased
5. Drawn to familiar places 15. Seeing deceased person
6. Anger about the death 16. Guild about being alive
7. Utter disbelief 17. Bitter about death
8. Continuing shock and disbelief 18. Envy towards others –
partner/child
9. Difficulty trusting others 19. Feeling utterly alone
10. Difficulty caring about others
Prigerson et al, 1995