Interventions for Prolonged Grief
Solution-focused therapists do not usually offer direct advice. However, in some circumstances they may choose to offer strategies or ideas which others have found to be of value. In common events such as grief there are a number of recognised options which can be tried. Some are drawn from my practice while others have been developed by different disciplines.
Losing a loved one by death or separation is followed by grief. Prolonged grief is defined as grief which is not moving through the expected stages at the expected pace or where grieving is continuing beyond the expected time period. This must be distinguished from a formal depressive illness arising from the stress of bereavement, which has identifiable symptoms and may require treatment in addition to any intervention required for the bereavement process. According to The Compassionate Friends organisation for bereaved parents (TCF; http://www.tcf.org.uk/) grief for a lost child is never wholly completed. This can apply to parents who lose children through adoption or separation as well as loss through death.
Normal grief after the death of a pet is a maximum of three months (Keddie 1977). But if we die, our pet will not grieve for three months. We grieve according to our kind, not according to the nature of the relationship. So there is a time of grieving which we cannot shorten, although some of the techniques described may reduce our pain. Equally, we can know that one day our pain will be less. When we receive a physical injury, often that first moment is the worst that it will ever be; thereafter, even in small ways, healing and recovery are reducing the pain. Mourning follows a similar pattern.
Prigerson et al (1997) propose that ‘traumatic grief’ predicts prolonged distress. Shear et al (2005) rename this concept ‘complicated grief’, identifiable within six months of the loss by ‘a sense of disbelief regarding the death; anger and bitterness over the death; recurrent pangs of painful emotions, with intense yearning and longing for the deceased; and preoccupation with thoughts of the loved one, often including distressing intrusive thoughts related to the death’. (They devised ‘complicated grief therapy’ (CGT): see below.)
However, Breen and O’Connor (2011) suggest that grief is not a fixed process with recognisable stages. Instead they conclude that grief comes and goes for a variable length of time, with recurrences that may be just as painful as the first time, although perhaps less prolonged. They suggest that support from others is important and helpful. The best support takes the form of listening and asking for details (‘what else?’) about the loss. Offering explanations and saying ‘pull yourself together’ is not helpful.
Prolonged grief may benefit from intervention. Also, certain individuals may benefit from earlier intervention in the grieving process. For example, a young mother who has lost her partner may not be able to care for her children adequately unless her own distress can be reduced. Similarly, personal distress can make it difficult for counsellors to practise their profession.
Some of the techniques below have proved useful in both prolonged and acute grief and are offered as possibilities for appropriate situations. The list is deliberately short and to the point. In acute grief many people do not find it easy to follow complex strategies or instructions. However, a single brief response or action may allow the pain to diminish for the time being.
The first session will often include future-focused questions such as the miracle question. With some clients who have experienced a recent loss or bereavement, their miracle will be a restoration of the loss such as ‘My girlfriend will come back’, ‘My gran will not be dead’. This is evidence that they are still in the ‘numbness’ stage of bereavement and have not yet accepted their loss. They will not be able to develop new visions of the future until they accept the loss, so further future-oriented questions are unlikely to be useful at this stage. Possible responses are: ‘Is there any chance that you will get together with your girlfriend again? or ‘It would be good if your grandmother could come back to life but I guess that this is not very likely to happen?’ Then the worker can move to crisis intervention questions.
Focused crisis intervention questions:
How will you get through the rest of today?
How have you kept going so far?
What else helps?
Is there anyone else who shares this with you?
What were the happiest times with X?
Can you do any of the same things without X?
What is happening now that you want to go on happening?
(Following a death) What can you do to keep the memory of X alive?
(Following a death) What would X want for you now?
John Sharry and his colleagues (2002) have suggested creative uses for rating scales from 1-10: ‘How confident are you that you can get through the day / the weekend? What would increase that by one point?’. They also use the interview to take stock of the effect of the event itself. ‘Has this event made you stronger or weaker? Are there things that you are thinking now that had not occurred to you before? Is it possible that some good might come of this? If you look back in six months and see that this turned out for the best, what will you be doing then?’.
It can be important to face and perhaps remove painful cues concerning the lost person (Shear et al 2005; Mawson, Marks and Ramm 1981). Some may be objects with a practical use and therefore worth keeping. It is usually advisable to retain one photograph of the person, preferably out of sight or put away for safe keeping. In the future, a single photograph can be useful for family memories or life history techniques. If some of the reminders are large items, consider a car boot sale or an auction house.
Dispose of favourite snacks and drinks.
Clean the whole house.
Vacuum everywhere: behind sofas, under beds, to remove any bodily trace of the lost person.
Clean baths / toilets.
Change bedlinen and towels; wash everything that has been in contact with the lost person.
Use air fresheners to dispel the scent of favourite perfumes and lotions.
Modern means of communication have added to the variety of reminders of the lost person that may be retained inappropriately.
Delete all emails with painful contents, but be careful not to delete email sequences until you have made sure that there are no useful facts further down in the sequence. Consider if you wish to block emails from the person and if they should remain in your ‘Contacts’ list.
Remove the person from your social networking groups.
Delete all relevant texts. Consider if you want the person’s number to remain in your phone. It can be helpful to change their name in your mobile phone directory so that you can recognise the caller without it being a painful trigger. In some cases you may wish to bar calls from a former significant other.
Remember that an itemised telephone bill will be a reminder of when contact stopped which may take you by surprise when the bill arrives weeks later.
Delete unwanted photographs from your mobile phone, camera and computer.
Shared life experiences
The object of these exercises is to begin the creation of new memories which do not include the lost person.
Visit all the places of which you have relevant memories, alone or with a friend:
Park in the same place.
Sit in the same seat.
Drink the same drinks, eat the same foods.
Walk the same walks or visit the same museums and galleries.
Play the same music: one track / one CD depending on what you can tolerate at one time. You can use the music as a background for writing tasks (see below).
If you have sexual fantasies about the person, replay them imagining some other person from your life or from magazines or films.
Eat the foods that they never liked; watch the movies that they did not enjoy as much as you.
Restrict talk about your loss to one or two people. These may be personal friends or professionals. Otherwise you will constantly be asked ‘how are things?’ and so be reminded again. Once your feelings have moved on, you may not wish people to know how distressed you were.
Change all documents such as bank statements which include the lost person.
Go out and meet people and have many brief conversations. This will also help you to identify aspects of the lost person for the exercises below.
If possible, do not move home until the grieving process has diminished. It is easy to make mistakes while distressed and the additional stress of removals will not help. It is usually wise not to form a new relationship until you have moved some way through the grieving process, as your distress means that you are likely to make mistakes and experience additional pain.
To reduce intrusive or negative thoughts
- Set aside a time every day to write about the person, your relationship and your current situation. It is best if you can arrange to do it at the same time every day. Length of time should be a few minutes longer than you think is really necessary. For example, set aside 20 minutes if you think 15 minutes will be enough. If you do not have enough thoughts to fill the time, copy out again what you have already written until the time is up. This may provoke some additional reflections as well as filling the allotted time. Some people find it helpful to keep a note of any points that seem essential, but otherwise destroy each sheet by shredding or burning within 24 hours.
- Use thought stopping techniques (snapping an elastic band on your wrist, popping bubble wrap) whenever negative thoughts arise. If the problem is a separation rather than a death, consider using the same technique every time you have a positive thought about the lost person. Although you will eventually want to recall the best parts of your relationship, in the early stages of grieving positive thoughts can also be painful or can reinforce reminders which you wish to avoid at this time.
- Another thought stop is to turn up lively music for a short time. Remember the neighbours and that prolonged loud music can damage your hearing.
- If a painful trigger phrase comes to mind, repeat it 10-20 times, aloud if possible, as a desensitisation process.
- Try not to think about the lost person while driving since your preoccupation or distress can lead to accidents.
- If flashback memories occur in social or sexual situations, or when alone, they are usually triggered by some ‘traumatic associational cue’ (Dolan 1999). Ask yourself: What situation was I in when I felt this way before? In what ways is the current situation similar to the traumatic memory? How is the current situation different? What action can I take to feel better in the present?
- Keep a single dose of your favourite relaxer (e.g. alcohol, diazepam, chocolate, herbal tea, incense) in a special place for use when all else fails. This reduces the risk of using such substances too often in an effort to relieve your distress.
Dreams of the lost person
During sleep, dreams of the lost person can be distressing reminders, which may also disturb sleep. Jungian practitioners have studied the psychotherapeutic aspects of the dreaming process for many years. They have found that dream material becomes less painful and less frequent if it is attended to in waking life. They advise writing down as much as you can remember of the dream and any thoughts and associations that come to mind about it while you are doing this (Martin 1955). This can form part of the ‘write, read and burn’ task described above. Dream content takes some months to catch up with changed appearances and relationships (Macdonald 1984).
- Use Healing Letters (Dolan 2000). Write letter 1 to the lost person, expressing all that you want to say, good and bad. At another time, write letter 2 back from them in a form based on your worst fears about how they will react to letter 1; at the same session, write another letter (3) in which they express what you would like them to say in response to letter 1. Then at another session (maybe much later), write letter 4 in which you express your final message to them. Usually, these letters are not sent in reality. Some people choose to keep the letters but many prefer to shred or burn them once the process is complete. Sometimes the exercise may be repeated if new ideas or material become available.
- It can be helpful to go to the graveside or to some other place closely associated in your mind with the lost person. Say aloud or to yourself what you really want to say to the person. It is best to prepare your statement in advance, but other thoughts may arise as you speak. You may also leave a written version or burn the written version at the spot. Public memorials can act as a generic ‘graveside’ for this purpose.
- Michael White (1998) suggests that in prolonged grief it can sometimes be helpful to ‘say hullo’ to the lost person. Instead of trying to suppress memories altogether, recall what they liked about you and how they viewed your talents.
- Write a newspaper obituary for the lost person, even if they are not dead, including some of their positive features.
- Write down the advantages and disadvantages of your new situation.
- Make a list of the good and bad features of your relationship with the lost person.
Some like to write these materials, reread them and then burn or shred them.
Complicated Grief Therapy (CGT)
A combination of imaginal exposure (from cognitive behavioural therapy) and restoration of effective functioning (from interpersonal therapy). Therapists record patients recalling stories of their loved one’s death and patients listen to the tape between sessions. They try to reduce distress levels during each session by “promoting a sense of connection” to the loved one, for example through imagined conversations with the deceased and a discussion of positive and negative memories about him or her. They ask patients to discuss what their plans and goals would be if their grief was not so intense.
Eye Movement Desensitisation and Reprocessing (EMDR)
This has been used in pathological grief with benefit. It cannot help in the initial ‘numbness’ stage. However, in subsequent phases it can remove specific blocks and can ease the grieving process. It cannot accelerate the adjustment process, which will remain painful. (See Solomon and Rando 2007.)
Further Reading and References
Breen, L.J. and O’Connor, M. (2011) Family and social networks after bereavement: experiences of support, change and isolation. Journal of Family Therapy, 33, 98-120.
Dolan, Y.M. (1999) Resolving Sexual Abuse: Solution-Focused Therapy And Ericksonian Hypnosis For Adult Survivors. New York: Norton.
Dolan, Y.M. (2000) Beyond Survival: Living Well is the Best Revenge. London: BT Press. (Previous publication: Papier Mache Press: USA 1998)
Keddie, K.M.G. (1977) Pathological mourning after the death of a domestic pet. British Journal of Psychiatry, 131, 21-25.
Macdonald, A.J. (1984) Dreams after amputation. British Journal of Psychiatry, 145, 669 (letter).
Macdonald, A.J. (2007) Solution Focused Therapy: Theory, Research and Practice. London: Sage Publications.
Martin, P.W. (1955) Experiment in Depth. London: Routledge and Kegan Paul.
Matthews, L. & Marwit, S. (2004) Complicated grief and the trend towards cognitive-behavioural therapy. Death Studies, 28(9), 849-63.
Mawson D, Marks IM & Ramm L (1981) Guided mourning for morbid grief: a controlled study. British Journal of Psychiatry, 138, 185-93.
Prigerson, H.G., Shear, M.K., Jacobs, S.C., Reynolds, C.F. (3rd), Maciejewski, P.K., Davidson, J.R., Rosenheck, R., Pilkonis, P.A., Wortman, C.B., Williams, J.B., Widiger, T.A., Frank, E., Kupfer, D.J. & Zisook. S. (1999) Consensus criteria for traumatic grief: a rationale and preliminary empirical test. British Journal of Psychiatry, 174, 67-73.
Sharry, J., Darmody, M. & Madden, B. (2002) A solution focused approach to working with clients who are suicidal. Symposium on Suicide. British Journal of Guidance and Counselling, 30, 383-99.
Shear, K., Frank, E., Houck, P.R. & Reynolds, C.F. (2005) Treatment of Complicated Grief: A Randomized Controlled Trial. Journal of the American Medical Association, 293, 2601-2608.
Solomon, R.M. & Rando, T.A. (2007) Utilization of EMDR in the Treatment of Grief and Mourning. Journal of EMDR Practice and Research, 1(2), 109-117.
White, M. (1998) Saying hullo again: the incorporation of the lost relationship in the resolution of grief. In: White, C. & Denborough, D. (eds). Introducing Narrative Therapy: a collection of practice-based writings. Adelaide: Dulwich Centre Publications.
White, M. & Epston, D. (1990) Narrative Means to Therapeutic Ends. New York: Norton.