M. Katherine Shear M.D. Professor of Psychiatry, Columbia University

Transcription

1 M. Katherine Shear M.D. Professor of Psychiatry, Columbia University

2 PART I: Complicated grief Grief and adaptation to loss: acute, integrated and complicated grief (CG; persistent impairing grief) How to diagnose CG: using ICD11 PGD PART II: Complicated grief therapy (CGT) The evidence base CGT as adaptive grief therapy: target, themes and procedures

3 Defining grief Grief is the response to loss and the form love takes when someone dies it s permanent when someone we love dies

4 A range of emotions, thoughts, behaviors and physical changes and variable Spiritual and Social changes Still there are important commonalities

5 Acute Grief: the initial Response to Loss Insistent Thoughts of the deceased person, disbelief, difficulty concentrating

6 Integrated grief has a place in our lives along with a renewed sense of purpose and meaning and renewed connections to others

7 To adapt to loss 1. We find a way to accept the reality of the death, including a changed relationship to the person who died 2. And to envision a future with possibilities for happiness

8 Bereavement Acute Grief Adapt to the loss Accept the reality Envision the future

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10 Isn t all grief complicated? The answer depends on how you define the term. In everyday life English complicated means something with intricately combined parts or something that is difficult to analyze, understand, or explain; In this sense grief is often complicated In medicine complicated refers to a process in which a superimposed problem prolongs the healing process. Less than 10% of grief is complicated.

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12 But there is another definition of complicated grief Complicated grief is complicated and cannot be confined to one syndrome or disorder. An illustrious group of colleagues Therese Rando, Kenneth Doka, Stephen Fleming, Maria Helena Fanco, Elizabeth Lobb, Colin Murray Parkes, Rose Steele A Call to The Field: Complicated Grief in the DSM-5 Omega, Vol. 65(4) , 2012

13 From Rando et. al.: not just a single form of complicated grief, but rather many forms of it...we urge that future endeavors seek to identify other forms of complicated grief [We favor] the delineation of additional diagnostic categories with their distinct criteria. This would produce a catalogue of bereavementrelated psychiatric diagnoses. Is this really what we need?

14 ICD11 and DSM5 have weighed in Both workgroups entertained proposals for a new diagnosis and both concluded that there was substantial evidence to support it Both workgroups grappled with what to call this syndrome and with two different empirically derived proposals for criteria one of them ours Both workgroups rejected the label complicated grief ICD named the condition Prolonged Grief Disorder, and developed a simple, clinically meaningful guideline DSM named the condition Persistent Complex Bereavement Disorder and developed a complex lengthy algorithm

15 There is recognition of a syndrome of persistent impairing grief, but there are at least 3 different names: CG, PGD, PCBD and four proposed criteria PGD : ICD PGD, PLOS PGD, and DSM5 PCBD Do these terms refer to the same or different individuals? How are they related to each other?

16 ICD and DSM: current status The guideline for PGD is included in the recently released ICD11 draft, slated for approval in 2019 DSM placed PCBD in Section 3, issuing a call for more research on the criteria We have conducted tests of the different criteria sets in two independent samples 1) A clinical treatment-seeking sample, independent from the one in which we developed the proposed criteria 2) A community-based survey of bereaved military family members PGD criteria have been used in many interesting studies since 2013; however, to our knowledge, the only tests of the criteria are our own and a re-analysis of the original data

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18 Stephen Cozza, M.D., F. Edward Hebert School of Medicine, Uniformed Services University Barry D. Lebowitz, Ph.D., University of California, San Diego Philip Lavori, Ph.D., Biomedical Data Science, Stanford University Christine Mauro, Ph.D., Columbia University Mailman School of Public Health Charles F. Reynolds III M.D., University of Pittsburgh Medical Center and Graduate School of Public Health Naomi M. Simon, M.D., M.Sc., New York University School of Medicine Robert J Ursano M.D., F. Edward Hebert School of Medicine, Uniformed Services University Sidney Zisook, M.D., University of California, San Diego

19 Performance of DSM-5 Persistent Complex Bereavement Disorder Criteria in a Community Sample of Bereaved Military Family Members Cozza et al 2016 Participants were surviving parents, spouses/partners, siblings, and adult children (N=1,732) of service members in the U.S. military (Army, Navy, Air Force, Marines, and Coast Guard) who died by all circumstances of death (i.e., combat, accident, suicide,homicide/ terrorism, illness, undetermined) since September 11, 2001.

20 Under the advice of two independent senior biostatisticians, the study evaluated the conditional probability of diagnosis in two groups: those who almost certainly did have persistent impairing grief and those who almost certainly did not. Clinical cases who almost certainly have the condition: ICG score at least 30 and Work and Social Adjustment Scale score at least 20 N= 260; 15% of the overall sample Nonclinical cases who almost certainly do not have the condition: ICG score <20 n=675; 39% of the overall sample

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22 PCBD: 53% of clinical cases diagnosed; 100% of non-clinical cases excluded PGD (Plos): 59% of clinical cases diagnosed; 100% of nonclinical cases excluded CG: 92% of clinical cases diagnosed; 98% of non-clinical cases excluded Cozza et al 2016

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24 Using the same criteria for clinical caseness (ICG > 30 and WSAS > 20) PGD PLOS and PCBD criteria correctly identified about 50% of cases and accurately excluded 96% CG and ICD11 PGD criteria correctly identified about 80% and accurately excluded more than 85%

25 CG and ICD11 PGD identify the same people PCBD and PLOS PGD identify the same people Diagram by Stephen Cozza M.D.

26 PLOS PGD Mean Score DSM5 PCBD Mean Score Inventory of Complicated Grief Work and Social Adjustment Scale 22 21

27 Performance characteristics and clinical utility of diagnostic criteria proposals in bereaved treatmentseeking patients Mauro et al 2017 Grief treatment-seeking participants bereaved for at least 6 months (n = 240) were recruited from ongoing studies at university based psychiatric research clinics at Columbia University (n = 70), Massachusetts General Hospital (n = 58), University of Pittsburgh Medical Center (n = 55) or University of California San Diego (n = 57).

28 Nonclinical grief cases in treatment seeking sample A comparison group of bereaved participants was constituted from ongoing research studies at The Latelife Depression Prevention and Treatment Center (P30 MH90333) at the University of Pittsburgh Medical Center (n = 62) or The Center for Anxiety and Traumatic Stress Disorders at the Massachusetts General Hospital (n = 24). For these participants, a mood or anxiety disorder was the primary diagnosis established using a structured clinical interview for DSM-IV and all scored <20 on the ICG.

29 A score of 30 or higher on the original 19-item ICG (strong evidence that an ICG score of 25 identifies clinically significant symptoms) Judged by an experienced clinician to have CG as the condition most in need of treatment. Affirmative response to the question: Overall, is grief interfering a lot with your ability to work or socialize or function in other ways?

30 Results from our field trial of DSM5 criteria in clinical samples Criteria set Correctly identify clinical cases n=240 Correctly identify clinical non-cases n=86 ICD11 PGD 93% (90 97) 100% CG 100% ( ) 100% DSM5 PCBD and PLOS PGD criteria fail to identify a substantial proportion of these individuals PCBD 70% (64 76) 100% PGD PLOS 50% (53 66) 100%

31 Prolonged grief disorder: clinical utility of ICD-11 diagnostic guidelines Christine Mauro, Charles F. Reynolds III, Andreas Maercker, Natalia Skritskaya, Naomi Simon, Sidney Zisook, Barry Lebowitz, Stephen J. Cozza, M. Katherine Shear Study participants with persistent impairing grief (n = 261) were enrolled at a university-based psychiatric research clinic at Columbia University (n = 23), Massachusetts General Hospital (n = 82), University of Pittsburgh Medical Center (n = 72), or University of California San Diego (n = 84) as part of the National Institute of Mental Health (NIMH)-funded collaborative treatment study (MH60783; MH85288; MH85308; MH85297).

32 Operationalizing ICD11 Guideline using the Structured Clinical Interview for CG (SCI-CG) Mauro et al 2018

33 Varying requirement for number of associated symptoms for ICD11 diagnosis

34 Mapping the PGD PLOS criteria onto the Structured Clinical Interview for CG (SCI-CG) Mauro et al 2018

35 The operationalized ICD-11 PGD guideline correctly identified 250/26: 96% (CI %) PGD PLOS criteria correctly identified 154/261: 59% CI %) χ 2 = 96.0, df = 1, p < Neither of the PGD criteria incorrectly diagnosed a bereaved clinical sample without evidence of persistent grief. Mauro et al 2018

36 Marital status : Widows more likely to receive a diagnosis (74%), than other participants, especially those who were married (38%) χ2 = 18.3, df = 3, p = Co-occurring MDD Those with a concurrent diagnosis of depression more likely to receive a diagnosis (64%) than those without depression (45%) χ2 = 7.8, df = 1, p = Mauro et al 2018

37 Person lost Those bereaved of a partner (69%)more likely to receive a diagnosis than other participants, especially those who lost a child (50%) or other (45%) χ2 = 9.23, df = 3, p = Circumstances of death Those bereaved by a non-violent death (65%) more likely to receive a diagnosis that those bereaved violently (47%) χ2 = 7.6, df = 1, p = Mauro et al 2018

38 NO DIFFERENCES in treatment response among those diagnosed or not using PGD PLOS criteria Response to CGT: 85.2% v. 87.7% χ2 = 0.04, df = 1, p = Treatment adherence: 70.6% v. 74.4% χ2 = 0.22, df = 1, p = Response to meds/clinical management: 57.5% v. 64.7% χ2 = 0.49, df = 1, p = Mauro et al 2018

39 Conclusion: The ICD11 Guideline is an excellent way of identifying individuals who may benefit from treatment ICD 11 Guideline For Prolonged Grief Disorder Persistent and pervasive longing or preoccupation with the deceased causing significant impairment in important areas of functioning At least one additional indicator of intense emotional pain, such as sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one s self, emotional numbness Persists at least 6 months and clearly exceeds expected social, cultural or religious norms for the individual s culture and context.

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41 Bereavement Acute Grief Adapt to the loss Accept the reality Envision the future

42 MALADAPTIVE THOUGHTS Second-guessing; grief-judging, catastrophizing the future DYSFUNCTIONAL BEHAVIORS Excessive avoidance, social withdrawal, substance use; negative health behaviors PROBLEMS REGULATING FEELINGS Overly intense negative emotions, low positive emotions, low selfcompassion SEVERE SOCIAL/ENVIRONMENTAL PROBLEMS Lack of any supportive companion; blamed by others; homeless, in poverty, loss of employment

43 Bereavement Estimated Population Prevalence: 7% Of Bereaved People Rate Is Higher (About 15%) Among Those Bereaved By Violent Death Acute Grief Impediments X Adaptation X Integrated Grief Complicated Grief (persistent impairing grief)

44 Grief is the story of love after loss. It s not a state or a moment in time or a single emotion.

45 A grief story usually unfolds and evolves as we adapt to the loss. and grief finds a place in our lives

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48 People experiencing complicated grief are relieved to hear that we know who they are OUR RADIO AD Have you lost someone you love? Do you often feel like you Are stuck in a place of pain and grief? Have others begun to Grow weary of hearing you talk about your loved one? Maybe You miss the person so much that it s hard to care about anything else. You might be suffering from complicated grief. If you are, the pain of the loss stays fresh and healing does not occur, it seems like time is moving on but you are not.

49 Screening questionnaires Brief grief questionnaire (BGQ: 5-items) developed for Project Liberty survey and performed well Inventory of complicated grief (ICG: 19 items) first instrument to identify CG a highly reliable screening tool Structured Diagnostic Interview Structured Clinical Interview for CG (SCI-CG: reliable and valid)...or do a Clinical interview Elicit symptoms of acute grief and grief complications

50 Bereavement Identify and resolve impediments Grief Therapy Facilitate adaptation Acute Grief impediments x adaptation x Integrated Grief

51 100% Average Response Rates across 3 90% NIMH-funded randomized controlled trials (n=643) 80% 70% 60% 50% 40% 30% 20% 10% 0% 71% CGT Study 1: P=0.006 NNT, 4.6 Study 2: P <.001; NNT, 2.56 Study 3: P =.002;NNT, % CONTROL

52 CITALOPRAM Week 0 PLACEBO CGT + CITALOPRAM CGT + PLACEBO WEEK 12 WEEK 20 All participants received CG-informed clinical management CGT = Complicated Grief Therapy Also, an AFSP pilot study of 58 Suicide bereaved individuals Added to the NIMH study Preliminary data regarding feasibility, acceptability and effectiveness of CGT among survivors of suicide with CG

53 Meet the HEAL PI s Naomi Simon MD PI: MGH Sid Zisook MD PI: San Diego Kathy Shear MD and Naihua Duan PhD PI s Coordinating Site: Columbia University Chip Reynolds MD PI: Pittsburgh

54 HEAL confirmed efficacy of CGT CGT markedly reduced symptoms of CG and SI in severely ill and highly comorbid individuals Antidepressant medications did not improve CG outcome but did produce a significantly greater reduction in depression Antidepressant medication was not significantly different from placebo for CG symptoms

55 Age M (SD) 53.0 (14.5) Gender N (%) Female 308 (78%) Race N (%) White 325 (82%) Black 39 (10%) Others 31 (8%) Hispanic N (%) 45 (11%) 58

56 Person who died N(%) Partner 144(36%) Parent 113(29%) Child 80(20%) Other relative or friend 58(15%) Time since loss M(SD), years 4.7(7.2) Violent death N(%) 132(33%) Suicide Bereaved 58(15%)

57 60 MDD current N(%) 262(66.3) PTSD current N(%) 154(39.0) CGI severity rating N(%) Mildly/Moderately ill 130(32.9) MARKEDLY ILL 199(50.4) SEVERELY/extremely ill 66(16.7) Since death wish to be dead N(%) 221(55.9) Since death non-specific active suicidal thoughts N(%) 103(26.1) Shear et al JAMA Psych 2016

58 Responder defined as much or very much improved Using a global improvement scale

59 1) Very Much Improved Compared to baseline: clear evidence that grief intensity and impairment is markedly improved. The person feels very differently about the role grief plays in their life. 2) Much Improved Compared to baseline, grief intensity and impairment are definitely and meaningfully improved. The person notices a definite difference in the role of grief in their life.

60 4. Moderate CG intrusive, painful but bearable Some interference with functioning, not substantially impaired; avoidance of reminders may occur; sense of purpose maintained but weakened; suicidal thoughts may occur but desire to live; distraction possible temporarily 4. Marked CG frequent and intrusive with substantial pain Definite interference with functioning; some avoidance of reminders; loss of sense of purpose, uncertain if happiness is possible; suicidal thoughts usually present; distraction difficult and short-lived 5. Severe CG nearly constant and preoccupying; Severe and impairing; extensive avoidance of reminders; feeling happiness satisfaction is no longer possible; active suicidal ideation or indirect suicidal behavior; distraction rarely possible and only partially effective

61 None Mild Moderate Marked Severe interference interference interference interference Because of grief my ability to do the following is impaired 1. Work 2. Home management 3. Private leisure activities 4. Social leisure activities 5. Ability to form and maintain close relationships

62 Not at all Somewhat Moderately Strongly Very strongly This death should not have happened You should have done something to prevent the death or make it easier Someone else could have prevented this death or made it easier The world is filled with unpredictable dangers

63 Illness-related death n=263 Violent death N=132 Moderate 31% 36% Marked 53% 45% Severe 16% 18%

64 Suicide Bereavement and Suicide Ideation * * Suicide Bereaved Not Suicide Bereaved SI (Before Death) SI (Since Death) P<0.05 Controlling for age, time since death, relationship and gender

65 100% 80% CIT PLA 100% 80% CGT + PLA CGT + CIT 60% 40% 60% 40% 83% 84% 20% 46% 38% 20% 0% Week 12 0% Week Shear et al JAMA Psych 2016

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67 Percent with Suicidal Ideation Percent with Suicidal Ideation CGT + PLA vs. CGT + CIT Week 1 Week 20 40% 30% 26% 32% 20% 10% 0% 7% CGT + PLA 4% CGT + CIT 40% 30% 20% PLA vs. CIT Week 1 Week 20 32% 31% 21% 21% 10% 0% PLA CIT 70 Shear et al JAMA Psych 2016

68 Boston, New York, Pittsburgh, San Diego

69 Shear et al JAMA Psych 2014

70 Suicide Homicide Natural death Wish to die before treatment Wish to die after CGT 73 Zisook et al J Clin Psych, 2018

71 Suicide Homicide Active SI before treatment Natural death Active SI after CGT 74 Zisook et al J Clin Psych, 2018

72 Persistent impairing grief is a recognizable syndrome that occurs when troubling concerns and excessive avoidance derail the healthy mourning process ICD11 Guideline for Prolonged Grief Disorder is an excellent way to diagnose these individuals This condition is associated with high rates of suicidal ideation Individuals who meet any of the criteria respond well to our targeted adaptive treatment 75

73 Complicated Grief Therapy A short-term evidence-based adaptive intervention Bereavement Find and resolve impediments Therapy goals Facilitate adaptation Encourage personal growth Build resilience Acute Grief Impediments X Adapt to the loss X Integrated Grief

74 Complicated Grief Therapy: A short-term intervention Objective To facilitate the natural adaptive process

75 What is our relationship to suffering? However, grief is not the problem and is not a target for intervention

76 Pico Iyer The Value of Suffering - The New York Times Almost eight months after the Japanese tsunami, I accompanied the Dalai Lama to a fishing village, Ishinomaki, that had been laid waste by the natural disaster. Gravestones lay tilted at crazy angles when they had not collapsed altogether. What once, a year before, had been a thriving network of schools and homes was now just rubble. Three orphans barely out of kindergarten stood in their blue school uniforms to greet him, outside of a temple that had miraculously survived the catastrophe. Inside the wooden building, by its altar, were dozens of colored boxes containing th remains of those who had no surviving relatives to claim them, all lined up perfectly in a row, behind framed photographs, of young and old. As the Dalai Lama got out of his car, he saw hundreds of citizens who had gathered on the street, behind ropes, to greet him. He went over and asked themhow they were doing. Many collapsed into sobs. Please change your hearts, be brave, he said, while holding some and blessing others. Please help everyone else and work hard; that is the best offering you can make to the dead. When he turned round, however, I saw him brush away a tear himself.

77 CGT focuses on... Warming things up Turning on a light and opening a door to the outside world

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79 What adapting means. A dynamic, ongoing, life-sustaining process by which living organisms adjust to environmental changes

80 We are naturally predisposed to adapt to loss How we adapt to loss Accept the reality of the death - its finality and consequences and changed relationship with the person who died Envision a future with a sense of purpose and meaning and possibilities for happiness

81 Accepting the change the painful reality of the death 1. Loss- focused Understanding the personal meaning of the loss; Coping with everyday life stresses that the death brings; Navigating a world of absence; Accepting the permanent absence of the person who died; Managing grief and difficult times Connecting in a meaningful way to memories of the person who died

82 Seeing possibilities for a promising future 1. Restoration-focused Reconnecting with personal intrinsic motivation core values and interests Restoring a sense of competence, interest and enjoyment in everyday life; re-establishing strong relationships; accepting grief and managing emotional pain Using personal assets and resources to promote health and wellbeing; enjoying strong relationships; allowing grief a place while envisioning a promising future with possibilities for joy and satisfaction

83 Grief changes as a person adapts to the loss

84 There is a renewed sense of purpose and meaning and renewed connections to others However grief is integrated and no longer dominates the person s life However, grief intensity can still surge in response to life events or calendar days that are reminders of the loss

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86 Understanding grief Connecting to memories Managing painful emotions Living with reminders Thinking about the future Telling the story of the death Strenghthening Social Relationships

87 We can deepen our understanding of grief by understanding close relationships

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89 Everyone loves in their own way Fehr B and Russell J: The Concept of Love 84 different definitions or characteristics

90 Biologically motivated Mediated by internalized mental representations A source of wide ranging effects on our lives

91 Defining features of secure attachment Feels rewarding Provides comfort and solace Encourages personal growth and discovery The urge to seek, form and maintain secure relationships is rooted in our biology

92 Close attachments are cornerstones in our construction of self The interpersonal self may be more important to self concept than the inner-directed self

93 The stronger, more satisfying the relationship the greater its importance to our self concept and the greater our Relational self-construal Self-compassion Self affirmation and authenticity Sense of self-expansion Self concept complexity Self concept clarity

94 PSYCHOLOGICAL Emotions, Thoughts, Attention, Social Behavior SENSE OF SELF Identity, Coherence,, Values and Goals PHYSIOLOGICAL Sleep Quality, Pain Intensity, Temperature Regulation Hormonal Response to Stress, and More

95 Secure attachment comes in many shapes and sizes The attachment motivational system is linked to systems for exploration and caregiving

96 We are deeply motivated to serve as a safe haven and secure base Secure attachment and effective caregiving usually go hand-in-hand For most of us, being an effective caregiver is at least as important as receiving effective care

97 Motivation to explore the world Desire to learn, grow, discover, accomplish goals

98 Attachment system activated Caregiving system activated Exploratory system inhibited Acute attachment insecurity: Anxiety, guilt, sadness, anger Proximity seeking Acute caregiver ineffectiveness: Separation guilt Proximity seeking Loss of interest in learning and discovery Loss of sense of competence The net result is a disorienting and disruptive experience

99 Proximity seeking activated Yearning, longing, frequent insistent thoughts and memories; wide-ranging psychobiological dysregulation Loss of sense of safety Feelings of sadness, anxiety, anger, insecurity, mistrustfulness, guilt Sense of caregiver ineffectiveness Feelings of not caring about others, self-blame, anger, remorse Exploration inhibited Difficult to care about anything other than the deceased; loss of motivation to learn, discover new things or perform in the world

100 Activated attachment and caregiving systems Inhibited exploratory system Yearning, longing, preoccupation, guilt Loss of psychological and physiological regulation Dysregulation in body and mind: dysphoria Loss of interest in exploring the world, learning and growing Over all, a highly emotional, disorienting and disruptive experience

101 Theme 2: Managing painful emotions We work with both painful and pleasant emotions

102 Ways bereaved people can manage painful emotions Oscillating attention Self-compassion Self observation, reflection Meaningful social companionship

103 Grief monitoring Understanding grief Promoting emotion regulation Observing and reflecting on an emotional experience is a way of diminishing its intensity. In addition the recording pattern can help people understand the ebb and flow of grief intensity and pay attention to emotions they are feeling.

104 Oscillate from pain to respite Self-observation and reflection xxxx Self-compassion Exploit possibilities for agency Experience positive emotions Receive support from others Notice variations in grief intensity Observe situations associated with high and low grief intensity Reflect on grief levels Notice effects of being active Reflect on low grief levels Share observations of grief levels However, monitoring grief levels can seem counterintuitive to grieving people

105 Explore long-term life aspirations or dreams - activities or goals - that can bring personal satisfaction and are consistent with intrinsic interests and/or values We uses a procedure that is a modification of a motivational interviewing procedure called personal goals work Based upon social psychologists Deci and Ryan Self-determination theory with extensive research backing

106 Two procedures that track through the treatment Planning simple everyday rewarding activities Creating and working toward long-term aspirational goals

107 Feeling of belonging and mattering is a basic human need Bereavement robs us of a sense of belonging

108 A premise of CGT: The presence and support of loving companions is an important context for successful adaptation to loss

109 1. Discuss the relationship between the visitor and the client 2. Get the visitor s perspective on the person who died and the client s life since the death 3. Provide an overview of grief, adaptation to loss and adaptive grief therapy 4. Discuss how friends and family can support a grieving person in adapting to the loss

110 Theme 5: Telling the story of the death Listening is a magnetic and strange thing, a creative force When we are listened to, it creates us, makes us unfold and expand. From Lipman: Brenda Uehland, Tell Me More: On The Fine Art of Listening. In Strength to My Sword Arm. Holy Cow Press: Minneapolis, MN, 1996 (1941).

111 To help understand what happened Decide if it is final or can changed Consider what it means for the future To be free to keep thinking about it and keep telling the story There is never just one story An opportunity to notice and work with impediments to adaptation To share the pain of loss To practice managing painful emotions

112 To help understand and accept what happened To share the pain of the story To notice and work with impediments to adaptation To see ways to manage painful emotions

113 The story of the death activates painful emotions 5 Intervention procedures that target emotion regulation 1. Story telling is highly structured almost like a therapeutic ritual 2. We check in with clients at regular intervals while they are telling the story 3. We ask what it was like to tell the story 4. We pay attention to helping the client set the story aside 5. We spend time planning a rewarding activity and getting a commitment to do it

114 Living with reminders is an important part of adapting to loss After a loved one dies, it is typical for everyday events, places, people and things to trigger painful reminders of the loss. People sometimes think the best way to manage the pain is to try to avoid these triggers. Avoidance has a place in the grieving process; however excessive avoidance can interfere with adapting to the loss

115 Since reminders are ubiquitous, bereaved people can t really avoid the pain of reminders of their deceased loved ones Trying to avoid leads to extensive restriction of movement in the world and ends up backfiring.

116 Reminders provide an opportunity to learn about what the the loss means to the bereaved person s life Learning to deal with the emotional activation frees the bereaved person to move about in the world as they wish We consider facing these situations to be a natural part of the process of adapting to a loss

117 Memories are residues of our close relationships Memories are living parts of us, not photographs fixed in time; they change and grow as we change and as we learn new things

118 how well they manage to take even death in their stride because although death can put an end to them right enough, it can never put an end to our relationship with them. Wherever or however else they may have come to life since, it is beyond a doubt that they still live in us. Memory is more than a looking back to a time that is no longer; it is looking out into another kind of time altogether where everything that ever was continues not just to be, but to grow and to change with the life that is in it still. The people we loved. The people who loved us. The people who, for good or ill, taught us things. Dead and gone though they may be, as we come to understand them in new ways, it is as though they come to understand us and through them we come to understand ourselves in new ways too. p.21

119 Bereaved people have a large reservoir of memories of the person who died, both explicit and implicit. However, with when grief is intense these memories may seem too painful and trigger experiential avoidance Or, memories may be compartmentalized and kept separate from the loss

120 People with intense grief sometimes daydream about being with their loved one. This type of memory blocks out current reality a kind of dissociative state The reality of the loss can t color or shade the memories so they don t grow and change with the bereaved person

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124 Summary Persistent impairing grief affects millions of people worldwide each year This syndrome can be identified using ICD11 guidelines CGT is a short-term evidence based adaptive therapy that can help bereaved survivors adapt to the loss; it s been proven efficacious in 3 separate NIMH-funded studies carried out in 5 separate clinical laboratories. CGT centers on 7 main themes and core procedures aimed at helping people understand the finality and consequences of a loss, change their relationship with the deceased and envision their future in a way that has possibilities for joy and satisfaction

125 For professionals Information and resources on our website Training video series Treatment Manuals Assessment Instruments Workshop series Weekly peer support meetings on zoom Webinars For the public Information and resources on our website Handouts on grief and adaptation to loss and Difficult Times Find a therapist Information about research For information visit our website

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