Fluent Essays

I need a 3-5 page paper on the tools, procedure protocol for assessing grief and loss. From J. William Worden (2009) Grief Counseling and Grief Therapy: ISBN 13:9780826101204 or ISBN 10:0826161208. Is this within your scope of writing? PRAISE FOR GRIEF COUNSELING AND GRIEF THERAPY “The fourth edition of this book retains all the theoretical strengths and clinical wisdom of past editions, while incorporating emerging theories and cutting- edge research. It is required reading for any counselor, educator, or researcher who wishes to understand grief.” —Kenneth J. Doka, PhD, Professor, The Graduate School, The College of New Rochelle; Senior Consultant, The Hospice Foundation of America “[If] you knew Worden’s work and his writings previously, you’ll fi nd an en- hanced book with a much broader and challenging perspective than his previ- ous editions. If you are not familiar with Bill Worden, then it is time to begin.” —Ben Wolfe, MEd, LICSW, Fellow in Thanatology, Program Manager/Grief Counselor, St. Mary’s Medical Center’s Grief Support Center, Duluth, MN; Past President, Association for Death Education and Counseling “This book challenges how we conceptualize the experience of grief and the process of mourning, it informs how we assess those experiencing problems in adjusting to loss, and it guides our treatment approaches. I can’t think of a thing Worden has missed.” —Stephen Fleming, PhD, Department of Psychology, Faculty of Health, York University, Toronto, Ontario, Canada “Simply stated, you will not fi nd a better book to guide you in assisting people struggling with the myriad of issues following a death.” —Donna L. Schuurman, EdD, CT, Executive Director, The Dougy Center for Grieving Children & Families Praise for Earlier Editions “This book is the ‘Bible’ for those involved in the fi eld of bereavement work. . . . It is a straightforward, tightly focused, practical, soundly reasoned, compact work- ing text.” —William M. Lamers, Jr., MD, The Lamers Medical Group “[Worden] has again provided mental health professionals with a superb guide describing specifi c . . . procedures that may be helpful in working with bereaved clients undergoing normal or abnormal grief reactions . . . [An] extremely prac- tical book and an invaluable resource.” —Contemporary Psychology, now known as PsyCritiques J. William Worden, PhD, ABPP, is a fellow of the American Psycholog- ical Association and holds academic appointments at the Harvard Medical School and at the Rosemead Graduate School of Psychol- ogy in California. He is also co-principal investigator of the Harvard Child Bereavement Study, based at Massachusetts General Hospital. Recipient of fi ve major NIH grants, his research and clinical work over 40 years have centered on issues of life-threatening illness and life-threatening behavior. His professional interests led him to become a founding member of the Association of Death Education and Counseling and the Inter- national Work Group on Death, Dying, and Bereavement. A pioneer in the hospice movement in the United States, Dr. Worden was on the advisory board for the fi rst hospice in the United States in Branford, Connecticut, as well as the Hospice of Pasadena, California. He has been a consultant to various research projects across the United States, including “Women and HIV” for Columbia University, “Assisted Suicide and End-of-Life Decisions” for the American Psychological Association, and “Fathers’ Experience With Pediatric End of Life Care” for the University of California, San Francisco. He served for 7 years on the national board of the American Cancer Society and is active in the society at the state and local levels. Dr. Worden has lectured and written on topics related to terminal illness, cancer care, and bereavement. He is the author of Personal Death Awareness and Children & Grief: When a Parent Dies, and is coauthor of Helping Cancer Patients Cope. Grief Counseling & Grief Therapy: A Handbook for the Mental Health Practitioner has been translated into 11 foreign languages and is widely used around the world as the standard reference on the subject. Dr. Worden’s clinical practice is in Laguna Niguel, California. Grief Counseling and Grief Therapy A Handbook for the Mental Health Practitioner FOURTH EDITION J. William Worden, PhD, ABPP New York Copyright © 2009 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or trans- mitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Sheri W. Sussman Production Editor: Julia Rosen Cover design: Mimi Flow Composition: Apex CoVantage Book cover photo: Celestino Garcia 08 09 10 11 12/ 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Worden, J. William (James William) Grief counseling and grief therapy : a handbook for the mental health practitioner / J. William Worden. — 4th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8261-0120-4 (alk. paper) ISBN 978-0-8261-2456-2 (int’1 ed.) 1. Grief therapy. 2. Mental health counseling. I. Title. [DNLM: 1. Counseling—methods. 2. Grief. 3. Psychotherapy—methods. WM 55 W924g 2008] RC455.4.L67W67 2008 616.8914—dc22 2008016551 Printed in the United States of America by Bang Printing. www.springerpub.com To my children, Michael and Karin And my grandchildren, Abigail Ann and Andrew William May these thoughts be helpful to you one day. This page intentionally left blank Grieving allows us to heal, to remember with love rather than pain. It is a sorting process. One by one you let go of things that are gone and you mourn for them. One by one you take hold of the things that have become a part of who you are and build again. —Rachael Naomi Remen Happiness has gone out of our lives; Grief has taken the place of our dances. —Lamentations 5 This page intentionally left blank ix Preface xiii Introduction 1 What Is the Nature of Complicated Bereavement? 1 Disenfranchised Grief 2 Continuing Bonds 3 Meaning Making 4 Resilience 5 Trauma and Grief 6 1 Attachment, Loss, and the Experience of Grief 13 Attachment Theory 13 Is Grief a Disease? 16 Normal Grief 17 Grief and Depression 31 2 Understanding the Mourning Process 37 Tasks of Mourning 39 Dual-Process Model of Grieving 53 3 The Mourning Process: Mediators of Mourning 57 Mediator 1: Who the Person Who Died Was 57 Mediator 2: The Nature of the Attachment 58 Mediator 3: How the Person Died 59 Mediator 4: Historical Antecedents 63 Mediator 5: Personality Variables 64 Mediator 6: Social Variables 73 Mediator 7: Concurrent Stresses 75 Caution 75 When Is Mourning Finished? 76 Contents 4 Grief Counseling: Facilitating Uncomplicated Grief 83 Goals of Grief Counseling 84 Identifying the At-Risk Bereaved 87 Counseling Principles and Procedures 89 Useful Techniques 105 The Use of Medication 108 Grief Counseling in Groups 109 Facilitating Grief Through Funeral Ritual 118 Does Grief Counseling Work? 120 5 Abnormal Grief Reactions: Complicated Mourning 127 Why People Fail to Grieve 127 How Grief Goes Wrong 134 An Emerging Diagnosis of Complicated Grief 135 An Existing Model of Complicated Mourning 137 Diagnosing Complicated Mourning 146 6 Grief Therapy: Resolving Complicated Mourning 153 Goals and Setting of Grief Therapy 155 Procedures for Grief Therapy 156 Special Considerations for Grief Therapy 167 Techniques and Timing 169 Dreams in Grief Counseling and Therapy 171 Some Considerations 172 Evaluating Results 174 7 Grieving Special Types of Losses 179 Suicide 179 Counseling Survivors of Suicide Victims 183 Sudden Death 187 Sudden Infant Death Syndrome (SIDS) 192 Miscarriages 195 Stillbirths 197 Abortion 199 Anticipatory Grief 201 AIDS 206 x Contents 8 Grief and Family Systems 217 Death of a Child 222 Children Whose Parents Die 230 Family Intervention Approaches 236 Grief and the Elderly 239 Family Versus Individual Needs 244 9 The Counselor’s Own Grief 251 Loss History 254 Stress and Burnout 255 10 Training for Grief Counseling 261 Grief Sketches 1–18 264 Appendix 283 Bibliography 285 Index 305 Contents xi This page intentionally left blank xiii Twenty-fi ve years have passed since the fi rst edition of Grief Counsel- ing & Grief Therapy was published. In these 25 years there have been a number of challenges and changes to the fi eld. Some have challenged the effectiveness of grief counseling, while others have suggested that it can have a negative effect on some mourners. Is grief counseling unnecessary, ineffective, and harmful? I want to address these issues in this edition of the book. Still others have wanted to challenge the tasks of mourning by suggesting that they are nothing other than stages of mourning, and that this stage theory of mourning is passé. This belief is based on a limited understanding of the task model and a failure to keep abreast of its development through the earlier editions of the book. Others support the task of mourning idea but put their own spin on how and when these tasks should be accomplished. For example, the dual process of mourning approach of Schut and Stroebe covers the tasks but does so in an oscillating fashion. Doka, Corr, and Rando have each increased the number of tasks and come up with an alterna- tive model. I still believe that the task model is a useful way to think about the process of mourning, but I have modifi ed it and made some changes in this edition of the book. Readers will notice that the mediators of mourning now has its own chapter. These mediators affect how the tasks are adapted to or not. While bereavement is a universal phe- nomenon, the experience of grief is not. These mediators account for much of this individual difference. Task III has been reformulated as “adjusting to a world without the deceased” and has been divided into three subtasks: external, in- ternal, and spiritual tasks. These subtasks were included in the third Preface edition, but some apparently missed this, so I have tried to make this emphasis clearer and link it with current research fi ndings, including those having to do with meaning making. Readers of earlier editions will understand how task IV has evolved from its original conceptualization of “emotionally withdrawing from the deceased so that emotional energy can be reinvested in other re- lationships.” This early Freudian notion gave way to object relations thinking, where the task involved “keeping the deceased in one’s life but emotionally relocating the deceased so that one can move forward with one’s life.” Currently, a good defi nition of this fourth task, which is supported by research on continuing bonds, would be: “To fi nd an enduring connection with the deceased in the midst of embarking on a new life.” Select a defi nition that makes the most sense to you in understanding your personal loss experience as well as in understand- ing what is going on with your clients. I do think that a fourth task is needed to round out one’s overall adaptation to the loss. Incidentally, I prefer to use the word “adaptation” rather than words like “recov- ery” or “resolution.” Special acknowledgments are due a number of people who assisted me with this project. I would like to thank Robert Cochran for his help in tracking down the vast amount of recent literature. My appreciation is also extended to Karin Worden, Jim Monahan, Carlos Canales, Sharon Hsu, and Jason Smith for their assistance, and Sheri W. Sussman, vice president, Editorial, at Springer Publishing Company, who has added her wisdom and encouragement for all four editions of this book. The professionals in the Worden group, which meets monthly for support and supervision, have inspired me and clarifi ed my thinking. These include Dennis Bull, Ann Goldman, Linda Grant, Bill Hoy, Annette Iverson, Michael Meador, Ron Ritter, Barbara Smith, and Stephanie Thal. And, as always, my family and friends provided im- portant emotional support. xiv Preface 1 Introduction Over the 25 years since the fi rst edition of this book was written, there have been a number of new concepts introduced into the fi eld of grief, loss, and bereavement. Before we get into the content of this fourth edition, I would like to highlight some that I believe are worth noting. Many of these appeared during the past 10 years, and some of these I discuss in more detail in the book. Although tempted to put these into the top 10 in order of importance as the E-Channel does, I will merely list them. They are all important. WHAT IS THE NATURE OF COMPLICATED BEREAVEMENT? For years, most of those working with complicated mourning and grief therapy have used terms like “chronic grief,” “delayed grief,” and “exaggerated grief ” to delineate the diagnosis of those with compli- cated bereavement or complicated mourning. In fact, some of these concepts were defi ned by consensus when Beverly Raphael and Warwick Middleton (1990) did a survey to determine which terms were the most frequently used by leading therapists in the fi eld. Although there was a surprising degree of consensus, the problem is that complicated grief is a V code in the DSM, and V code diagnoses do not qualify for third-party payment through insurance carriers. 2 Grief Counseling and Grief Therapy Another problem has been the lack of precise defi nitions of these terms, which makes rigorous research of them diffi cult. The easiest solution has been to do research using well-defi ned pathological en- tities like depression, anxiety, and somatization, for which there are good standardized measures. Although these clinical entities may be part of the mourner’s experience, they clearly are not measures of grief. There were a few measures of grief like the Texas Revised Grief Inventory and the Hogan Grief Reaction Checklist, but most were normed on a clinical population. Beginning with the work of Holly Prigerson and Mardi Horowitz, there has been a 10-year-plus attempt to come up with a diagnosis of complicated grief that would be acceptable to go into the DSM-V, scheduled for release in 2010. Such a diagnosis would make insurance money available for the treatment of patients with this diagnosis and would make research funds available for further investigation on this clinical entity. Details on this diagnosis and its development can be found in chapter 5. DISENFRANCHISED GRIEF This term, coined by Ken Doka and further developed by Attig (2004), has been an important addition to the fi eld. Although Doka’s fi rst vol- ume came out in 1989, he updated the concept in a second volume that came out in 2002. Disenfranchised grief refers to losses in the mourner’s life of relationships that are not socially sanctioned. A clas- sic example would be the death of someone with whom the mourner is having an affair. If this affair is not widely known, the mourner will not be invited to participate in the funeral rituals and may not receive the social support that many people fi nd helpful after a death. Alternate lifestyles may not be socially sanctioned, and the friend or lover may be ostracized by the dead person’s family. There are nu- merous other examples of disenfranchised grief and there are sugges- tions in this book for reenfranchising some of these losses to aid the mourner in adapting to the loss. Aaron Lazare (1979), an early colleague at Massachusetts General Hospital, talked about two kinds of loss that are directly related to Introduction 3 this concept of disenfranchised grief. Socially negated losses are those losses that society treats as non-losses. Examples of this would be preg- nancy losses either spontaneous or induced. The second kind of loss related to disenfranchised grief would be socially unspeakable losses. These are specifi c losses about which the mourner has a diffi cult time talking. Common examples would be deaths by suicide and death by AIDS. Both of these losses carry some stigma in the broader soci- ety. One intervention that can be helpful to those experiencing these types of losses can be assisting them in talking about them and ex- ploring their thoughts and feelings about the death. Reenfranchising suggestions for these types of losses can be found in chapter 7 of this volume. CONTINUING BONDS Attachments to the deceased that are maintained rather than relin- quished have been called continuing bonds. This is not an entirely new concept. Shuchter and Zisook (1988) noted that widows in their seminal studies in San Diego maintained a sense of their loved one’s presence for several years after the death. In the Harvard Child Bereavement Study, Silverman, Nickman, and I observed ongoing connections with the dead parent among a large number of these bereaved children. For most it was a positive experience; for some it was not. The book by Klass, Silverman, and Nickman titled Con- tinuing Bonds: New Understandings of Grief (1996) pulled together information from our study and several others to promote the notion that people stay connected with the deceased rather than emotionally withdrawing, as was the notion promoted by Freud. This new concept was not embraced by all and questions soon arose as to whether continuing bonds can be adaptive for some and maladaptive for others? Are continuing bonds actually associated with a healthy ongoing life? A lot of this controversy is based on the lack of good research evidence for the effi cacy of continuing bonds. As more research is done, some of these questions will be resolved. Essentially, the questions center around fi ve main issues: (1) What types of bonds are the most helpful in the adaptation to loss? These 4 Grief Counseling and Grief Therapy would include objects from the deceased (linking and transitional objects, keepsakes), a sense of the deceased’s presence, talking to the deceased, introjecting the deceased’s beliefs and values, taking on characteristics of the deceased, and the like. (2) For whom are con- tinuing bonds helpful, and for whom are they not? This necessitates the identifi cation of subgroups of mourners; the concept should not be applied to everyone. One promising approach to this is to look at the mourner’s attachment style in relationship to the deceased. In the case of anxious attachments that can lead to chronic grief, hold- ing onto the deceased may not be adaptive. Some mourners need to relinquish and move on (Stroebe & Schut, 2005). (3) In what time frame are continuing bonds the most adaptive and when are they less adaptive—closer to the loss, farther from the loss? (Field, Gao, & Paderna, 2005). (4) What is the impact of religious and cultural dif- ferences on maintaining healthy bonds? This would include beliefs and rituals that promote a connection and memorialization of the deceased in various societies. (5) What is the relationship between maintaining a continuing bond with the deceased and relocating the deceased, which is an important part of Worden’s fourth task of mourning? More on bonds can be found in chapter 2. MEANING MAKING Meaning reconstruction and meaning making, concepts introduced and promoted by Robert Neimeyer, have been an important emphasis in the fi eld over the past 10 years. He sees meaning reconstruction as the central process faced by bereaved individuals. This reconstruction is primarily accomplished through the use of narratives or life stories. When unanticipated or incongruous events such as the death of a loved one occur, a person needs to redefi ne the self and relearn ways to en- gage with the world without the deceased. The person cannot return to a pre-loss level of functioning but learns how to develop a mean- ingful life without the deceased loved one. This is central to my third task of mourning, in which the mourner must learn to adjust to a world without the deceased. Death can challenge one’s assumptions about the world (spiritual adjustments) and one’s personal identity (internal Introduction 5 adjustments). Bereaved individuals have serious questions such as: “What will my life look like now? ” “What did the deceased’s life mean? ” “How can I feel safe in a world such as this? ” and “Who am I now that this death has occurred? ” (Neimeyer, Prigerson, & Davies, 2002). I think it is important to note, however, that some deaths do not challenge personal meaning making in any fundamental way. Davis and colleagues (2000) conducted research on two different bereaved populations and found that 20\% –30\% of the bereaved individuals appeared to function well without engaging in the process of mean- ing making. Of those who searched for meaning, fewer than half of the individuals found it even over a year after the death. Those who did fi nd meaning, however, were better adjusted than those who searched and didn’t fi nd it, but, interestingly, for some the quest to understand continued even after meaning was found. Neimeyer (2000), commenting on the Davis research, makes note that the majority in the studies were struggling with meaning mak- ing and these should be helped with this process. But, he cautions the counselor about initiating this process if it does not occur spon- taneously. He concludes his comments with an important distinction: meaning making is a process, not an outcome or achievement. The meanings associated with death loss are constantly revised. We see this clearly in our work with bereaved children, who, as they age and pass through new developmental stages, ask: “What would my parent be like now? ” and “What would our relationship be like now that I am graduating college, getting married, etc? ” (Worden, 1996). More on meaning making as a task of mourning can be found in chapter 2. RESILIENCE When Phyllis Silverman and I studied 125 parentally bereaved chil- dren over a 2-year period after the death, we noted that children fell into one of three groups. The fi rst was the group of children (approximately 20\%) who were not doing well during the 2 years after the death. Since our research grant came from the NIMH for a study intended to identify bereaved children at-risk and prevent problem outcomes, this group became a major focus of our study. Could we 6 Grief Counseling and Grief Therapy identify at-risk children early after the loss so that early intervention might be offered to prevent later negative sequelae from the death? However, we also noticed a second smaller group of children who seemed to be doing very well, and we identifi ed them as resilient children. Their academic performance, social life, communication about the deceased, self-worth, sense of control, and healthy identifi - cation with the dead parent were all on the high side. The third and largest group was “making do” during the fi rst 2 years of bereavement (Silverman, 2000; Worden, 1996). Thanks to the work of George Bonanno (2004), we have begun to look at resilient bereaved individuals. These are people who adapt well to the loss and are not in need of either counseling or therapy. I think this focus is overdue. In Arizona, Irwin Sandler, Sharlene Wolchik, and Tim Ayers (2008) have added to our thinking on resilience. Like myself, they prefer the term “adaptation” to “recovery.” Those mourners who make a good or effective adaptation to the loss have made a “resilient adap- tation.” Sandler’s group has identifi ed both risk and protective factors in their study of parentally bereaved children and their families that lead to a good (resilient) or a less good adaptation to the loss. By fo- cusing on positive as well as negative outcomes, a resilient approach goes beyond the more narrow focus of pathological outcomes. It is interesting that the risk and protective factors found in Arizona fami- lies are similar to those Silverman and I found in the Harvard study. Multiple factors at both the individual and social environmental levels are at work here, so Sandler’s group calls their theory a contextual framework on adaptation. Individuals are seen as nested within fami- lies, which are in turn nesting within communities and cultures. This fairly new research and thinking on resilience in bereavement holds promise for our understanding of grief and loss. More on this can be found in chapter 3. TRAUMA AND GRIEF Like depression and grief, trauma and grief share many of the same behavioral features. A number of articles discuss how they are similar Introduction 7 and how they are different. There are some, like Rando, Horowitz, and Figley, who would subsume all grief under trauma, but I fi nd this a stretch. I prefer the model offered by Stroebe, Schut, and Finkenauer (2001), which makes the following three distinctions: The fi rst is trauma without bereavement. Here the person experiences a traumatic event that gives rise to trauma symptoms leading to a diag- nosis of posttraumatic stress disorder or acute stress disorder, mostly depending on the time frame. Other symptoms of depression and anxiety may lead to a comorbid diagnosis. In this fi rst distinction the traumatic event has not led to any deaths and the person is dealing with one or more of the classic trauma symptoms (intrusion, avoidance, hyperarousal) without bereavement. Bereavement without trauma is the second distinction. Here the person has experienced the death of a loved one without experiencing trauma symptoms as sociated with the event. If there are complications after the loss, one of the compli- cated mourning categories would apply to this compli cation. The third category could be called traumatic bereavement. Here the person ex- periences a death and there is something about the death itself (often violent deaths) or something about the person’s experience of the death (often related to an insecure attachment or confl icted relation- ship with the deceased) that gives rise to symptoms associated with trauma. Two questions emerge in any discussion of traumatic bereave- ment. First, which is the most important in defi ning traumatic be- reavement—the circumstances of the death or the reaction of the mourner? Second, in the treatment of traumatic bereavement, which symptoms should be addressed fi rst—the trauma symptoms or the grief symptoms? Traumatic stress interferes with grief over loss; grief interferes with trauma mastery (Rando, 2003). Many believe that the trauma symptoms must be dealt with fi rst before the grief can be addressed. There have always been people who have been exposed to violent deaths, but the number of violent events seems to have increased during the past 10 years. The recent rash of school shootings as well as September 11, 2001, illustrate the pervasiveness of violence in our society. Such violent events will continue to expose more people to both trauma and bereavement. We need more research on grief and 8 Grief Counseling and Grief Therapy trauma, including research on which interventions are most effective. We need to educate the media that interventions done in the days following school shooting are not grief counseling but rather crisis intervention, and there are major differences between the two in goals and techniques. Let me conclude this introduction with something that causes me concern—the failure of both clinicians and researchers to recognize the uniqueness of the grief experience. Even though the mourning tasks apply to all death losses, how a person approaches and adapts to these tasks can be quite varied. A one-size-fi ts-all approach to grief counseling or grief therapy is very limiting. When I was a graduate student at Harvard, Professor Gordon Allport had a strong impact on my thinking. Allport (September 1957, lecture notes) would tell students that “Each man is like all other men; each man is like some other men; and each man is like no other man.” Allport was affi rming his longtime professional interest in in- dividual differences—an interest that led to his collaboration with Robert White on the longitudinal case studies of men called Lives in Progress (1952). These studies affi rm both the similarity and unique- ness of each person. If we were to translate Allport’s dictum into the fi eld of bereave- ment, we would say, “Each person’s grief is like all other people’s grief; each person’s grief is like some other person’s grief; and each person’s grief is like no other person’s grief.” Over the last 25 years we have tended to lose sight of the uniqueness of the …