There is no single intervention that is appropriate to all bereaved people.
The following two types of interventions have proved beneficial in subjects
at high risk for problematic bereavement:
Emotion-focused interventions: encouraging the expression of grief
and other emotions
These aim to facilitate the expression of grief, both emotionally
and verbally. Don't be afraid to ask, "How did you feel?"
and to reassure people if they apologize for crying "It's the most natural
thing in the world to cry, it just means that you care". It is a
good idea to have tissue at hand, but don't rush in with them or people
will think you disapprove of them crying.
Cognitive-focused interventions: encouraging problem solving and
re-planning one's life
These aim to help people to look forward and re-plan their
lives. They may need to be reassured that grief is not a sacred
duty to the dead, the lost person would not want them to suffer for
ever, but to draw upon the treasures of the past in order to move forward. The
aim is not to forget the dead but to find a new place for them in our lives.
Gender Differences
Men benefit more from emotion-focus and women from cognitive focused interventions
(Schut 1997). Schut's findings came as
a surprise to many people, who assume that men should be encouraged
to do what they are best at, keeping a stiff upper lip, and women
to "Have a good cry." But in fact the reverse is the case,
men who seek help after bereavement are more likely to benefit from permission
to share feelings, while women, most of whom are more in touch with their
emotions than men, may need permission to dry their tears and look
ahead.
Bereavement Support
Bereavement support can be provided by trained hospice volunteers or other
care providers who have received training in providing counsel
Helpers can be trained in provision of both emotional and cognitive focused
interventions and to switch between them as the need arises.
Interventions
Anxiety
Helpers should be trained to recognize the normal physical
manifestations of anxiety, to provide explanation and reassurance along
with appropriate relaxation techniques. Because of the danger of habituation
anxiolytic medication and sedatives should seldom be prescribed and then
only in single or a few doses.
Depression
In those with evidence of clinical depression of mild to moderate intensity
cognitive behavior therapy is as effective as anti-depressant medication
(Dobson 1989). Harris et al.
(1999) have shown that volunteers
can use 'fresh start' techniques that reduce depression. No convincing
evidence has been published to support the widely held belief that anti-depressants
interfere with the course of normal grief.
In cases of severe depression, anti-depressants such as Fluoxetine may
even save the life of a person tempted to suicide. Fluoxetine is also
likely to benefit anxiety although a few patients become more nervous.
Because transient side effects often occur before any benefit is felt
(all anti-depressants take about two weeks to take effect), patients may
need encouragement to give them a fair trial.
Suicide Prevention
All helpers should be trained to assess the risk of suicide. The most
common mistake is failure to ask a simple question such as 'Has it been
so bad that you have wanted to kill yourself?' This will almost always
receive an honest answer. Those at serious risk will have a plan and the
helper should find out what this is.
Before the interview ends, the potential suicide should be given the
telephone number of a suitable 'hot-line' and, if possible, any store
of drugs removed. Medication should be placed in the hands of a responsible
other person. This is one situation where immediate consultation with
a supervisor and/or psychiatrist is essential (Even if this necessitates
breaching client confidentiality). The support of the patient's family
is of particular importance.
Complicated Grief
Complicated grief often follows long-standing insecurity of attachments
which undermine trust in oneself and/or others (Parkes
2004). Positive results have been obtained from the use of short-term
dynamic therapies and prescription of selective serotonin reuptake inhibitors
such as paroxetine (Prigerson 2001).
People with chronic grief are often dependent individuals with a tendency
to cling. Indeed they may cling to their therapist or seduce us into thinking
that we can run their lives for them The most important thing we have
to offer them is not our pity, but our respect for their true worth and
potential. They need reminding that the memory of the lost person remains
an internal source of support in the next chapter of their lives (Parkes
2004).
People whose grief is delayed are often intolerant of closeness and likely
to have had an ambivalent relationship with the lost person and others.
Repressed grief sometimes partially emerges as identification symptoms
resembling those of the lost person. The avoider may need encouragement
and reassurance that it is all right to express natural feelings of guilt,
anger and grief. When they do this there is often a dramatic improvement
(Ramsay 1979, Mawson 1981).
Post-Traumatic Stress Disorder
While minor or partial forms of PTSD will sometimes respond to short-term
dynamic therapies that encourage people to stop avoiding and live with
traumatic memories, more severe cases should be referred to a clinical
psychologist. Effective treatments for the condition include Eye Movement
Desensitization (Shapiro 1989)
but those who have successfully completed a course of treatment may still
need help in coming to terms with their grief.
