Complicated Grief

Scientific Foundations for Health Care Professionals

Margaret Stroebe, Henk Schut, Jan van den Bout, Margaret Stroebe, Henk Schut, Jan van den Bout

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415625050
  9780415603935
• Edition: 1
• eBook ISBN:
  9781136252426
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

How can complicated grief be defined? How does it differ from normal patterns of grief and grieving? Who among the bereaved is particularly at risk? Can clinical intervention reduce complications?

Complicated Grief provides a balanced, up-to-date, state-of-the-art account of the scientific foundations surrounding the topic of complicated grief. In this book, Margaret Stroebe,Henk Schut and Jan van den Bout address the basic questions about the concept, manifestations and phenomena associated with complicated grief. They bring together researchers from different disciplines, providing a broad range of cultural and societal perspectives, to enable the reader to access the scientific knowledge base regarding complicated grief, on both theoretical and empirical levels.

The book is divided into four main sections:

• An exploration of the nature of complicated grief
• Diagnostic categorizations
• Contemporary research on complicated grief
• Treament of complicated grief

Illuminating the foundations and new innovations in research, Complicated Grief will be essential reading for professionals working with bereavement such as clinical psychologists, health psychologists and psychiatrists, researchers, as well as graduate students of psychology and psychiatry.

Margaret Stroebe is Professor at the Department of Clinical and Health Psychology, Utrecht University, and the Department of Clinical Psychology and Experimental Psychopathology, University of Groningen,The Netherlands.

Henk Schut is Associate Professor at the Department of Clinical and Health Psychology, Utrecht University, The Netherlands.

Jan van den Bout is Professor of Clinical Psychology at Utrecht University, The Netherlands.

Contributors: Paul Boelen, Kathrin Boerner, George Bonanno, Laurie Burke, Rachel Cooper, Atle Dyregrov, Kari Dyregrov, Francesca Del Gaudio, Ann-Marie Golden, Jennifer Jacobs, David Kissane, Rolf Kleber, Yeulin Li, Jeffrey Looi, Anthony Mancini, Mario Mikulincer, Michelle Moulds, Robert Neimeyer, Mary-Frances O'Connor, John Ogrodniczuk, William Piper, Holly G. Prigerson, Therese Rando, Beverley Raphael, Paul C. Rosenblatt, Edward Rynearson, Henk A.W. Schut, Phillip Shaver, Margaret S. Stroebe, Jan van den Bout, Marcel van den Hout, Birgit Wagner, Jerome C. Wakefield, Edward Watkins, Talia I. Zaider.

Part I Introduction

1 Introduction Outline of goals and scope of the book

Margaret Stroebe, Henk Schut, and Jan Van Den Bout

DOI: 10.4324/9780203105115-1

A basic motive in compiling this volume has been to try to gain understanding of complicated grief, at a time in history when this seems particularly pertinent. In general terms, complicated grief (CG) can be understood as something like a “derailing” of the normal, usually painful process of adapting to the loss of a significant person. However, it will become evident to readers of the current volume that different definitions and criteria have been adopted to try to describe the concept more precisely, for both scientific and clinical purposes. To provide some basis for comparison: our earlier definition of CG has been along the lines of

a clinically-significant deviation from the (cultural) norm (i.e., that could be expected to pertain, according to the extremity of the particular bereavement event) in either (a) the time course or intensity of specific or general symptoms of grief and/or (b) the level of impairment in social, occupational, or other important areas of functioning. (Stroebe, Hansson, Schut, & Stroebe, 2008, p. 7)

However, such an apparently detailed characterization has shortcomings (e.g., it does not explicitly specify different types of complications that have been suggested, such as absent, delayed, or chronic grief). Further difficulties in operationalizing and applying such a definition will become apparent through the pages of this book.

In our view, CG is perhaps the most important contemporary topic of concern both for the scientific community of bereavement researchers and for health care professionals supporting bereaved people. This is reflected in a huge expansion of research, which has resulted in broader and deeper understanding of CG in recent decades: Earlier assumptions have been put to empirical test, new research domains have been added, innovative techniques have been applied, novel theoretical perspectives have been introduced, and significant developments in intervention programming have been realized. Different academic and clinical disciplines have been involved in this endeavor. Many of these contributions have bearing on – or are a direct consequence of – the consideration whether complicated/prolonged grief should be included as a category of mental disorder in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association. Currently, developments point in the direction of the inclusion of such a category in the near future.

Notwithstanding such advancements, there is often still lack of clarity or integration, and there are differences of opinion with respect to fundamental issues surrounding CG – ones that go beyond the problems of definition, raised earlier. Furthermore, although the body of knowledge on CG has increased considerably in the past few decades, there are still many limitations in understanding and in empirical investigation. Many fundamental questions remain unanswered. Many theoretical claims still need to be put to empirical test. Empirical research has improved significantly over the last decade but it still has not always been rigorous. Along similar lines, intervention efficacy studies have sometimes lacked adequate methodology (e.g., control groups, preferably attention-placebo control groups, and long-term follow-up measurements). Such gaps in knowledge and shortcomings in investigation need to be identified and directions for future empirical study inventoried.

In our view, it seems appropriate at this point in time to take stock, to compile and assess the contribution of the scientific knowledge base regarding CG, on not only theoretical and conceptual but also empirical levels. Balanced inclusion of a variety of different perspectives and approaches within one volume is timely, to enable review of these diverse contributions, and to relate this research base, where possible, to contemporary societal and practice issues, and to provide critical appraisal of ongoing research and societal developments relating to the topic of CG. Thus, the objective for this volume is to provide a balanced, up-to-date, state-of-the-art account of the scientific foundations surrounding CG. Key questions will be addressed by our authors, such as: How is CG distinct from normal grief, or from other psychiatric disorders? Should it be included in DSM? How can CG best be measured/assessed? Is there an absent grief subtype of CG? How efficacious is professional intervention? Can we prevent CG, or at least identify those at most risk? Have we established determinants of CG, or pinpointed underlying mechanisms? What are the implications of CG for health, well-being, and daily functioning?

We hope this review will be of relevance to the bereavement research community, health care professionals, and policy makers. However, it is important to emphasize that the volume is not designed as a sourcebook for practitioners seeking practical tips or concrete guidelines for intervention with bereaved persons. Rather, it is intended – insofar as can be done in a single volume – to provide an overview of contemporary research on CG in relationship to practice, identifying developments in the field, discussing current controversial issues, encouraging debate about them, proposing research, and – again where possible – deriving implications for treatment and implementation agendas for the future. In line with this, the aim of the book is to approach the topic from diverse perspectives, allowing authors the freedom to elaborate on their own scientific standpoint, to respect different types of scholarship rather than to strive for consensus. Nevertheless, the editors try in the final chapter to assess the contribution of the volume as a whole to scientific knowledge about complicated grief.

The volume is divided into six parts. After outlining the scope of the volume in the remaining part of this chapter, the focus in Part II (Chapters 2–6) is on different conceptualizations of CG. Here the phenomena and manifestations associated with CG are explored. These chapters provide a variety of disciplinary perspectives. In Chapter 2, Rachel Cooper reviews diverse philosophical approaches that can potentially help us address key questions relating to complicated grief, examining how common philosophical accounts of disorder can elucidate the concept of CG. First: What is disorder? Fundamental points are raised: Might we think of normal grief as being a mental injury analogous to physical injury? Second, philosophical work on the role of classification in science is drawn on to discuss the question whether CG should be considered a distinct disorder, or a variant of another condition (ones that are already in the DSM system). At the outset, with this contribution, awareness is gained of the complexity of the issues we are dealing with. In Chapter 3, written by Paul Rosenblatt, the perspective shifts to consideration of CG in different cultures from those Western ones where CG has mostly been investigated. This raises fundamental problems: Deviant grieving may not be seen as a “complication” in the same way as Western cultures view it, or the loss experiences and concerns may be very different from ours, ones that do not fit the language of a DSM category, for example. Rosenblatt emphasizes that CG and research on CG are grounded in a particular culture and we should be cautious about applying this in other cultures. His perspective brings to light basic questions on a societal level: What, for example, is the place of psychological treatment in the face of economic, political, or environmental disasters? In Chapter 4, Theresa Rando elucidates the concept of CG among adults from the standpoint of her clinical practice, illustrating how a clinical perspective on CG can clarify scientific understanding. She considers CG as a distinct diagnostic entity as well as a clinical phenomenon, addressing some controversial and/or problematic issues, and arguing the need to consider CG from both these angles. Consideration is given to different forms and functions of CG. She suggests her own operationalization of CG, based on a conceptual model, which she puts forth for further discussion and research. In Chapter 5, by Kathrin Boerner, Anthony Mancini, and George Bonanno, CG is regarded in the context of normal grief, thus looking more from the perspective of the opposite side of the coin. Focus is on the complex distinction between uncomplicated and complicated grief. What distinguishes these phenomena, how prevalent are they, and what underlies the formation of the different response patterns to loss of a loved one? Drawing on their extensive research examining the course of grief over time, these authors relate the patterns to different trajectories of grief and grieving and describe predictors for complicated or uncomplicated grief patterns. Importantly, they attest to the resilience of the majority of bereaved people. Finally in this section, attention turns to the nature of CG in a specific subgroup of bereaved individuals. Within the scope of this book, valuable though examination of specific kinds of bereavement is for our understanding of CG, we have been able to select only two special cases. Here we focus on CG among children (in a later section we include consideration of CG following violent death). With few exceptions, there has been little research on CG among children so far. One of the exceptions has been the work of Atle and Kari Dyregrov, who contribute Chapter 6. In what ways and to what extent does CG in children parallel or differ from that among adults? This chapter covers several important topics, each being related specifically to children’s grief: the phenomenology of CG; its distinctiveness from normal grief; assessment and treatment of CG; and risk factors. The authors stress the importance of enhancing knowledge about the phenomenology, assessment, and treatment of problems among children.

In Part III (Chapters 7–12), categorization of CG as a mental health condition is the central underlying theme. This brings the discussion regarding DSM inclusion, which was mentioned earlier, center-stage. Chapters in this section provide a variety of viewpoints. In the first of these (Chapter 7), Paul Boelen and Holly Prigerson present arguments in favor of CG becoming a new psychiatric condition, based on their extensive research. They review studies that in their view support the case that CG (or, in their terms, also prolonged grief disorder, abbreviated to PGD) meets the definition of a mental/psychiatric disorder and that it should therefore be included in the DSM system. They go on to describe the criteria that they have derived from their empirical and conceptual work for PGD/CG. Given this, they explain why they consider it timely to include PGD/CG in the DSM system; they outline the consensus criteria, detail the available empirical evidence, and indicate how they think CG should be conceptualized and assessed. By contrast, in the following chapter (Chapter 8), by Jerome Wakefield, critical issues to do with CG’s entry in the DSM system are brought forward, so that the reader is able to assess both the pros and cons of this (potential) major development. Wakefield examines six arguments put forward by advocates of the proposal in support of CG’s conceptual validity. He argues that, despite the enormous effort to research CG over the past decades, close inspection of these aspects reveals deficiencies that lead him to conclude that the majority of persons who would be diagnosed under the CG proposal are suffering from lengthy but normal grief. Next (Chapter 9), and again with DSM inclusion in mind, Jan van den Bout and Rolf Kleber draw on the experience gained from the related area of posttraumatic stress disorder (PTSD) to consider what consequences could ensue should CG be included as a diagnostic category in DSM-5. PTSD was already included in DSMIII in 1980, so there has been time to assess the scientific, clinical, and societal consequences. These researchers identify some positive aspects (e.g., the furtherance of research on a wide range of traumatic experiences, and development and testing of new models on origins and maintenance). They also pinpoint matters for concern (e.g., controversy about diagnostic criteria, clinical utility, and accuracy of prevalences) that could apply in the case of CG too. Whereas Chapter 9 focuses on lessons learned from PTSD for a diagnostic category of CG, in Chapter 10, by Beverley Raphael, Jennifer Jacobs, and Jeff Looi, the interest is in placing CG in the context of other disorders. Again, traumatic experiences and PTSD provide a useful domain for discussion of this, in the final chapter in this section. Manifestations and phenomena following the stressors of trauma and loss through bereavement are described, as well as overlapping versus distinct symptomatology (and associated additional complications). Issues of comorbidity and possible etiologies of PTSD and CG are discussed. Finally, assessment and management strategies for CG with trauma syndromes as comorbidity are outlined.

Part IV (Chapters 11–15) covers contemporary empirical research on risk factors, processes, and mechanisms associated with CG. First, who among bereaved persons are most vulnerable to CG; can we identify empirically supported factors that predict susceptibility to CG? In Chapter 11, Laurie Burke and Robert Neimeyer have taken on the daunting task of reviewing the extensive body of scientific research on risk factors, sifting the literature to find those studies that are the most informative with respect to CG. They cover intra- and interpersonal as well as situational features that increase an individual’s vulnerability. As far as possible given the current state of knowledge, they link these risk factors to the full range of responses to bereavement, and point to factors that merit further scientific and clinical investigation. Subsequent chapters in this section cover a range of perspectives that help understand cognitive and emotional functioning in persons with CG. Two chapters focus on specific processes. First, Edward Watkins and Michelle Moulds explore the role of rumination and of repetitive thought in CG (Chapter 12). Given that rumination has to do with repeatedly dwelling on personal concerns and feelings, it stands to reason that it may be related to chronic grief. Does it in fact contribute to the development or maintenance of CG? Does it have constructive or unconstructive consequences? These questions are explored in this chapter, on the basis of extant evidence, considering recent theoretical and empirical approaches to rumination and exploring their relevance for understanding CG and its treatment. They provide an integrative model that helps to guide both research and clinical practice. Second, Ann-Marie Golden focuses on autobiographical memory (Chapter 13), that is, memories specifically concerned with the recollection of previously experienced personal events, which – importantly – contribute to a person’s sense of self. In the context of CG, one key feature of autobiographical memory is overgenerality (the tendency to recollect in terms of regularities across multiple experiences rather than specific events), being linked as it is with psychopathology. The phenomenon of overgeneral memory bias in relationship to CG is described, research is reviewed, and methodologies and limitations are suggested. Future research lines are laid out specifically for CG investigation, to further detail the psychological mechanisms involved; the clinical relevance of this research line is considered. On a different level, the next chapter in this section (Chapter 14), by Mario Mikulincer and Phillip Shaver, examines the relationship between attachment patterns and CG, following the attachment theory perspective. This theory has had and still has enormous influence in the bereavement field. The authors summarize this approach and present their own psychodynamic model of the activation and functioning of the attachment behavioral system, using it to conceptualize two types of CG: chronic grief and prolonged absence of grieving. They review relevant research findings linking anxious attachment to chronic and avoidant attachment to absent grief. They delineate implications of their perspective for diagnosis, case formulation, and therapy of bereaved clients with CG. Shifting directions again, the section closes with a chapter on physiological mechanisms and the neurobiology of CG by Mary-Frances o’Connor (Chapter 15). This represents a new area of research into CG. The chapter reviews current studies of these mechanisms, including functional magnetic resonance imaging (fMRI) studies of bereavement, genetic analysis, and endocrine data. The evidence is placed in the context of literature on the physiology of the stress response, the biological attachment system, and theories of physiological co-regulation. The benefits of using physiological and neurological variables in bereavement research, as part of a multi-method approach, are described and it is shown how this line of investigation has potential to increase understanding of CG.

Part V (Chapters 16–20) spans a variety of topics relating to the treatment of complicated grief. The first few chapters present a number of intervention principles, paradigms, and procedures, to enable the reader to understand different types of professional help that may be available and appropriate, and to learn the extent to which these programs have been tested for their efficacy. In the first of these (Chapter 16) the authors, Paul Boelen, Jan van den Bout, and Marcel van den Hout, describe a new theoretically based treatment program for CG, based on the cognitive–behavioral approach (CBT). They review theoretical underpinnings and the effectiveness of treatment based on CBT. They then describe their own theoretical approach applying CBT to PGD/CG. They explain how this framework may be useful not only for generating hypotheses about causes and processes but for designing effective interventions for PGD/CG. They go on to describe their treatment program for PGD/CG based on this approach, and to review research testing the effectiveness of CBT interventions for PGD/CG. Chapter 17, by Birgit Wagner, introduces a different contemporary perspective to the treatment of CG, namely, that which is Internet-based; most Internet-based approaches are also based on a cognitive–behavioral framework. She gives an overview of computerized and Internet-based interventions for (complicated) grief, describing the different treatment approaches that are currently available, ranging from those that provide some level of therapist support to online bereavement self-help groups. She describes procedures used in Internet intervention programs and identifies key components of the therapist-supported interventions. She discusses the effectiveness of these programs for CG and elaborates on the advantages and dis...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Contents
• List of illustrations
• List of Contributors
• Part I Introduction
• Part II The nature of complicated grief Conceptual approaches
• Part III Diagnostic categorization Scientific, clinical, and societal implications
• Part IV Contemporary research on risk factors, processes, and mechanisms
• Part V Treatment of complicated grief Principles, paradigms, and procedures
• Part VI Conclusions
• Author index
• Subject index