therapy is usually applied in cases such as the one exhibited by Kong, following the loss of a loved one. The procedure is outlined below:
The Semi-Structured Clinical Interview
The informal assessment of individuals faced with the effects of the loss of a loved one such as Kong’s case is the semi structured interview. This approach allows the therapist to classify victims according to the symptoms that they exhibit. The approach allows for the recording of changes in profile symptoms demonstrated over time. The information below should be collected from a client.
The mental illness history of the family
Ones medical history
Any past visits or interactions with a psychiatrist
One’s social history
Varying aspects of one’s specific information should be collected regarding the loss of a loved one
There is need to focus the interview details on the secondary and primary characteristics of the death of the son. More questions touch on:
Symptoms that can be linked to the state of bereavement such as instances of intensively yearning for contact with the diseased, self blame, anger and avoiding anything that reminds them of the diseased
A personality that can only be described as pre-morbid
Features that are related to depression, substance abuse, aggression or anxiety
In other words, there is need for the clinician to ask relevant pointed questions directed at unveiling details to do with the symptoms of post traumatic stress, the frequency of content, its nature, duration, intensity and short descriptions of the signs (Shear et al., 2012)
Examination of the State of Mind
A person’s state of mind is professionally assessed during an interview using Mental State Examination. The method applies a common language and format to capture the information that the patients who have gone through loss manifest in the course of the interview. The main objective is to identify the symptoms so as to seek the most appropriate intervention while any risks are taken into consideration.
The aspects that must be considered when conducting a loss assessment include behavior, appearance, speech, content of speech, thought, cognition, perception, mood effect and insight (Marks, Jun, & Song, 2007).
Important questions to ask while screening bereavement
Elderly individuals that manifest severe symptoms of bereavement as a result of the loss of a loved one need to be assessed for symptoms of complex bereavement and grief. These are potential triggers for serious reactions, including possible suicidal tendencies. Kong may still succumb to effects of bereavement and grief despite his cultural values. Kong feels that he will face many challenges in the country following the death of his love one. He thinks that life has no meaning any more. He may even be contemplating death because it will give him an opportunity to reunite with the diseased. Suicidal ideation is an important subject to explore with grieving veterans. Direct questions that avoid ambiguity such as the ones below are important in this respect.
Do you sometimes think of killing yourself especially when things are bad?
Do you ever figure out how you can kill yourself?
Can you access . . . . (Mention opportunity or means)
Is there a time you tried killing yourself?
Do you drink, smoke or use other amphetamines and intoxicating substances?
Put other risk factors, such as being isolated or abusing substances into consideration. Other critical factors to consider include
Can you divulge to me more regarding the death?
Tell me what transpired that day
What are noteworthy developments since that day?
How have matters unfolded between you and friends?
Such questions dig into the matter of bereavement and grief. They offer the bereaved person a chance to talk about their loss. It sheds light on circumstances and nature of the death. Factors such as denial will start to show. It is likely that feelings of anger and guilt will also manifest if they are present. There is likely to be the typical emotional response from a bereaved person manifested. Congruence between effect and content along with the history will be a sure indicator of conflicted emotions and ambivalence.
The signs of bereavement and grief may be pointed out by indicating the progress point in the bereavement process. Furthermore, the questions give you a chance to explore the patterns of interaction at a social level after the death. It is important to take terms of inclusion into consideration to help in the assessment of the client’s acceptance of the permanent loss (Grief counselling through questioning, 2013).
People in grief commonly experience dreams. It is a helpful intervention to talk about their dreams. While there is no need to attempt an interpretation of these dreams, a therapist should simply lad the patient in talking about them when the patient has a desire to discuss them.
Tools for Formal Assessment
Information that has been overlooked in the semi structured interview can be accessed through the formal assessment process. There exist several assessment approaches that can be applied to people who have gone through loss.
The Geriatric Depression Scale
This procedure can be applied in Kong’s case to establish the possibility of developing depression complications as a result of the loss of his son. It is a useful tool in screening adults of advanced age.
I. Cognitive Impairment Assessment
It is common and normal for elderly people to experience impairment of memory. These may be typical symptoms of normal aging, including cognitive function depreciation and dementia. As a result of being bereaved, memory loss has been noted to be a common occurrence resulting from the accompanying grief. Therapists must also differentiate such a scenario from dementia in its early stages. Dementia and depression are known to commonly exist side by side; and late occurrence of depression is noted to be a common cause of the dementia. Therefore, there is need to assess the possibility of cognitive impairment in an older person experiencing signs of dementia.
More and more attention is being given to psychophysiological techniques to add value to clinical interviews along with the psychometric tools used to assess traumatized people. Heart rate is a common major psychophysiological index. Others include muscle tension, skin conductance and response, peripheral temperature and blood pressure. The approach is a useful guard against response bias. It can also detect elements that may be hard to identify by other means. A lot of studies on post traumatic stress have exhibited multiple psychophysiological processes in resonance to trauma cues. There is a concurrence that such responses can be used to discriminate people experiencing post traumatic stress from those who are not (Bryant & Harvey, 2000).
Current Issues Faced by Kong- Provisional Diagnosis
The client is undergoing a period of emotional stress as a result of being exposed to the traumatic stressor; being the act of suicide by his son. The experience is beyond the normal experience that his culture has exposed him to. Kong is devastated by his son’s loss and is further dismayed that he thought that he, Kong, was a disappointment. Kong blames himself for having confronted his son on the issue of drug abuse and thinks that things would have been different if he had used a better approach to handle the matter. Kong is full of guilt and frequently cries about his predicament. He often shows signs of confusion. He is in disbelief.
With the symptoms and such history in mind, a bereavement diagnosis refereeing to the DSMV (APA, 2013) can be applied on the client. The approach is used when the therapist is focused on normal reactions to the loss of a loved one. Grieving people commonly exhibit the following symptoms.
Depressive episodes such as sad feelings, sleeplessness, crying spells and poor appetite are common.
a. They are preoccupied with the diseased
b. Intense and persistent yearning for the company of the diseased
c. Can’tmake sense of the loss
d. Misinterpretation of some aspects of the loss
e. Avoiding anything that reminds them of the loss
f. Can’t make sense of life after the death of the loved one
g. Extended feeling of grief that runs beyond a year. Nevertheless, the full assessment of the case depends on the detailed examination of the client
Multidisciplinary Referrals for Client
Instances of grief are commonly associated with regret, guilt, anger; among other similar symptoms. While some people can’t make meaning of life, others experience a feeling of relief. Grieving individuals can oscillate between different contradicting thoughts as they try to make sense of their loss. A client may be sent to the health providers listed below for management of their condition:
Psychiatrist: for the management of chronic and severe issues. A psychiatrist can review a case and prescribe medication. They can also diagnose a patient and manage other complications that are co-occurring.
Clinical Psychologist: Psychologists have the skills to assist a client to lead a normal functional life in their new surroundings. They employ therapies such as stress inoculation training.
Rehabilitation Homes: Therapists should consider vocational training services or psychosocial services provided by independent organizations. These often lay claim to provision of several other services including cardiac rehab, orthopedics and memory care.
The Mutual Support Approach: Support groups can be instrumental in assisting grieving patients to reconcile their predicament with reality. People share common life experiences that they go through and in the process, assist each other to cope with reality. Decisions regarding the content, its organization and outside relationships are developed by the members/participants.
Mutual support group provide members with the following:
Exchange between person to person; based on reciprocity and identification
Accessing specialized information
Share techniques for coping derived from realistic expectation and optimal function
Heightened sense of self-worth by comparing with others in similar situations
A focus on positive change as a result of performance and feedback
A place for social change and advocacy
It’s a chance to learn and educate oneself about others in similar situations and even other professional aspects and the general public
A chance to help someone else by extending concrete aid and being a role model
Helping others through shared goals and activism
Mutual support groups have been crafted as alternative care systems. They serve as adjuncts to the conventional care systems (Osterweis, Solomon, & Green, 1984).
Comprises of three therapies as follows:
Bereavement/ Grief Therapy
When thoughts of bereavement are intense and become severely distressing, the intervention of a mental health professional suffices. Therapy helps people to cope with the effects of the stressors such as the loss of a loved one. Such techniques as meditation and relaxation are commonly applied. Therapists have explored varying approaches in the treatment of post traumatic stress such as the loss of a loved one over time. Such techniques as medication administration, client centered therapy, supportive therapy, meaning oriented therapy, interpersonal therapy (IPT), cognitive behavioral therapy (CBT) and brief dynamic therapy have been applied (Whetherell, 2012).
Each grief experience is unique. Therefore, therapists will customize treatment based on the circumstances and experiences of the client. Group therapy can also be applied to complement individual therapy. It is instrumental for the clients who find solace in sharing thoughts with others in reciprocate fashion. Recovery outcomes are often fast with this approach.
Bereavement/ Grief Models
Psychologists have outlined several bereavement models. According to research conducted by Elisabeth Kubler-Ross in 1969, there are five stages of grief/bereavement. They occur in linear fashion. These are:
The original model developed by Elisabeth (1969) was made to illustrate bereavement from death. However, she later reshaped the model to reflect the reaction from any type of bereavement. The author pointed out that each of us experiences at least two of the five steps of grief/bereavement. She also noted that some individuals may revisit some stages severally throughout their lifespan.
Psychologists also came up with strategies to cope with the death of a close person. These strategies were referred to as the Four Tasks of Mourning. They are:
1. Accept that loss is a reality
2. Working through the grief process
3. To adjust to living without the diseased person
4. To establish a healthy connection with the diseased while life goes on normally
The linear stepwise model has a dual process model as an alternative. Two tasks of bereavement were identified:
Stressors and loss oriented activities are the ones linked to the loss. They include experiencing sadness, dwelling on the death circumstances, denial or anger and an avoidance of restoration attempts
Activities associated with restoration and stressors are linked to secondary loss in one’s routine, relationships and lifestyle. They call for the adopting of a new life including connecting with others such as friends and family, and starting a new life.
According to Stroebe and Schut, people oscillate between the two stages (Doughty, Wissel, & Glorfield, 2011).
The Narrative of Death Retold
1. Recount the loss narrative for at least 10 minutes. Begin with when the death is impending and conclude with when the contact with diseased has ended or at the end of the first day.
2. You may close your eyes in the course visualization to invoke stronger emotion
2. Debriefing by therapists can be achieved by focusing on appreciation of the self, promoting reappraisal, deferring the story for later exploration and organizing for transitioning and rewards.
3. May use restorative retelling to seek meaning and to empower the victims.
May help to enhance further narrative mastery by listening to recorded accounts between sessions. This should, however be done only after negotiating a safe placement for the experience. It helps the process of emotional disclosure, loss and other business that stays unfinished (Robert, 2016).
Complicated Grief Therapy (CGT)
CGT can be used in clinical practice flexibly. It, however, has 16 sessions each of which lasts 45 to 60 minutes. Each session includes a section for a review of the previous week, work in session and assignments for the forthcoming week. Here are the details:
The first session is meant for orientation to CG and the ensuing treatments. The main objective of session 1 is to unveil information regarding one’s early relationships with family, the diseased, other possible losses and the narrative of the death and current relationships. The therapist and client explore the life situation of the client at the moment and touch on the stressors and coping strategies. The therapist highlights the details of the CGT procedure in summary. The therapist eventually introduces assignments between sessions. This includes the bereavement and grief monitoring diary for clients to record daily catalysts and moments that are less distressing. Interval plans and customized activities meant to assist clients to move closer to their hopes. They should also be given a handout that acts as a template for their CG practice and treatment.
The client and therapist review the diary to establish trends and patterns in the grief manifestations. An overview of the therapy is given by the therapist. The client is encouraged to figure out scenarios that give them a chance to reawaken the joys in their life and a reason to move on. The therapist gives the client another handout of the CGT to give to a supportive person that will attend the forthcoming session.
A supportive individual such a member of the family or close friend i included in the third session. The point in such inclusion is that grieving individuals often lose social connections with significant people in their lives. CGT is used to reestablish such connections. The presence of the supportive individual is also meant to help such a person to understand the processes that the client is going through and thus empowering them to give better support. The supportive person is asked to describe the client from the point of death of a loved one, including reactions at the general and specific level. The support person is then given an overview of CG and how they can assist the client. Further discussion aimed at mitigating loss reaction by the client is discussed between the supportive person and the therapist. The final 15 minutes are used to review the monitoring diary for grief and update goals.
This is where CGT properly starts imaginal revisiting. This is more like prolonged exposure – used to handle traumas and post traumatic stress disorders (PTSD). The client is required to briefly visualize and recount the story of the loss and when they learnt of the death. The story is recorded on tape and revisited for debriefing by both the client and therapist later. The idea is to help the client integrate the emotional aspects of the experience with rational realities that the loved one has actually died. In the course of debriefing, the client is required to describe what they visualized during the recount of the experience. The discussion is aimed at encouraging the client to reflect on the present perspective. The client is yet again subjected to visualization while the story is put away. The client is asked to identify an appropriate reward for the courage to go through the revisiting experience over and over.
The session is about reviewing the imaginal revisiting, restoration experience and the monitoring diary. A new element called situational revisiting is introduced in this session. The client is asked to identify the places that were previously avoided because they remind them of the loss. The client is encouraged to repeat the activity several times every day.
Sessions 6 to 9
Here the client completes a series of forms that highlight the positive aspects and pleasant memories of the diseased. They are also required to recall the unpleasant moments and memories. The clients come for therapy with photos and other items that remind them of the diseased person.
An inventory for complicated grief or similar questionnaire is used to help the client keep track of their own progress including the points where they may be stuck. The client agrees with the therapist on the next move in the treatment process for the remaining part. They may embrace Interpersonal therapy relationship treatment or explore other losses.
Sessions 11 to 16
Clients are subjected to more therapies involving reviewing diaries for grief monitoring, situational revisits and work on aspirations. Imaginal conversation is a useful exercise that helps to bring closure between the client and the diseased with regard to the unavoidable facts. The activity involves the client in a dual role play for both themselves and the diseased. The client imagines that the loved one just died but they can still speak and hear. A conversation ensues in which the client asks the diseased questions and responding in the role of the dead person by reassuring the client. The exercise is more useful if the client and the diseased were in a positive relationship.
In case the client is attending CG in multiple places, they may be subjected to different loss experiences. Treating other losses is usually faster after successful treatment of the initial major loss. Clients may also choose to pursue activities that have no connection with CG but have elements of IPT and its accompanying goals for relationship conflict and or transition. Such activities as analysis of problematic relationships suffice. Sessions 11 running through to 16 involves terminating the therapy. For some clients, there is need for discussion in order to process the loss of the therapy-based relationship (Wetherell, 2012).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Pub.
Bryant, R. & Harvey, A. (2000). Acute stress disorder (1st ed.). Washington, DC: American Psychological Association.
Doughty, E. A., Wissel, A., & Glorfield, C. (2011). Current Trends in Grief Counseling. Vistas Online, 94(3), 36-47. Retrieved from http://counselingoutfitters.com/vistas/vistas11/Article_94.pd
Elisabeth, K., R. (1969). On death & dying (1st ed.). New York: Scribner.
Grief counselling through questioning (2013). Retrieved from http://www.counsellingconnection.com/index.php/2010/03/16/grief-counselling-through-questioning/
Marks, N., Jun, H., & Song, J. (2007). Death of Parents and Adult Psychological and Physical Well-Being: A Prospective U.S. National Study. Journal of Family Issues, 28, 1611-1623. doi: 10.1177/0192513X07302728
Osterweis, M., Solomon, F., & Green, M. (1984). Bereavement: Reactions, consequences and care. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK217843/
Robert, N. (2016). Techniques of Grief Therapy: Creative Practices for Counseling the Bereaved. Retrieved from https://www.uwlax.edu/uploadedFiles/Academics/conted/DGB/2016-DGB-handout-Techniques-Grief-Therapy-Neimeyer.pdf.
Shear, M., Simon, N., Wall, M., Zisook, S., Neimeyer, R., & Duan, N. et al. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28(2), 103-117. http://dx.doi.org/10.1002/da.20780
Wetherell, J. L. (2012). Complicated grief therapy as a new treatment approach. Dialogues Clin Neurosci, 14(2): 159 — 166. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384444/
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