New Approaches to Reducing Impairments and Expediting Recovery in the Bereaved.
Melissa Aslan Williams
University of California, Santa Barbara
Introduction
Grief is humanity’s way of responding to loss. Encompassing syndromes of emotions, cognitions, and behaviors that arise following the death of loved ones, grief includes emotional numbness, emotional pains, yearning for the deceased, preoccupation with thoughts about the related person, and subjective imaginations of futures without the deceased. This paper reviews grief-caused impairments within those suffering from the loss of loved ones (hereafter, the bereaved), and two approaches to expediting recovery or reducing impacts. First, it will define complicated grief, followed by an analysis of Cognitive Behavioral Therapy (CBT) and its history in assisting the bereaved. A second analysis will review the inclusion of social support in the healing process. Many studies have examined the effectiveness of both approaches in regard to the impairments and recovery of the bereaved, however, research revealed no such efforts to combine the two approaches for more effective results. This analysis will, lastly, suggest such a combination, in specific relation to changing the communication between the bereaved and their support network through changing both parties’ cognitive processes.
Grief and Complicated Grief Defined
Grief has been defined as the adoption of the lifelong development process of emotions, cognitions, and behaviors that arise from the loss, or death, of a loved one (American Psychiatric Association, 2013). Additionally, the recent approaches to grief have emphasized that there is no single pathway through grief; it is an idiosyncratic process. Researchers have also shifted the normal timeframe from the mythological 12 months and it is now recognized as the period between the death of the loved one to resuming the normal life, beyond which it is termed as “complicated grief” (Malkinson, 2010). Therefore today, an individual’s grief not only includes the loss of the loved one, but also the process and period during which the bereaved searches for and constructs the meaning of life without the deceased.
Complicated grief is a syndrome of emotions, cognitions, and behaviors that follow the death of a loved one and which persist over a long period of time sufficient enough to cause impairment and distress. Complicated grief occurs in about 6.7% of bereaved adults and is highly connected to functional impairment, suicidal tendencies, and adverse psychological outcomes such as anxiety, depression, and post-traumatic stress disorder (PTSD) (Kersting, Brahler, Glaesmer, & Wagner 2011).
Cognitive elements of complicated grief are the mental thoughts of the bereaved that become engulfed by thoughts of the deceased. Researchers show that such cognitive elements include grief-related hallucinations and perceptual illusions (Boelen, de Keijser, van den Hout, & van den Bout, 2011). The findings on attention and perception suggest that bereaved adults with complicated grief are likely to exhibit impairment and biases in interpretation of information in their surrounding environment as well as misinterpretation of internal information.
The ABC Model of CBT
CBT uses an Adverse event – Belief – Consequences (ABC) model that is cognitively oriented. The CBT model emphasizes the importance of cognitive processes in the understanding of emotions. The ABC model offers guidelines for assessing the bereaved by interpreting the experiences of their loss while providing strategies to facilitate a healthy course for their grief (Bernard, et al 2010).
The idea behind the CBT model is that the sources of distress are emotional, behavioral, and cognitive. Cognition acts as the mediator between the emotional consequences of an event and the event itself, where an event occurs, cognition acts, and emotional consequences play out. (Stroebe & Schut, 2006). The ABC model of CBT proposes that individual’s emotional consequences (C) are not solely determined by the causing event (A) but also, and more significantly, by the beliefs (B) the individual has about the event. Death, for instance, is an event (A) that affects the belief (B) of an individual, the bereaved, and then affects the behaviors and emotions (C) of that individual.
Application of CBT in Grief
Currently, there are a substantial number of cases where Cognitive Behavioral Therapy (CBT) is used as an effective way of supporting people din the grieving process (Horowitz, 2003). The beliefs of CBT hold that physical sensations, emotions, and behaviors are controlled by cognitive processes and can, therefore, be reconstructed to curb or reduce emotional stress (Bernard, Froh, Digiuseppe, Joyce, & Dryden, 2010). Consequently, the processes of appraisal can be modified to reduce distress, hence the application of CBT in grief.
Boelen (2011) conducted a study that evaluated the effectiveness of CBT as a treatment for those diagnosed with complicated grief (Boelen, et al, 2011). The study divided the bereaved into three groups; the cognitive reconstructing (CR), the social support (SS), and the exposure (ET), each group receiving 12 treatment sessions. The result of the study found the groups that received CBT (CR and ET), improved more than did the group receiving the social support. Also, the CBT group that received pure exposure (ET) had better improvements than the CR group that received some exposure. Thus, the results support CBT as a treatment to complicated grief patients. Research on the treatment of complicated grief also emphasizes the effectiveness of CBT and its reliance on the changing of cognition which has proven to give negative emotional results.
As stated earlier, the fundamental assumption of this model relates to the individual’s ability to think, rationally or irrationally, during events such as death. Research reveals that mental changes of an individual such events as loss. The bereavement adaptation process, from the perspective of cognition, is the process of changing mental thoughts to reflect the new situation; the problems in adapting to such changes involve the dominance of irrational thoughts and beliefs that follow complicated grief (Whitfield, & Williams, 2004)
Another study conducted by Boelen and colleagues (Boelen, et al, 2011), experimented on 30 students who were mourning their loved ones, with 30 non-bereaved students as a control group. The aim was to determine whether the cognitive process is affected by loss. The results found the bereaved had more negative perceptions of the world, higher irrational thinking, and lower self-worth than the non-bereaved group.
Meta-analyses of related studies show that in treatment interventions using CBT, the focus should be based on the identification of the negative thinking patterns. CBT distinguishes healthy from unhealthy adaptation with relation to one’s beliefs in reaction to the loss, and therefore, involves reconstructing an individual’s irrational thinking about the loss event to more rational and realistic emotional consequences.
Application of Social Support in Grief
Shumaker and Brownell (1984) defined social support as “an exchange of resources between at least two individuals perceived by the provider or the recipient to be intended to enhance the well-being of the recipient” (p. 13). Burke and colleagues (2010) assess that the majority of the relationships between the bereaved and their social support network are established as a result of the causal loss (p. 5). Cohen and Wills (1985) proposed two parts of social support, the first where support prevents a stress appraisal response, and the second where the mere knowledge of the availability of support “softens the blow” of the loss for the bereaved (p. 312). As Stroebe and colleagues (2005) pointed out regarding the latter, even if the perceived social support was unavailable to act as a buffer against the impact of the loss, the knowledge of their existence could inhibit or expedite coping and recovery (p. 1032), thus, social support seems supported as a successful approach to “treating” grief.
However, many studies have failed to produce evidence that suggests recovery effects are strengthened by high levels of support. In Cohen and Wills’s study, it was argued that recovery effects would only occur if there were a “reasonable match between the coping requirements and the available support (p. 314),” which means the support must be able to acknowledge and handle the requirements of the bereaved in order to see results.
A related study by Krause found that while high levels of support did seem to reduce somatic symptoms such as fatigue or restlessness, there was little impact on emotions like sadness and depression (Stoebe et al., 2005, p. 1034). Another study by Greene and Feld, in fact, found reverse effects that suggested the subjects who had more social support experienced more negative effects from their loss (Stoebe et al., 2005, p. 1034-5). Meta-analyses of studies that examined the effects of social support on the bereaved show little to no significant impact on the grieving process.
A New Approach
Reviewing the approaches of CBT and social support as methods for expediting recovery and reducing impacts after loss of a loved one yields frustrating inadequacy when considering such a significant affected population size. While CBT aims to change cognitive appraisals to the events surrounding and including the loss, it does not consider the opportunity to change communication by reconstructing cognitive appraisals. Related, the research regarding social support’s effectiveness widely fails to consider the communication between the bereaved and the members of the social support network as significant to results.
A proposed new approach to bettering the bereavement process suggests a redefining of the CBT method that focuses on changing cognitive appraisals to enhance communication, and, similarly, on perfecting the appraisals of incoming, whether internal or external, communication. This means the CBT approach would help the bereaved focus on more positive cognitions and would assist them in making more accurate assessments of their incoming internal (self-talk) and external (interpersonal) communication.
In addition, this approach proposes that by enhancing such communication through the changing of cognitive appraisals, social support networks could more accurately assess the needs of the bereaved and, thus, more appropriately support them. As Cohen and Will’s (1985) argued, significant recovery effects can only occur if there is a match between coping requirements and the available support. This new approach aims to meet such criteria (p. 314).
References
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