Most of the support that people receive after a loss comes from friends and family, but physicians and nurses can identify and orchestrate mechanisms for support and healing and make an important difference.[1] For those who are experiencing particularly difficult problems in their bereavement, specific interventions may be considered. Psychotherapeutic interventions for grief vary widely, and include individual and group methods. Treatment methods found to be effective with various populations of bereaved individuals include time-limited dynamic psychotherapy, cognitive-behavioral intervention, hypnotherapy, and trauma desensitization.

Grief counseling and grief therapy are distinguished from each other.[2] Grief counseling guides uncomplicated (normal) grief to a healthy completion of the tasks of grieving within a reasonable time frame, usually without a time-limited template. Grief counseling can be provided by professionally trained individuals, or in self-help groups in which bereaved persons offer help to other bereaved persons. All of these services can be offered in individual or group settings. Grief counseling seems to be most useful for those bereaved persons who perceive their families as unsupportive or who, for other reasons, are thought to be at special risk.

The goals of grief counseling as outlined by one author [2] include:

• Helping the bereaved to actualize and to accept the loss, most often by helping him or her to talk about the loss and the circumstances surrounding it.
• Helping the bereaved to identify and to express feelings related to the loss (e.g., anger, guilt, anxiety, helplessness, sadness).
• Helping the bereaved to live without the deceased and to make independent decisions.
• Helping the bereaved to withdraw emotionally from the deceased and to begin new relationships.
• Providing support and time to focus on grieving at critical times such as birthdays and anniversaries.
• Normalizing appropriate grieving and explaining the range of individual differences in this process.
• Providing support in an ongoing manner, usually not on a time-limited basis (as with grief therapy).
• Helping the bereaved to understand his or her coping behavior and style.
• Identifying problematic coping mechanisms and making referrals for professional grief therapy.

Bereavement is among the most disruptive of all life processes, and it is difficult to put an arbitrary limit on the expected duration of bereavement.[3] Grief therapy is used with people who have abnormal or complicated grief reactions (refer to the Complicated Grief section of this summary for more information). The goal of grief therapy is to identify and resolve the conflicts of separation that interfere with the completion of the tasks of mourning. The conflicts of separation may be absent or masked as somatic or behavioral symptoms; delayed, inhibited, excessive, or distorted mourning; conflicted or prolonged grief; or unanticipated mourning (though this is usually not present with cancer deaths).

Grief therapy can be provided on an individual basis or in group therapy. Regardless of setting, a therapeutic contract is established with the patient that defines the time-limited basis of the therapy, any fees, and the expectations and focus of the therapy. If the patient presents with physical complaints, medical illness must be ruled out.

Grief therapy requires talking about the deceased, and recognizing whether there are minimal or exaggerated emotions surrounding the loss. Persistently idealized descriptions of the deceased can be indicators of the presence of more ambivalent, angry feelings. Grief therapy may allow the individual to see that anger, guilt, or other negative or uncomfortable feelings do not preclude more positive ones and vice versa.

The focus of grief therapy is dependent on an assessment of the four tasks of mourning. Human beings have a tendency to make strong affectional bonds or attachments with others.[2] When these bonds are severed, as they are in death, a strong emotional reaction occurs. The tasks of mourning serve as a means whereby grief may be resolved. After one sustains a loss there are certain tasks of mourning that must be accomplished for equilibrium to be established and for the process of mourning to be completed.[2] Adaptation to loss may be seen as involving the following 4 basic tasks:

1. Acceptance of the reality of the loss.
2. Working through and experiencing the physical and emotional pain of grief.
3. Adjusting to an environment in which the deceased is missing.
4. Emotionally relocating the deceased and moving on with life.

It is essential that the grieving person complete these tasks before mourning can be accomplished.

Six tasks of grief [4] have been identified that help focus problem-specific therapeutic interventions for bereaved spouses:

1. Develop the capacity to experience, express, and integrate painful grief-related affects.
2. Use the most adaptive means of modulating painful affects.
3. Establish a continuing relationship with the deceased spouse (not necessarily to decathect from the dead person).
4. Maintain one’s own health and continued functioning.
5. Achieve a successful reconfiguration of altered relationships and understand why others may have difficulty empathizing with the bereaved.
6. Achieve an integrated, healthy self-concept and stable world view.

Complications in grief may arise because of uncompleted grief related to earlier losses. The grief for these previous losses must be managed in order for the current grief to be resolved. Additionally, identification of transitional or linking objects that allow the relationship with the deceased to be maintained externally is useful, as the objects may be interrupting successful completion of the grieving tasks. One author [5] notes that grief therapy includes dealing with resistances to the mourning process, identifying unfinished business with the deceased, and identifying and accommodating secondary losses resulting from the death. Ultimately, the bereaved is helped to accept the finality of the loss and to picture what his or her life will be like after the grief period. It is helpful to acknowledge that repetition may be a part of treatment, but only when in the service of working through the grief.

References

1. Casarett D, Kutner JS, Abrahm J, et al.: Life after death: a practical approach to grief and bereavement. Ann Intern Med 134 (3): 208-15, 2001.  [PUBMED Abstract]
   
   
2. Worden JW: Grief Counseling and Grief Therapy. New York: Springer Publishing Company, 1991. 
   
   
3. Zisook S: Understanding and managing bereavement in palliative care.. In: Chochinov HM, Breitbart W, eds.: Handbook of Psychiatry in Palliative Medicine. Oxford: Oxford University Press, 2000, pp 321-34. 
   
   
4. Shuchter SR, Zisook S: Treatment of spousal bereavement: a multidimensional approach. Psychiatr Ann 16 (5): 295-305, 1986. 
   
   
5. Rando TA: Treatment of Complicated Mourning. Champaign: Research Press, 1993. 
   
   

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