An Introduction to CG
Shear et al. (2011) write that acute grief is “a normal response to loss with symptoms that should not be pathologized” and that “for most people grief intensity is fairly low by a period of about 6 months. This does not imply that grief is completed or resolved, but rather than it has become better integrated, and no longer stands in the way of ongoing life” (p. 104).
CG, in contrast, occurs when “complications derail or impede healing after loss and lead to a period of prolonged and intensified acute grief” (Shear et al., 2011, p. 105). Spuij, van Londen-Huiberts, and Boelen (2013) write that the symptoms of CG are “distinct from depression and Posttraumatic Stress Disorder (PTSD),” and they note that CG can occur in children, adolescents, and adults (p. 349). Although the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, only lists CG as a condition requiring further study, its definition of it is well-informed and worth reviewing:
Persistent complex bereavement disorder is diagnosed only if at least 12 months (6 months in children) have elapsed since the death of someone with whom the bereaved had a close relationship (Criterion A). This time frame discriminates normal grief from persistent grief. The condition typically involves a persistent yearning/longing for the deceased (Criterion B1), which may be associated with intense sorrow and frequent crying (Criterion B2), or preoccupation with the deceased (Criterion B3). The individual may also be preoccupied with the manner in which the person died (B4). Six additional symptoms are required, including marked difficulty accepting that the individual has died (Criterion C1) (e.g., preparing meals for them), disbelief that the individual is dead (Criterion C2), distressing memories of the deceased (Criterion C3), anger over the loss (Criterion C4), maladaptive appraisals about oneself in relation to the deceased or the death (Criterion C5), and excessive avoidance of reminders of the loss (Criterion C6). Individuals may also report a desire to die because they wish to be with the deceased (Criterion C7); be distrustful of others (Criterion C8); feel isolated, (Criterion C9); believe that life has no meaning or purpose without the deceased (Criterion C10); experience a diminished sense of identity in which they feel a part of themselves has died or been lost (Criterion C11); or have difficulty engaging in activities, pursuing relationships, or planning for the future (Criterion C12). (American Psychiatric Association, 2013, p. 790)
Slyter (2012) notes that, in addition to these symptoms, adolescents with CG are at a heightened risk for developing different externalizing and internalizing problems and that, if their grief is unresolved, it may continue to affect them for the rest of their lives (pp. 18-21). Shear et al. (2013) cite studies showing that “CG occurs in about 10% of bereaved people overall, with higher rates among individuals bereaved by disaster or violent death” (p. 105). Melhem et al. (2011) write that ten percent of children and adolescents still experience “high and sustained prolonged grief manifestations nearly 3 years after parental death” (p. 915).
How CG is Developed and Maintained
a) Failure to Accept the Permanence of the Loss
Boelen et al. (2006) write that individuals with CG are “more often and more easily reminded of the lost person than are individuals without CG,” and they often have “intrusive recollections of events surrounding the death,” and yet “rather than these recurring memories making the loss more ‘real,’” these individuals “continue to be shocked by the loss” (pp. 111-112).
b) Distorted Cognitions
Boelen et al. (2006) write that CG is often enabled by two types of distorted cognitions: “[n]egative global beliefs about the self, life, and the future, and catastrophic misinterpretation of the grief reactions” (p. 114). First, the loss “may present mourners with information that violates previously held global beliefs,” sometimes shattering “expectations for the future,” sometimes disrupting “ideas about life’s meaning” (p. 114). Second, mourners “may interpret their emotional pain as intolerable. Likewise, they may label the intensity of their sadness as signaling loss of control, view their numbness as depression, and interpret vivid intrusions as reflecting insanity” (p. 114).
c) Anxious Avoidance and Depressive Avoidance Strategies
Boelen et al. (2006) write that anxious avoidance occurs “when mourners believe that confronting the reality of the loss—that is, confronting feelings, thoughts, or memories linked with it—will lead to ‘madness,’ ‘loss of control,’ or otherwise ‘unbearable consequences’” (p. 115). Consequently, they might avoid “situations (places the deceased used to come), people (who might ask about the deceased), or objects (pictures of the deceased)” that might “elicit feelings or thoughts about the loss” (p. 115). Or they might try to “suppress painful memories about the events leading up to the death” or engage in continuous rumination about their own reactions or reasons why the loss occurred as a means to escape from having to admit to the loss and the emotions linked with it” (p. 115). Depressive avoidance occurs “when mourners engage in behavioral patterns of inactivity and withdrawal, and refrain from social, occupational, and recreational activities that could provide positive reinforcement and were important prior to the loss” (p. 116).
Literature Review
Interventions Targeting Adolescents
Currier, Holland, and Neimeyer (2007) found in their meta-analysis that grief interventions targeting children and adolescents did not “have a significant influence on adjustment” and that “the treated child did not appear to be better than bereaved children who did not participate in grief therapy” (p. 257). Rosner, Kruse, and Hagl (2010) were more optimistic in their meta-analysis and pinpointed two “[p]romising” models: two music therapy interventions and the trauma/grief-focused intervention developed by Goenjian et al. (1997) (p. 130). Since music therapy is not my forte and not something I plan on employing, I will focus on the trauma/grief-focused intervention, which over the years has slightly evolved and is now referred to as Trauma and Grief Component Therapy for Adolescents (TGCT-A).
TGCT-A is a school-based group intervention intended to mitigate symptoms of post-traumatic stress disorder (PTSD) and maladaptive grief (MG) for adolescents who have experienced trauma or traumatic loss (Layne et al., 2008, p. 1051). The program generally consists of around 20 sessions, each session lasting anywhere from 60 to 90 minutes (p. 1052). Layne, Steinberg, Arslanagic, and Pynoos (2002) write that TGCT-A targets five main areas—trauma experience, trauma reminders, grief, secondary adversities, and developmental impact—through a combination of cognitive-behavioral, exposure-based, and narrative techniques.
Layne et al. (2008) conducted a randomized controlled trial (RCT) in which 127 Bosnian adolescents who had been “exposed to severe war-related trauma, traumatic bereavement, and postwar adversity” were assigned to either receive TGCT-A or “a classroom-based psychoeducation and skills intervention” (p. 1048). These authors found that at a four-month follow-up both groups had experienced reductions in PTSD and depression symptoms, as measured by the Posttraumatic Stress Disorder Reaction Index and the Depression Self-Rating Scale (DSRS), but only the group that received TGCT-A experienced significant “reductions in maladaptive grief,” as measured by the UCLA Grief Inventory (p. 1048). Grassetti et al. (2015) conducted a single-system design in which a group of American middle schoolers who had “experienced a trauma or loss” were given TGCT-A (p. 935). These authors found that “61% of students showed reliable change in either PTSD symptoms or [maladaptive grief] reactions” (p. 939). These authors used the UCLA-RI to measure PTSD and the Persistent Complex Bereavement Disorder Checklist to measure maladaptive grief (p. 936).
The Family Bereavement Program (FBP) is another recent intervention that has been shown to be effective. FBP is a group intervention with separate groups for caregivers and children/adolescents. The program consists of 12 two-hour sessions for each group, four sessions involving conjoined group activities, and two one-hour individual sessions meant “to tailor the program to the needs of each family” (Ayers et al., 2014, p. 295). FBP seeks to change risk and protective factors “that have been demonstrated to relate to adaptation of parentally bereaved children,” and consequently it teaches caregivers such things as positive parenting practices and youth such things as maladaptive grief skills and more effective communicate methods (Ayers et al., 2014, p. 295).
Sandler et al. (2010) conducted a RCT with caregivers and youth (ranging from ages eight to sixteen) from families where a parent had died; they divided participants into two groups, one that completed FBP and the other that received three grief-related books (p. 133). The authors found that at a six-year follow-up the treatment group had significantly lower scores on the Intrusive Grief Thoughts Scale (IGTS) than the control group (p. 139). The IGTS is a “nine-item scale” “developed to assess the frequency of intrusive, negative, or disruptive grief-related experiences” (p. 133). Sandler et al. (2003) had previously found that, at an 11-month follow-up, FBP led to improved parenting “for those who started with the poorest scores on positive parenting” and that it reduced internalizing and externalizing problems for girls and for children who had lower scores at baseline (p. 597).
Grief-Help is another recent intervention that shows promise, although it has not yet been subjected to a RCT. Grief-Help is based on the work of Boelen et al. (2006), who, as described above, conceptualized CG in cognitive-behavioral terms. These authors hypothesized that CG can best be treated through a mixture of cognitive-behavioral and exposure-based techniques. Boelen, de Keijser, van den Hout, and van den Bout (2007) tested this hypothesis by assigning individuals with CG to one of three groups; one group received six sessions of CBT followed by six sessions of ET, another group received six sessions of ET followed by six sessions of CBT, and a third group received twelve sessions of supportive counseling (p. 277). At post-treatment, both groups that received CBT showed a greater improvement on the Inventory of Complicated Grief (ICG) than the group that received supportive counseling, with the group that first received ET showing the greatest improvement (p. 282). Further supporting the hypothesis of Boelen et al. (2006), Malkinson (2010) has outlined research showing that the bereaved have “fewer positive beliefs about the significance of the world, of their self-worth, and a higher level of irrational thinking than [do] the non-bereaved” (p. 294).
Grief-Help has taken this general framework, while adding some writing exercises, and adapted it to individually treat adolescents with CG. Spuij, Dekovic, and Boelen (2015) conducted a single-system design and found that, at post-test, children and adolescents who completed the program had significantly reduced symptoms of PTSD and CG, as well as “small to moderate improvement in depression and internalizing and externalizing problems” (p. 185). These authors measured PTSD with the Child PTSD Symptom Scale (CPSS), CG with the Inventory of Prolonged Grief for Children (IPG-C), depression with the Children’s Depression Inventory (CDI), and internalizing and externalizing problems with the Child Behavior Checklist (CBCL) (p. 188). These authors further found the intervention to be “less efficacious for children and adolescents further removed from loss and those confronted with suicidal loss” (p. 185).
Writing Exercises
While both TGCT-A and Grief-Help contain some writing exercises, there are other forms of grief therapy that consist entirely of such exercises. I could not find any writing-based interventions used to treat bereaved American adolescents, but I found interventions used to treat bereaved American and European adults, as well as bereaved Afghani and Rwandan adolescents. Taken together, these studies, along with the above studies of TGCT-A and Grief-Help, suggest that writing-based interventions can effectively treat bereaved American adolescents.
Wagner, Knaevelsrud, and Maercker (2006) conducted a RCT with German-speaking Europeans with severe “symptoms of intrusion, avoidance, and maladaptive behavior caused by the death of a significant other,” as measured by the Horowitz stress response model of CG (p. 434). The treatment group was given six writing assignments over the internet; they were asked to write two essays about “the circumstances of the death,” two essays about a distressing moment “that kept coming to mind intrusively,” one “supportive and encouraging letter to a hypothetical friend,” and one letter “to a significant person,” outlining “their most important memories regarding the death of their loved one” (pp. 438-440). Compared to the control group, which received no treatment at all, the treatment group saw their “symptoms of intrusion, avoidance, maladaptive behavior, and general psychopathology” decline significantly, and they maintained these reductions at a three-month follow-up (p. 429).
Lichtenthal and Cruess (2010) conducted a RCT with American college undergraduates who had “experienced an interpersonal loss that was considered significant” (p. 479). The students were asked to “complete three 20-min writing sessions” over a week (p. 481). The control group was instructed to write about a neutral topic, while one treatment group was to “focus on making sense of the [loss] by exploring what causes they attributed the loss to and by constructing a narrative about how this event fit into their lives and into their assumptions about the way the world works” and another treatment group was to “to focus on any positive life changes that have come about as a result of their loss experience” (p. 481). Although all three groups had reduced prolonged grief and depressive symptoms at a three-month follow-up, as measured by the ICG and the Center for Epidemiological Studies-Depression Scale (CES-D), the two treatment groups showed significantly greater reductions (p. 491).
Kalantari, Yule, Dyregrov, Neshatdoost, and Ahmadi (2012) conducted a RCT with Afghani adolescents who had “experienced the trauma of war, losing their parent, home, and school” (p. 144). They used “Writing for Recovery,” a treatment developed by Yule et al. (2005b) that consists of six 15-minute writing assignments. Kalantari et al. (2012) explain the intervention as follows:
The writing sessions progress from unstructured writing about their innermost feelings and thoughts about their traumatic event/loss to more structured writing where they have to reflect on what they would have given as advice to another in the same situation as themselves. In the last writing task they are asked to imagine that 10 years has passed and from this time point they are to look back and think what they have learned from their experience. (p. 145)
Kalantari et al. (2012) found that at post-test the grief of the treatment group had significantly fallen, while the grief of the control group, which had received no treatment, had slightly risen (p. 145). These authors measured the grief of the participants with the Traumatic Grief Inventory for Children (TGIC),
Unterhitzenberger and Rosner (2014) conducted a RCT with bereaved Rwandan adolescents. The treatment group was asked “to write about their deepest emotions concerning their loss,” while one control group was asked “to write about their basic hobby” and a second control group was given no instructions at all. Contrary to the authors’ hypothesis, the treatment group did have decreased levels of grief at post-test, as measured by the Prolonged Grief Questionnaire for Adolescents (PGQ-A), while, unexplainably, both control groups had significantly decreased levels. The authors concluded that unstructured writing assignments are not “effective in reducing [prolonged grief] or depressive symptoms in long-term grieving adolescents.”
Cultural Considerations
Cultural issues must be considered when treating adolescents with CG, as different cultural groups mourn differently. As Lopez (2011) writes, “Established traditions of mourning may vary for such practices as decisions about burial or cremation, funeral or memorial services, acceptable lengths of time for grieving, expressions of grief and emotional responses of grievers, use of customs and rituals, and help-seeking behaviors” (p. 10). Consequently, it is important to understand the culture from which clients come in order to better understand their mourning process and to better help them.
Walter (2010) writes that it is “impossible for bereavement practitioners to be well informed about the culture of every client” and that they should instead be aware of their “own cultural assumptions about grief” and make sure to observe and listen “in order to learn about the client’s culture” (p. 5). To achieve this end, he has created a checklist of questions, found in Appendix A, that grief therapists can ask themselves and clients.
Nelson and Nelson (2010) note that most definitions of “culture” focus on “what is shared among a group of people and can include such features as shared experiences, values, and challenges” (pp. 305-306). Given this definition, they argue that there is such a thing as adolescent culture. As they explain:
[A]dolescents often share daily experiences (e.g., frequent use of technology), hold common values (e.g., an emphasis on peer relationships), and face common challenges (e.g., formation of a personal identity and individuation from parents). Further, adolescents often share other features associated with culture, including a shared language, music, and rituals. (p. 306)
Nelson and Nelson (2010) proceed to argue that treatment for adolescents must heed these cultural factors, and they adduce the Youth, Osteoporosis, and Understanding Total Health Project (YOUTH) as a program that effectively did this. The YOUTH program “ utilized relevant technology by including a website with interactive health information related to the project goals,” it “focused on the peer context of adolescent health behaviors and created an online peer-support community by incorporating some of the features of social networking sites,” and it “emphasized self-management of health behaviors, promoting adolescent responsibility and independence” (p. 309).
Intervention
My intervention is based on the CG model posited by Boelen et al. (2006), and it consists of techniques gathered from various sources. My intervention has three main stages: assessment, psychoeducation, and psychotherapy.
Assessment
Since this intervention is intended for clients with CG, it will first be important to determine if my client has CG. As listed in my literature review, there are two main inventories that can be used to measure CG, the ICG and the PGQ-A. I will use the PGQ-A because it was specifically designed for adolescents and as such contains more accessible language. A copy of the PGQ-A can be found in Appendix B.
If I determine that my client has CG, my next step will be to gather more information about the distinctiveness of their grief. It is important to determine which specific cognitive-behavioral dysfunctions the client is suffering from, because, as Boelen et al. (2006) write, “CG symptoms can often be conceptualized as arising from two of the three [dysfunctions] working together” (p. 123).
Psychoeducation
Following the lead of Layne et al. (2002), I will next teach my client about “age-appropriate reactions to trauma and loss.” Layne et al. (2002) believe that this education is important because it helps adolescents to “identify trauma/loss related distress reactions and difficulties, and to reduce [the] perception that [their] reactions are bizarre or related to personal shortcomings.”
During this stage, I will also introduce my client to the tasks of mourning, that is, the tasks that mourners must complete in order to “integrate the reality of moving forward in life without the person who died” (James & Gilliland, 2013, p. 416). Worden (1999) lists four tasks that bereaved adolescents must complete:
- To Accept the Reality of the Loss
- To Experience the Pain or Emotional Aspects of the Loss
- To Adjust to an Environment in Which the Deceased Is Missing
- To Relocate the Dead Person within One’s Life and Find Ways to Memorialize the Person (pp. 13-15)
Introducing these tasks will prepare my client for what to expect in the forthcoming therapy. Introducing my client to the fourth task will assuage any worry that they will be expected to forgot about the deceased.
Psychotherapy
To review, CG is developed and maintained by at least two of the following cognitive-behavior dysfunctions: (a) failure to accept the permanence of the loss, (b) distorted cognitions, and (c) anxious avoidance and depressive avoidance strategies. Given this, it follows that successful therapy must help the client to (a) accept the permanence of the loss and/or (b) change their distorted cognitions and/or (c) change their avoidance strategies. I also believe that successful therapy must (d) help the client complete Worden’s (1999) fourth task and “find a new and appropriate place for the dead in their emotional lives” (p. 16).
a) Accepting the permanence of the loss. This phase of therapy involves different exposure activities meant to encourage the client to “confront [the reminders of the loss] and elaborate on the implications of the loss” (Boelen et al., 2007, p. 278). I will consider using imagery exposure (having the client tell “the story of the loss event”) and in vivo exposure (“visiting the scene of the death”) (Spuij et al., 2013, p. 199).
I will also consider encouraging the client to participate in death rituals. Slyter (2012) writes that adolescents who participate in such rituals are “more apt to acknowledge the reality of death,” as each “aspect of involvement, planning the ritual, taking part in it, contacting others to participate, requires recognition that the death has occurred and the adolescents’ lives have been irrevocably altered” (p. 29). It might be necessary to have my client create their own rituals. Examples include “commemorating the dead person on the anniversary of the death, lighting a memorial candle, visiting the grave, recalling the person’s life, or writing letters to the person who has died” (p. 30).
Additionally, I will consider having my client engage in a writing activity. Below are two writing activities intended to help a bereaved individual accept the permanence of a loss. These assignments are based on the assignments proposed by Wagner et al. (2006), Yule et al. (2005a), and Yule et al. (2005b). Although the assignments created by Yule et al. (2005b) have not yet been subjected to a RCT, they were adapted from the assignments studied by Kalantari et al. (2012) (Atle Dyregrov, personal communication, November 20, 2015).
Writing activity #1. One thing that can help you adjust to your loss is to write about it. So for the next 15 minutes, I would like you to write about the circumstances surrounding the death of your loved one. Were you there with them? Did someone tell you that they died? What do you know about their death? “I want you really to let go and write about all the ways you remember this”—“sights, sounds, smells, thoughts, feelings” (Yule et al., 2005a, p. 7). You don’t have to share this writing with anyone, although if you want to share, I’d like to read it. The important thing is for you to be “completely honest with yourself. Really let go and explore your very deepest emotions and thoughts” (Yule et al., 2005b, p. 2).
Writing activity #2. For the next 15 minutes, I would like you to write about “[o]ne moment that you can hardly bear to think about, but that keeps intruding on your thoughts. Describe the picture you have when you think of your [loved one’s] death. Write down the most painful memories and emotions you have when you think of him and describe everything that you experience—every feeling, every thought and physical reaction’’ (Wagner et al., 2006, p. 439).
b) Changing Distorted Cognitions. This phase of treatment involves challenging the distorted cognitions that are enabling my client’s CG. Using Beck (1995) as my guide, I will join with the client and, through guided questioning, examine their cognitions in terms of their truthfulness and usefulness and, when appropriate, encourage them to replace these cognitions with more truthful and useful ones. To change my client’s distorted cognitions, I will also employ some behavioral interventions. For instance, I might ask my client to schedule a “pleasant event” in hopes of challenging the belief that they are “no longer capable of experiencing pleasure” (Boelen et al., 2006, p. 122).
To challenge my client’s distorted cognitions, I might also assign a writing exercise, Below is a possible assignment. I would want to tailor my assignment to my particular client and their specific cognitive distortions.
Writing assignment #3. I’d like you to imagine a teenager named Paul. Paul has suffered a similar loss. Paul is still really sad, and he doesn’t see the point of things anymore. He’s stopped hanging out with friends. He doesn’t want to play sports anymore. He just doesn’t see why this stuff matters since he thinks life is so meaningless and cruel. So as a result, Paul keeps getting sadder and sadder. Write a letter to Paul and give him some advice. Tell him what he should do and why (Wagner et al., 2006, p. 439).
c) Changing avoidance strategies. Boelen et al. (2006) write that the thought suppression experiment and response prevention can be used to reduce anxious avoidance strategies (p. 122). Ehlers and Clark (2000) explain their thought suppression experiment as follows:
For many patients who attempt to deal with intrusions by pushing them out of their mind, a thought suppression experiment can be a useful way of illustrating the problematic consequences of this strategy. For example, the therapist might say to the patient “It doesn't matter what you think for the next few minutes as long as you don't think about one particular thing. It is extremely important you don't think about that thing. . . The thing is a fluorescent green bunny rabbit eating my hair!” Most patients find they immediately get an image of the rabbit and have difficulty getting rid of it. (p. 337)
From this experience, the client learns that “thought suppression increases rather than decreases the frequency of unwished thoughts” (Boelen et al., 2006, p. 122). Boelen et al. (2006) describe response prevention as follows:
Together with the patient, the therapist first identifies the short-term effects of these attempts (e.g., they help to escape from the pain that is felt when thinking about the irreversibility of the loss) and their long-term effects (e.g., they prevent the mourner from adjusting his/her internal and external world to the new situation). Next, thoughts that go behind the fear of confronting the loss are discussed. Finally, the patient is encouraged to reduce the compulsive behavior in a step-by-step manner. (p. 122)
Boelen et al. (2006) write that depressive avoidance can be reduced through such behavioral activation strategies as pleasant event scheduling and systematic activation, where the therapist helps the client establish and systematically work through certain educational, recreational, and social goals (p. 122).
d) Relocating the deceased in the client’s life. Worden’s (1996) final task of mourning requires the bereaved to relocate the deceased into the their life, or as Slyter (2012) puts it, to “establish a continuing bond with the deceased” that honors “the relationship while still moving forward with life” (p. 27). I might encourage my client to relocate the deceased by emphasizing the importance of linking objects, wherein the bereaved keeps “a few items to remember the person” (Slyter, 2009, p. 27). I might also encourage my client to “create a lasting document expressing their feelings” for the deceased (Slyter, 2009, pp. 27-28).
I might also encourage my client to relocate the deceased with a final writing assignment, My hope is that this exercise will spur the client to think of steps they could take to move forward.
Writing assignment #4. “Imagine that it is ten years on from now and you are looking back on what happened. How will you want to think about the loss? What does it mean to you now and what do you think you will see as the most important learning from your loss when you look back on it in ten years time?” (Yule et al., 2005b, p. 6). What will you be doing to remember your loved one and to make sure that they remain a part of your life?
Conclusion
I feel ready to implement my intervention, and in fact as I designed this intervention I kept thinking about a specific client I have been working with. As I begin my intervention, the only additional resource I anticipate needing will be the feedback and guidance of my supervisor. My intervention is well-researched and evidence-based, and I feel confident that I will be able to effectively use it to help adolescents with CG.
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