Working With Grieving Adults

164 Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/

Clark Advances in Psychiatric Treatment (2004), vol. 10, 164170

Grief is the price of love. It is the cost of commitment,as Colin Murray Parkes entitles the opening chapterof his seminal work Bereavement: Studies of Grief inAdult Life (Parkes, 1986). Just as close attachmentrelationships (which may not always be loving) area near-universal human experience, so grieffollowing the permanent loss of such a relationshipis a normal part of being human. It is also one of themost intensely painful of all human experiences.

What is the role, if any, of professionals in contactwith people who are going through an intenselypainful but natural process? What are the indi-cations that the process of bereavement is notpursuing a natural course, and what can mentalhealth professionals offer in these circumstances?To address these questions, we need first to turn towhat is known about the natural process of grief.

The anatomy of natural grief

We owe a great debt to John Bowlby and hiscolleague Colin Murray Parkes for their clarificationof the key elements of natural grief (Bowlby, 1980;Parkes, 1986). For both, grief was an extension ofthe natural human response to separation. Just asphysical trauma to the body evokes the inflammatoryresponse redness, swelling, heat and pain so thepsychological trauma of loss leads to a sequence ofnatural experiences, as detailed in Box 1.

Bowlby was at pains to stress that these phasesare not clear-cut and that bereaved individuals mayfor a time oscillate back and forth between any twophases. He was also reluctant to detail a precisetimescale for progression through these phases,noting the impact of the culturally diverse ritesand rituals of mourning. He also suggested that

timescales can reflect more the wishes of thosewitnessing a persons grief rather than the indi-viduals natural process. With these provisos, it isgenerally accepted within Western culture (e.g.Royal College of Psychiatrists, 1997) that the initialresponse is one of shock, emotional numbness anddisbelief. Within a few days, this gives way toagitation and pining for the dead person. Agitationis at its worst at around 2 weeks, usually givingway to depressive symptoms, which peak at about46 weeks after the death. Pangs of grief may occurat any time, sparked off by people, places or thingsthat bring back memories of the dead person. Astime passes, the intense pain of early bereavementbegins to fade. The depression lessens and it ispossible to think about other things and even to lookagain to the future. Most people recover from a majorbereavement within 12 years.

Psychological theories of grief

In his classic paper Mourning and Melancholia(1917), Freud observed that although these twostates of mind have a number of similarities, such

Working with grieving adultsAndrew Clark

Abstract Despite the dearth of recent psychiatric literature on the subject of grief, mental health professionalscontinue to see patients suffering from complex responses to grief. This article reviews psychologicaltheories about normal and abnormal grief, drawing particularly on the work of Freud, Klein, Bowlbyand Parkes. It describes the principles of grief work, using as illustration clinical examples of adultsgrieving as a result of bereavement. These principles also apply to work with adults grieving otherforms of loss (e.g. breakdown of a love relationship, loss of employment or loss of physical health).

Andrew Clark is a consultant psychotherapist and group analyst working in a multidisciplinary psychotherapy service inBristol (Cedar House, Blackberry Hill Hospital, Manor Road, Bristol BS16 2EW, UK. E-mail: [email protected]). Hisparticular interests include training in psychodynamic and group analytic psychotherapy for mental health professionals.

Box 1 Phases of normal grief reaction

Phase I Shock and protest includes numb-ness, disbelief and acute dysphoria

Phase II Preoccupation includes yearning,searching and anger

Phase III Disorganisation includes despairand acceptance of loss

Phase IV Resolution

Working with grieving adults

165Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/

as profound dejection and loss of interest, theyare distinguished by the presence, in melancholia,of a marked lowering of self-regard. He explainedthis by proposing that in melancholia the self-reproaches are reproaches against a loved objectwhich have shifted away from it onto the patientsego (Freud, 1917: p. 248). Thus, the ego internalisesthe lost person, the shadow of the object fallsupon the ego (p. 249), and both ego and object fallunder the harsh judgement of a critical agency, aconcept later developed into the super-ego. Bycontrast, Freud suggested that in normal mourningthere is no process of identification and internal-isation, but rather a gradual withdrawal of libidofrom the lost person. Once this task is completedthe libido is free to be invested elsewhere.Mourning and Melancholia is such a seminal paperthat Freuds subsequent thoughts about mourningare not always given the attention they deserve. Bythe time he wrote The Ego and the Id (1923), herecognised that the withdrawal of the libido thatattaches one person to another can take place onlywhen the lost person has been reinstated withinthe ego.

Melanie Klein developed this notion further.Drawing on her own experience of mourning forher son, who died in a climbing accident, shesuggested that in adult mourning we revisit earlyexperiences of mourning for a lost other:

My contention is that the child goes through statesof mind comparable to the mourning of the adult,or rather, that this early experience is revivedwhenever grief is experienced in later life (Klein,1940: p. 344).

In good enough early experiences, we repeatedlylose and refind our loved objects. Through thecumulative effects of many such experiences as achild, we internalise a sense of a present loved other.This cumulative process of internalisation will behindered if the child experiences major separationsfrom or loss of loved ones. Klein went on to say thatwhen we are bereaved as adults we fear that wehave lost not just this loved one, but also ourinternalised loved ones:

Through the work of mourning [the bereavedindividual] is reinstating all his loved internal objectswhich he feels he has lost . . . Every advance in theprocess of mourning results in a deepening of theindividuals relation to his inner objects, in thehappiness of regaining them when they were felt tobe lost (p. 362).

The clinical significance of her theory is that, ifindividuals have not had the early experiences thatenable them to internalise a good object, thenmourning as adults will be complicated by signifi-cant depression.

Bowlbys thoughts on loss and grief weredeveloped over a period of decades and areexpressed most completely in his book Loss: Sadnessand Depression (1980). His ethological attachmentperspective allowed him to draw direct parallelsbetween an infants response to separation from itsattachment figure and the phenomenology of grief.He proposed that the absence of an attachmentfigure activates an innate motivational system thatcompels the individual to search for the person andto do everything possible to regain that personsproximity and care. When these efforts fail, thebereaved individual experiences profound sorrowand despair. Through the work of mourning, thebereaved individual reorganises his or her represen-tations of the world in a way that allows a return tonormal activities and the seeking out or renewal ofsocial relationships.

In summary, it seems that the natural process ofgrieving allows the bereaved eventually to reinstateor refind some aspect of the person they have lost.The beginning of this process is movingly describedin C. S. Lewiss account of his personal grieffollowing the death of his wife, whom he refers toas H.:

And suddenly at the very moment when so far Imourned H. least, I remembered her best. Indeed itwas something (almost) better than memory; aninstantaneous unanswerable impression. To say it wasa meeting would be going too far. Yet there was thatin it which tempts one to use those words. It was as ifthe lifting of sorrow removed a barrier . . . Why hasno-one told me of these things? How easily I mighthave misjudged another man in the same situation?I might have said, Hes got over it. Hes forgottenhis wife, when the truth was, He remembers herbetter because he has partly got over it (Lewis, 1966:p. 37).

Unnatural grief

Following Bowlby, pathological grief is usuallysubdivided into inhibited, delayed and chronic grief(Box 2). This can be thought of simply as too little(inhibited or delayed) or too much (chronic) grief.

Box 2 Types of pathological grief

Inhibited grief Absence of expected griefsymptoms at any stage

Delayed grief Avoidance of painful symp-toms within 2 weeks of loss

Chronic grief Continued significant grief-related symptoms 6 monthsafter loss


Clark

I find it useful to think of inhibited/delayed grief asbeing related to factors that get in the way of theexpression of grief and acceptance of loss, whereaschronic grief is associated with factors that inhibitthe process of reinstatement (Fig. 1).

Inhibited/delayed grief

Bowlby suggested that delayed grief is morecommon in people with avoidant attachment styles.They often see expression of feeling as a sign ofweakness or as an invitation to ridicule. Theyusually have an early history in which expressionof feeling was either actively discouraged or felt tobe unsafe because of the unresponsiveness ofcaregivers. This leads to personality traits such asexcessive self-reliance or compulsive caregiving.Such people find it hard to express any strongfeeling, let alone one as intensely painful as grief.

Lack of family support and social isolation mayalso contribute to delayed grief reactions (Bowlby,1980). For example, Maddison & Viola (1968), in astudy of 40 widows in Boston, USA, found that thosewho had a close ongoing relationship with theirmother had better outcomes than those who hadlittle contact with their mother.

The expression of grief may also be inhibited bythe sheer unbearable intensity of feeling towardsthe lost other or over the manner of the loss. Thus, ifthe bereaved person feels guilty about unresolved

issues in relation to the lost other or feels especiallyangry towards them, they may be unable to expresstheir grief, fearing that such feelings are un-acceptable (Dont speak ill of the dead). The mannerof death may be associated with intense guilt (Ifonly I had been there for him) or anger (If only thedoctors had diagnosed the condition sooner). Deathby murder or suicide is associated with suchoverwhelming feelings of helpless anger and guiltthat bereaved individuals often feel that no one couldbear the intensity of their feelings. Compared withother types of bereavement, bereavement by suicideis more commonly characterised by stigmatisation,shame, guilt and a sense of rejection (Hawton &Simkin, 2003).

Chronic grief

This seems to be more common in people who havehad an overly dependent relationship to the lostother. In attachment language, they usually have anambivalent attachment style. These are the peoplethat Parkes described as having a grief-pronepersonality (Parkes, 1985). Their previous relation-ships are usually haunted by an overriding fear oflosing the other. Bowlby thought that theseexpectations were based on early experiences ofdiscontinuities in parenting and/or frequentrejection by parents. As a result of such experiences,these children struggled to internalise a good object

Fig. 1 Some factors that inhibit the natural grief process.

Expression of griefand acceptance of loss of the other

Natural grief

Delayed grief

Inhibit

Unbearable feelings regarding manner of deathUnbearable feelings towards lost other

Use of alcohol, illicit drugsSocial isolation

Avoidant attachment style

Bereaved

Lostother

Bereaved

Chronic grief

Psychological reinstatementof the lost other

Inhibit

Ambivalent attachment styleUnbearable feelings regarding manner of death

Unbearable feelings towards lost otherUse of alcohol, illicit drugs

Social isolation



and so their mourning as adults is complicated byprotracted attempts to refind a good object andreinstate the lost other. The chronic grief is a chronicsearching for something that cannot be foundinternally. The process of reinstatement may also becomplicated by hateful or fearful feelings towardsthe lost other. For example, if the lost other was anabusive, frightening mother, then refinding aspectsof her internally is inevitably disturbing.

Psychiatric sequelaeof pathological grief

In pathological grief, the mental health professionalwill need to make an assessment of the nature ofany psychiatric disorder and associated risk. Com-munity studies show that 50% of bereaved spousesmeet the criteria for a major depressive episode atsome point in the first year following their loss, butthis will usually have resolved by 6 months; 10%suffer from depression for the entire year (Mitchell& House, 2000). The features that distinguish majordepression from a normal grief response are listedin Box 3. In a small US study of bereaved spouses(n=54), Jacobs et al (1990) found that 24 (44%)developed an anxiety disorder during the first yearof their loss and 5 (9%) developed the symptoms ofpost-traumatic stress disorder. If pharmacologicaltreatment is indicated, then this should be pre-scribed as for non-bereaved individuals, bearingin mind that certain medication, particularlyanxiolytics, can inhibit the natural grief process.

Evidence base for grief work

As far as psychological treatments are concerned,there is a dearth of literature about effectivetreatments. Raphael (1977) found that preventiveinterventions in the early bereavement period were

effective for widows at high risk of pathologicalgrief. The risk factors selected were lack of supportfrom social networks, previous highly ambivalentrelationship with the deceased and the presence ofat least three concurrent stressful life events.

The treatment group in Raphaels study receivedan average of four 2-hour sessions of counselling.Of 200 high-risk widows, 77% in the treatment groupwere improved 13 months after their husbandsdeath and 23% were unimproved, compared with41% improved and 59% unimproved in the un-treated group. Marmar et al (1988), also in the USA,reported a randomised controlled trial of briefpsychodynamic psychotherapy v. mutual-helpgroup treatment for widows who had soughttreatment for unresolved grief reactions between 4months and 3 years after the death of their husband.Women in both groups experienced a reduction instress-specific and general psychiatric symptoms aswell as improvement in social and work functioning.The two treatments were equally effective, althoughthere was greater attrition of numbers in the grouptreatment condition.

Principles of grief work

For professionals meeting newly bereaved indi-viduals, Parkes (1986) gives some helpful words ofwisdom:

Do nothing that will inhibit the expression ofappropriate grief . . . The bereaved person has apainful and difficult task to perform which cannot beavoided or rushed. True help consists in recognisingthis fact and in helping the bereaved to arrange thingsin whatever way is necessary to set him or her freefor the task of grieving (p. 174).

Support from family and friends is crucial at thisstage. Voluntary organisations such as CRUSE andCompassionate Friends (in the UK) are also able tooffer significant support, especially through oppor-tunities to meet with other bereaved individuals.

Mental health professionals will work with griefin many different settings, for example on hospitalwards or in the community, and in many differentroles, perhaps as part of a treating team or as a singletherapist. However, whatever the setting or role, thefollowing principles are important.

Providing a secure base

The secure base is a term coined by Bowlby todescribe the role of the caregiver to whom a childturns when distressed. The concept has beenusefully extended to psychotherapeutic work withadults (Holmes, 2001). As well as referring to anactual person who provides a sense of security, the

Box 3 Clinical features suggesting a majordepressive episode rather than normal grief

Guilt about things other than actions takenor not taken by the survivor at the time of thedeath

Thoughts of death except in relation to thedeceased

Feelings of worthlessness Psychomotor retardation Prolonged and marked functional impair-

ment Hallucinations except in relation to the

deceased


Clark

concept also refers to a representation of securitywithin the individuals mind. Attention to thephysical and psychological setting of grief work canallow the grieving patient to feel safe to explorepainful feelings. Consistency of venue, personneland timing (including protection from interruptions)will all help to create the experience of a secure base.

Facilitating the expression of grief

In Shakespeares Macbeth, after MacDuff learns thathis family have been killed, Malcolm comforts him:

Neer pull your hat upon your brows;Give sorrow words. The grief that does not speakWhispers the oerfraught heart and bids it break

(Macbeth, Act IV, Scene iii, line 208).

The bereaved need to feel that their grief isspeakable and hearable. They may use a varietyof avoidance strategies to protect themselves fromthe pain of grief. These will need to be exploredwith due respect for their defensive function. Ifalcohol, illicit drugs or anxiolytic medication arebeing used to dampen down distress, this needsto be addressed at an early stage in the grief work.Considerable time may be needed to explore apatients fear of expressing grief. For example, theymay fear that if they start crying they will neverstop, that no one will be able to bear their pain.This links with Bions helpful concept of contain-ment (Symington & Symington, 1996). If theprofessional can contain the pain of grief, thenthis can help the patient internalise a sense thattheir pain can be borne and thought about.Patients can also fear being be severely judged ifthey express their grief (They all say I should beover it by now). Professionals, like Malcolm, needto indicate by their words and non-verbalcommunication that they are prepared to listen inan accepting, non-judgemental manner.

Clinical example 1Mr A was a 30-year-old single man who workedas a nurse. His mother had died a year ago frombreast cancer. He developed a depressive episodecharacterised by intense feelings of guilt for nothaving been present when she died. He had nursedher during her final illness but on the night of herdeath had been out with a friend. He was unableto visit his mother s grave or sort out herbelongings. He was unable to function at work.His guilt eventually drove him to take anoverdose, which led to his psychiatric referral.

Grief work involved exploring his relationshipwith his mother. He had always felt that his olderbrother was the favoured child and that he couldnot do anything right in his mother s eyes. Herecalled that she had been very busy running acentre for homeless adults and so had had very

little time for her two sons. Initially, Mr A wasreluctant to voice any difficult feelings towardshis mother, fearing this would be disloyal. Instead,he spoke admiringly of her devotion to her work.As the therapy progressed, Mr A was able toacknowledge angry feelings towards his motherand that these might have been stirred up whilehe was nursing her before she died. Eventually,he was able to understand some of the difficultiesthat his mother must have faced in her life, whichallowed him to be more accepting of her tendencyto put her work before child care. He became ableto visit his mother s grave, sort out her belongingsand return to work.

Some patients may need encouragement to facereminders of their grief so that their feelings canbe brought to the fore. This might involve ad-dressing issues such as sorting out belongings orvisiting the grave. Some authors advocate abehavioural approach to this, known as guidedmourning. This approach likens unresolved griefto other forms of phobic avoidance, which havebeen treated successfully by exposure to theavoided situation (Mawson et al, 1981). Mawsonet al summarise guided mourning as involving anintense reliving of avoided painful memories andfeelings associated with bereavement. Duringtreatment, patients are exposed both in imagin-ation and in real life to avoided or painfulmemories or situations related to the loss of theirloved one. This might include visiting thecemetery, looking at photographs or handlingpossessions of the deceased.

Revealing feelings that block naturalgrieving

The professional needs to help the bereavedperson to recognise and name the difficult feelingsthat are blocking the natural grief process. Thesemay include anger, guilt, shame, hatred or fear.Again, recognising these feelings may requiregroundwork exploring why the feelings may notbe acceptable to the individual.

Making sense of these feelings

Helping a grieving person to make sense of andunderstand these feelings will require discussionof the individuals relationship to the lost otherand how this relationship might follow a particularpattern of relating to others.

Clinical example 2Mrs B was a 50-year-old woman married to a 35-year-old man. She had two daughters, aged 19 and20, from a previous marriage. She became depressed



following the collapse of her catering business andincreasing estrangement from her second husband.Her daughters had recently left home and she nolonger felt she had a role in the family. Shepresented to psychiatric services in a highly suicidalstate and was admitted to a psychiatric ward. Ondetailed exploration of her suicidal thoughts andfantasies it emerged that she longed to reunite withher first boyfriend, a young Italian, whom she hadknown 30 years previously. They had known eachother for a year before he was killed in a caraccident at the age of 20. The accident happenedfollowing an argument with Mrs B, which she feltcaused him to lose concentration while driving with fatal consequences. In many of her subsequentrelationships she had sought to recreate this firstrelationship. Significantly, she had married hersecond husband when he was 20. When thisrelationship faltered and other roles changed, heronly hope of recreating her first love relationshipas an adult was to join him in death.

Grief work involved exploring her chronic grieffor her Italian boyfriend. In her early history, itemerged that she was the oldest of four childrento an Italian father and English mother. Her fatherhad been an alcoholic and her mother had strug-gled coping with four children, marital disharmonyand poverty. As the oldest child, Mrs B had helpedher mother look after younger siblings, but feltunable to express her own emotional needs,becoming a highly independent girl. She longedfor her father s loving attention, but he was rarelyable to provide this. During the course of grief workshe was able to reflect on how her Italian boyfriendhad provided her with an experience of being lovedand cared for that she had longed for from herown father. Her grief at her boyfriends death couldthen be seen as an extension of her more hiddengrief for her father s love. These issues wereexplored over eight sessions and this enabled herto leave hospital with some hope of finding arenewed purpose in her life through voluntarywork.

Addressing social isolation

It is easy for the bereaved to feel that others havenot experienced pain like theirs and do notunderstand. Encouraging ongoing contact withfamily and friends or with others who have beenbereaved (e.g. using organisations such asCRUSE) is important.

Showing the universality of grief

Ultimately, one of the most helpful realisationsfor the bereaved is recognition that what they areexperiencing is known the world over and hasbeen known since time immemorial. This is whereliterature, poetry, music and art can offer so much

solace. In her first novel, Our Father Who Art in aTree, Judy Pascoe (2002) gives a powerful descrip-tion of a family grieving for their father. The 20th-century English composer Herbert Howellscomposed his choral masterpiece Hymnus Paradisiin memory of his son, Michael, who died as a boy.Both works are less familiar examples of the manyworks of art that express grief in a deeply movingway.

Addressing spiritual beliefs

Grief can only be fully worked with if the pro-fessional has some understanding of the bereavedpersons perspective on what lies on the other sideof death. It is so easy to neglect this or assumethat the bereaved person shares ones ownperspective. It surely matters whether the bereavedbelieves that death is a final and complete end ora gateway to a different state of being.

SupervisionClinical example 3

In the supervision of a psychotherapists work withMr C, a depressed father who had lost his daughter2 years earlier from a brain tumour at the age of10, a number of important issues emerged. Whenthe therapist first reported the case he made a slipof the tongue, referring to the lost daughter as MrCs wife. Reflecting on this we were able to discernthe degree to which Mr Cs relationship with hisdaughter, in particular their mutual love offootball, had become a substitute for his hollowand unsustaining relationship with his grievingwife. Thus, grief for his daughter was mixed withgrief for the relationship he did not have with hiswife and had not had with his depressed mother.This became an important part of the therapy. Asthe work proceeded, the pain of Mr Cs griefbecame difficult to listen to for the therapist who,as a father of a young daughter himself, imaginedwhat it might be like to lose her. Supervision wasimportant to enable the therapist to bear thepatients distress. After 20 sessions the therapyended with signs that Mr Cs marital relationshipwas beginning to improve. He was also able totake up his love of football again with the poignantassociated memories of his daughter s enjoymentof the game.Working with grief can be challengingfor professionals. Overzealous attempts to makethings better or an unwillingness to hear and thinkabout the pain of grief are commonplace. Manyprofessionals will be confronted with reminders oftheir own experiences of grief and this can eitherinterfere with or enhance their capacity to help.Self-reflection and supervision are crucial ifprofessionals are to make best use of theirhumanity.


Clark

MCQ answers

1 2 3 4 5a F a T a F a F a Tb T b F b T b T b Tc T c F c T c T c Td F d F d T d T d Te T e T e F e F e F

References

Bowlby, J. (1980) Attachment and Loss. Volume 3. Loss: Sadnessand Depression. London: Penguin Books.

Freud, S. (1917) Mourning and melancholia. Reprinted(19531974) in the Standard Edition of the CompletePsychological Works of Sigmund Freud (trans. and ed. J.Strachey), vol. 14. London: Hogarth Press.

Freud, S. (1923) The ego and the id. Reprinted (19531974)in the Standard Edition of the Complete Psychological Worksof Sigmund Freud (trans. and ed. J. Strachey), vol. 19.London: Hogarth Press.

Hawton, K. & Simkin, S. (2003) Helping people bereavedby suicide. BMJ, 327, 177178.

Holmes, J. (2001) The Search for the Secure Base. London:Brunner-Routledge.

Jacobs, S., Hansen, F., Kasl, S., et al (1990) Anxiety disordersduring acute bereavement: risk and risk factors. Journalof Clinical Psychiatry, 51, 269274.

Klein, M. (1940) Mourning and its relation to manicdepressive states. In The Writings of Melanie Klein. Volume1. Love, Guilt and Reparation , pp. 344369. London:Hogarth Press.

Lewis, C. S. (1966) A Grief Observed. London: Faber & Faber.Maddison, D. & Viola, A. (1968) The health of widows in

the year following bereavement. Journal of PsychosomaticResearch, 12, 297306.

Marmar, C. R., Horowitz, M. J., Weiss, D. S., et al (1988) Acontrolled trial of brief psychotherapy and mutual-helpgroup treatment of conjugal bereavement. AmericanJournal of Psychiatry, 145, 203209.

Mawson, D., Marks, I. M., Ramm, L., et al (1981) Guidedmourning for morbid grief: a controlled trial. BritishJournal of Psychiatry, 138, 185193.

Mitchell, A. & House, A. (2000) Adjustment to illness,handicap and bereavement. In New Oxford Textbook ofPsychiatry (eds M. G. Gelder, J. J. Lopez-Ibor & N. C.Andreassen), pp. 11391147. Oxford: Oxford UniversityPress.

Parkes, C. M. (1985) Bereavement. British Journal ofPsychiatry, 146, 1117.

Parkes, C. M. (1986) Bereavement: Studies of Grief in AdultLife. Harmondsworth: Penguin Books.

Pascoe, J. (2002) Our Father who Art in a Tree: A Novel.Harmondsworth: Penguin Books.

Raphael, B. (1977) Preventative intervention with therecently bereaved. Archives of General Psychiatry, 34, 450454.

Royal College of Psychiatrists (1997) Bereavement. MentalHealth Information Leaflet. London: Royal College ofPsychiatrists.

Symington, J. & Symington, N. (1996) The Clinical Thinkingof Wilfred Bion. London: Routledge.

Multiple choice questions

1 The following features are consistent with a normalgrief reaction:

a disbelief 1 month after lossb depressive symptoms 6 weeks after lossc hearing the voice of the deceasedd significant functional impairment at 6 monthse pangs of grief on the anniversary of the loss.

2 After a bereavement, the following features arestrongly suggestive of a major depressive episode:

a a profound sense of worthlessnessb a transient wish to join the deceased in deathc guilt over not having been present at the time of

deathd transient visual hallucinations of the deceasede psychomotor retardation.

3 Factors contributing to delayed grief include:a a secure attachment styleb excessive alcohol consumptionc lack of social supportd the lost others death by suicidee a close relationship with surviving family.

4 In grief work:a medication is never appropriateb Bowlbys concept of the secure base is importantc grief avoidance may be treated by exposure therapyd poetry can play a useful rolee a persons spiritual beliefs are irrelevant.

5 Supervision of grief work:a can help professionals to distinguish between the

patients grief and their ownb can prevent overzealous attempts to cure griefc can enhance a professionals capacity for self-

reflectiond can help a therapist bear the pain of the patients

griefe should discourage ordinary human responses to a

patients grief.

10.1192/apt.10.3.164Access the most recent version at DOI: 2004, 10:164-170.APT

Andrew ClarkWorking with grieving adults

Referenceshttp://apt.rcpsych.org/content/10/3/164#BIBLThis article cites 7 articles, 3 of which you can access for free at:

permissionsReprints/

[email protected] To obtain reprints or permission to reproduce material from this paper, please write

to this article atYou can respond http://apt.rcpsych.org/letters/submit/aptrcpsych;10/3/164

from Downloaded

The Royal College of PsychiatristsPublished by on December 14, 2014http://apt.rcpsych.org/

http://apt.rcpsych.org/site/subscriptions/go to: Adv. Psychiatr. Treat. To subscribe to

Documents

Working With Grieving Adults